• Click here to watch Pattani on “The Daily Report.”
• Read Pattani’s “From Narcan to Gun Silencers, Opioid Settlement Cash Pays Law Enforcement Tabs” and “Sock Hops and Concerts: How Some Places Spent Opioid Settlement Cash.”

KFF Health News Southern correspondent Sam Whitehead discussed government claims that new technologies will help Medicaid recipients comply with new work requirement rules on WUGA’s “The Georgia Health Report” on Oct. 31.

• Click here to hear Whitehead on “The Georgia Health Report.”
• Read “Officials Show Little Proof That New Tech Will Help Medicaid Enrollees Meet Work Rules,” by Whitehead and KFF Health News Colorado correspondent Rae Ellen Bichell

KFF Health News Southern California correspondent Claudia Boyd-Barrett discussed the presence of Immigration and Customs Enforcement agents in and around health care facilities such as hospitals and community health centers on Radio Bilingüe’s “Línea Abierta” on Oct. 30.

• Click here to hear Boyd-Barrett on “Línea Abierta” (beginning at 46:00).
• Read Boyd-Barrett’s “California Faces Limits as It Directs Health Facilities To Push Back on Immigration Raids.”

KFF Health News executive editor Alex Wayne discussed the federal government shutdown and rising Affordable Care Act premiums on Sirius XM’s “The Smerconish Podcast” on Oct. 30.

• Click here to hear Wayne on “The Smerconish Podcast.”

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

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Vought has exerted extraordinary control over government spending this year, usurping congressional decisions on how the nation’s money is used. His push for more layoffs during the government shutdown is only the latest blow, following months of firings, canceled grants, and withheld funds.

By cutting and freezing public health funds, in particular, the Trump administration has already begun to undercut efforts to provide medical care, outbreak response, housing assistance, and research across the U.S., according to health officials, nonprofit directors, and federal agency staffers interviewed by KFF Health News.

Since most federal funds for public health flow to states, Vought is rivaling the Department of Health and Human Services secretary, Robert F. Kennedy Jr., in his ability to upend government-led efforts to keep Americans healthy. In Texas, Centers for Disease Control and Prevention funds to stem a measles outbreak weren’t available until after the crisis had subsided and two children had died. A project to protect Alabamans from raw sewage and hookworm was abandoned. People with HIV have had to delay medical care as clinics scale back hours. Time-dependent surveys on HIV and maternal mortality were halted. Food banks have canceled events. Tobacco prevention programs lapsed. Initiatives to protect older adults at risk of falling have been harried.

No matter what budget Congress ultimately passes for next year, the Trump administration may continue to thwart financial support for such programs in ways that will harm people’s health. “The White House has shown that they are willing to unilaterally exert control over funding,” said Gillian Metzger, a constitutional law professor at Columbia University.

“This is a huge deal,” she added, “because the power of the purse is central to Congress’ ability to shape and direct policy.”

Before he was appointed to lead the White House’s Office of Management and Budget this year, Vought outlined budgetary strategies the executive branch could deploy to wrest power from Congress and federal agencies in Project 2025, the Heritage Foundation’s conservative blueprint.

Vought’s tactics unfolded this year, often below the radar. They include abrupt grant cancellations, extraordinary constraints on how funds can be spent, and excessive layers of review, agency officials say, at every step in the grantmaking process. Getting money out the door has been further complicated by layoffs that have gutted offices overseeing grants on chronic disease prevention, HIV, maternal mortality, and more.

Government employees have described these tactics to members of Congress, said Abigail Tighe, executive director of the National Public Health Coalition, a group that includes current and former staffers at the CDC and HHS. “We want Congress to act, because this is preventing states and communities from doing critical public health work to keep our country safe,” she said. “If they don’t have capacity, we all collectively suffer.”

Democrats on the House and Senate appropriations committees have pushed for transparency, but the extent to which money Congress appropriated for public health in 2024 and 2025 has gone unspent because of the administration’s disruptions is not yet known. “This is a sophisticated strategy to cause money to lapse and then say, ‘If they can’t spend it, they don’t need it,’” said Robert Gordon, a public policy specialist at Georgetown University and a former assistant finance secretary at HHS.

“No one thought this was possible or legal, but that is what’s happening,” he said.

Details on how the administration has subverted health spending have received little attention because many changes have been made quietly — and people who rely on federal funds fear retribution. The Trump administration has defunded and threatened federal offices that hold the government accountable and fired whistleblowers. It has abruptly revoked funds for local governments and organizations.

Vought and spokespeople at the White House and the OMB did not respond to queries from KFF Health News. However, Vought described his intentions in a Sept. 3 speech. He said that federal agencies and Congress had gained more power over spending since the 1970s and that their control became “woke and weaponized” under Presidents Barack Obama and Joe Biden.

“Thankfully, President Trump won,” he said. “And we have now been embarked on deconstructing this administrative state.”

Many Parts, Many Malfunctions

Like a car, the federal budget process has many components that can break down. Through the OMB and its partner, Trump’s Department of Government Efficiency, or DOGE, the administration has intervened at various junctures. “There are so many ways in which money is not operating in the way it is supposed to operate,” said Bobby Kogan, the senior director of federal budget policy at the Center for American Progress, a left-leaning think tank, and a former OMB adviser.

Typically, Congress passes a budget that appropriates money for the next fiscal year to federal agencies. For many public health programs, ranging from housing assistance to cancer screening, agencies then post open calls online for states, local governments, and organizations to apply for funding. Agency experts select winners and send notices of awards — or notices of ongoing funding to groups that previously won multiyear awards.

Next, the OMB, which administers the federal budget, activates money for agencies, like a bank activates a credit card, so that grantees can spend and get reimbursed rapidly. Auditors keep an eye on spending, but the government has in the past limited interruptions so that programs run smoothly.

Early on, the Trump administration canceled billions of dollars in awards granted in 2024 and early 2025 for research and global health. In March, it clawed back $11.4 billion in covid-era funds that Congress had earmarked for health departments that were using the money for disease surveillance, vaccinations, and more.

Although some funds have been restored because of lawsuits, the Supreme Court has allowed other cuts by the administration to stand while the cases move through the courts.

Beyond these “shotgun” cancellations, the administration has taken a quieter, “in-the-weeds, slowing, cutting, conditioning” approach that’s frozen funds for public health, said Matthew Lawrence, a law professor specializing in health policy at Emory University.

By August, the CDC’s center for HIV and tuberculosis prevention had doled out $167 million less than the historical average, according to an analysis by the Center on Budget and Policy Priorities, a think tank focused on reducing inequality. The CDC’s funding for chronic disease prevention lagged by $259 million, the Ryan White HIV/AIDS Program had underspent by $105 million, and funds for mental health at the Substance Abuse and Mental Health Services Administration were more than $860 million behind what was expected.

An unknown amount of Congress’ 2025 funding for research and public health has yet to be awarded and will probably lapse this year, said Joe Carlile, an author of the center’s analysis and an associate OMB director during the Biden administration. The obstructions appear to be concentrated in areas where the White House proposed cutting the federal budget next year. “The administration may be executing their 2026 budget request through administrative controls,” Carlile said.

“This is boring but crazy-high stakes,” he added. “A one-branch veto of spending neuters the power of the purse in the Constitution that Madison said was the fundamental check on the executive branch.”

Incremental Chaos

A key tactic Vought described in Project 2025 occurs when the OMB activates funds for agencies in installments, called apportionments. Vought wrote that “apportioned funding” could “ensure consistency with the President’s agenda.”

Under Vought, the OMB shrank the size of apportionments, HHS and CDC staffers said. It’s illegal for agencies to let grantees withdraw money before the total amount is in the metaphorical bank, so that delayed agencies’ ability to greenlight spending.

The OMB and DOGE also placed conditions on apportionments through memos, footnotes, and spoken directives telling agencies to ensure that spending “aligns with Administration priorities,” according to reports and HHS employees who said that notices of funding opportunities and awards required excessive layers of sign-off. The CDC and other agencies circulated lists of priorities that reflect White House stances, including those targeting diversity, equity, and inclusion efforts; immigration; and transgender rights. Public health efforts have been especially caught up in red tape, since many focus on populations bearing an unequal burden of death, disease, and injury.

Groups that rely on federal funds have largely been unaware of the reasons grants were held up, but they’ve fielded what they viewed as unsettling queries. For example, Kathy Garner, the head of a Mississippi nonprofit, said officials asked her to defend the exclusion of men from a program to shelter women who experienced domestic violence.

Delays were made worse by uncertainty. Grantees said they’ve been unable to reach program officers because tens of thousands of federal workers have been laid off. Agency officials said firings slow funding further.

“Everyone’s inbox is full of letters from grant recipients asking, ‘How do we proceed?’” one high-ranking CDC official told KFF Health News, which granted agency officials anonymity because of their fears of retaliation. “We just say, ‘Please wait.’”

Time was critical as a measles outbreak surged in West Texas early this year. The state asked for federal funding for the response in March, but it didn’t arrive until May, after the outbreak had largely faded in Texas, according to an investigation by KFF Health News. Apportionment control was a key reason, CDC staffers said.

In July, 81 HIV organizations sent a letter to Kennedy. “With every day of delayed FY2025 funding release, the delivery of essential HIV services is compromised,” said the letter, which was reviewed by KFF Health News. Because of delays and uncertainty, it said, HIV clinics had laid off case managers and reduced clinician hours, closed sites, and pared down hotlines that patients call with urgent questions. The funds arrived about a month later, but HIV providers remain shaken.

Lauren Richey, medical director at University Medical Center’s HIV clinic in New Orleans, backed out of hiring a sorely needed dentist she had recruited. “I was afraid to tell someone to move across the country for a job when I wasn’t sure if or when we’d get the funding for their salary,” she said. “The wait is now three to four months for dental services, when it was usually a couple of weeks at most.”

Tamachia Davenport, program director at the St. John AIDS outreach ministry in New Orleans, said that “a lot of us are having to rob Peter to pay Paul.”

When the group didn’t get CDC funds it expected this summer, Davenport had to decide between cutting staff or supplies. Concerned her top employees would take jobs elsewhere, she stopped buying the condoms they distribute throughout the city to prevent the spread of sexually transmitted infections.

Louisiana already has one of the highest rates of HIV, chlamydia, and gonorrhea in the country. Condoms cost far less than treating these diseases. For a person infected by HIV at age 35, such costs exceed $326,000.

Groups focused on cancer, diabetes, and heart disease also report lasting repercussions from delays, as well as ongoing fears that they will happen again. Louisiana State University’s Healthy Aging Research Center canceled some of its workshops to train health workers on caring for people with dementia. “There may be fewer people who have this very specific expertise next year in Louisiana and Mississippi,” said Scott Wilks, the director of the center. “That’s on top of the big shortage we have already.”

Nationwide surveys tallying maternal and infant mortality froze for about five months because of funding delays, causing an irrecoverable gap in data that had been collected continuously since 1987, CDC officials say.

“We are seeing the administration get their way with or without an approved budget,” one said. “It’s such a terrible shame to play with people’s health this way.”

DOGE also inserted itself into grant reimbursements this year, stalling the rapid turnaround that public health groups typically expect to cover salaries, rent, and other monthly costs outlined in budgets that have already been approved. In what’s now labeled Departmental Efficiency Review, itemized expenses must be regularly justified by multiple government officials, according to documents reviewed by KFF Health News.

DOGE posted on its website expense reports covering about a month’s span from April to May. Nearly 230 of the individual expenses filed to federal agencies during that period are for $1 or less. Other entries break down monthly salaries for individual employees and petty costs for postage or monthly subscriptions.

“Public funds deserve scrutiny, but this is different from audit practices I’ve been a part of,” Carlile said.

DOGE also stalled calls for applications for 2025 funding — and some calls never appeared as the fiscal year came to a close on Sept. 30. Among them are programs for groups that provide housing assistance. People will be evicted when these organizations run out of money left over from 2024, said Steve Berg, chief policy officer at the National Alliance to End Homelessness.

Other solicitations came out months behind schedule, leaving groups with a few weeks to put together complicated applications for multimillion-dollar awards, including for Alzheimer’s care, addiction recovery, senior support, and chronic disease management.

“They’ve set projects up to fail,” one HHS official said.

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Kopplin, a physician assistant who works with seniors, low-income people, and mental health patients in the rural Black Hills, shared her thoughts at a meeting hosted by state officials.

South Dakota’s leaders did a “good job of diving in” and asking questions to get “deeper at the root of the problem,” she said.

Kopplin later told KFF Health News how one of her rural patients recently missed two appointments because of a broken-down car and no access to public transportation.

Nationwide, health care workers like Kopplin and thousands of others — from patient advocates to technology executives — flocked to town halls or online portals during the seven weeks state leaders had to craft and submit their applications for the Rural Health Transformation Program to the federal Centers for Medicare & Medicaid Services. That deadline was Nov. 5.

“We will give $50 billion away by the end of the year,” CMS Administrator Mehmet Oz said Nov. 6 at a Milken Institute event in Washington. He said all 50 states had submitted applications.

The program will “allow us to right-size the health care system,” Oz said, adding that innovations from the rural work “will spill over to suburban and urban America as well.”

Among applications and summaries publicly shared by states, themes include workforce development, telehealth, and access to healthy food. In Kansas, leaders want to build a “Food is Medicine” program. Wyoming officials propose a new program called “BearCare,” a state-sponsored health insurance plan that patients could use only after medical emergencies.

But many health policy experts and Democrats are raising alarms that the Republican-backed program will become a “slush fund.” Critics worry it will fail to reach the small-town patients they say need it most, especially as states face nearly a trillion dollars in Medicaid spending reductions over the next decade. Medicaid, a joint federal-state program, serves nearly 1 in 4 rural Americans.

“The status quo is tremendous distress in rural communities,” said Heather Howard, a professor of the practice at Princeton University and director of the university’s State Health and Value Strategies program, which is tracking the rural health fund. The new funding won’t be enough to offset the Medicaid losses, she said.

Congressional Republicans added the five-year, $50 billion Rural Health Transformation Program as a last-minute sweetener to President Donald Trump’s massive tax-and-spending legislation. The move helped win support for the One Big Beautiful Bill Act from conservative holdouts who worried that the Medicaid cuts in the bill would harm rural hospitals in their states.

In Montana, which hosted an online public forum before submitting its application, a nonprofit director pitched youth peer support as a way of battling high suicide rates. A registered nurse asked state leaders to “think maybe even bigger” and consider statewide universal health care.

And in Georgia, a technology-focused chain of primary care clinics that serves seniors proposed expanding its operations into that state in its online public comment. A rural grant writer asked for “safe and stable housing.”

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be doled out according to a points-based system. Of the second half, $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that score well on initiatives and policies that, in part, mirror the Trump administration’s “Make America Healthy Again” objectives.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who called on a federal watchdog agency to investigate the fairness and implementation of the fund. Taylor Harvey, a Wyden aide, said the Government Accountability Office has confirmed it will investigate.

According to the federal statute, no less than a quarter of states with an approved application may share the second half of the funding each fiscal year, CMS spokesperson Catherine Howden said. The agency plans to publish summaries of approved state projects, according to CMS guidance.

A handful of conservative-leaning states — including Texas, Arkansas, Louisiana, and Oklahoma — have already instituted regulatory and legislative initiatives, such as prohibiting “non-nutritious” foods in benefit programs, that garner additional points in the program application process.

Michael Chameides, a county supervisor in rural New York, said he fears the money could “be used in ways that would hurt certain states or reward certain states.” Chameides is also the communications and policy director with the Rural Democracy Initiative, a national advocacy organization that released a rural action report last month.

Edwin Park, a research professor at Georgetown University’s Center for Children and Families, said federal lawmakers gave Oz and his agency “really excessive discretion” when awarding the money.

Federal administrators have added rules that aren’t within the statute that created the program, Park said. For example, its application guidelines say states cannot use more than 15% of their funding to pay providers for patient care — payments that are expected to take a hit due to the Medicaid cuts.

Georgetown’s health policy experts and Democrats aren’t the only ones with concerns. Some Republicans and small hospitals in Ohio worry the money will go to large health systems instead of smaller, independent hospitals that serve people within their rural communities.

CMS’ Oz repeated the idea of getting “big hospitals to adopt smaller institutions” at the Washington gathering after applications were filed. He used similar language at a rural health summit hosted by South Dakota-based Sanford Health. “How do we get big hospitals to adopt smaller hospitals? Not to take them over, but to keep them viable by giving them good telehealth services, specialty support, radiology support,” he said at the October event.

Sanford owns or manages dozens of hospitals and hundreds of clinics and long-term care centers, as well as a health insurance company. The system reported about $81 million in operating income during the first six months of fiscal year 2025, according to a recent bond rating report.

Last year, Sanford opened a “command center” for its systemwide telehealth initiative. It launched a telehealth expansion in 2021 and offers virtual care for 78 medical specialties, Sanford President and CEO Bill Gassen said.

“We’ve tried to imagine, what if that number doubles?” Gassen said. The startup costs for telehealth are high, he said, and the rural fund could be a unique opportunity “for us to make virtual care available to more patients, to more communities, to more hospitals and health systems across the country.”

Gassen, who is set to chair the American Hospital Association in 2027, said Sanford leaders have met with state and federal officials, including Oz, whom he’s known for years, and Chris Klomp, a top deputy at CMS and a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

The word “telehealth” appears 36 times in the rural health program’s 124-page application guidelines. But Don Robbins Jr., chief executive of a small hospital on the Illinois-Kentucky border, chuckled at the idea of using the funding for that purpose.

Robbins, whose 25-bed Massac Memorial Hospital averages five to seven patients in its beds each day, said his hospital does not regularly offer telehealth. Even if it did, he said, patients living more than a mile outside of town couldn’t use it because they don’t have a good internet connection.

The small hospital reported a $31,314 loss in September, Robbins said. “I think if we get anything out of it,” Robbins said of the rural health program, “we’ll be lucky.”

Kopplin, the physician assistant who attended the South Dakota meeting, is cautiously optimistic about the rural health fund. She views it as a wonderful chance for states to test out ideas and learn from what works and what doesn’t.

But “in a lot of ways this bill is going to be a band-aid approach” for rural health, she said. “It’s not really going to fix the problem.”

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The Hospital Preparedness Program was created more than two decades ago in response to the Sept. 11, 2001, terrorist attacks on New York City’s World Trade Center and the Pentagon, and the deadly anthrax attacks that began days later. The fund has provided nearly $2.2 billion to states, territories, major cities, and other entities over the past 17 years to ready health care systems for the next pandemic, cyberattack, or mass-casualty event.

Recently, that money has been used to combat the bird flu that has sickened at least 70 people in the United States, killed at least one, and remains a threat. The funds also have been used to respond to crises such as hurricanes, tornadoes, mass shootings, floods, and heat waves.

But the budget request sent to Congress by Trump’s budget director, Russell Vought, proposes eliminating the program, saying the effort “has been wasteful and unfocused” and that cutting it would allow states and cities to “properly” fund their own preparedness plans. Any action is currently stalled by the government shutdown, which stems from a partisan dispute over expiring health care subsidies that affect many of the 24 million Americans who buy coverage from Affordable Care Act marketplaces.

Red and blue states say the hospital preparedness funds are essential and could not be readily replaced with local funds. It’s an example of how the White House’s efforts to reduce its role in responding to public health and natural disasters have imperiled state and municipal reliance on federal resources to meet community needs.

The program “is the main source of government funding for disaster preparedness among hospitals, EMS providers, and other parts of the health care system,” Texas Department of State Health Services spokesperson Chris Van Deusen said.

Texas received more than $20 million from the Hospital Preparedness Program this year, and Van Deusen said it’s unlikely the state could backfill any federal funding gap in the short term since the budget has been finalized through August 2027.

The funds help Texas’ health providers create disaster plans and test hospitals’ ability to boost their capacity in an emergency, he said, while enabling the distribution of medical resources and patient loads so hospitals aren’t overwhelmed during disasters. The program, along with state funding, supports the state’s Emergency Medical Task Force, which responded to deadly floods this year and the Uvalde school shooting in 2022, among many other emergencies.

Georgia, which received $13.5 million this year, “continues to monitor and plan for potential changes to future federal funding while ensuring health care preparedness efforts across Georgia remain strong and sustainable,” said public health spokesperson Eric Jens.

A California health official called the money vital to ensuring local health care systems can respond to emergencies beyond their usual capacity. The program is the only federal funding devoted to health care system preparedness for such catastrophes, said Department of Public Health spokesperson Robert Barsanti.

“Without this funding, California risks losing critical infrastructure for emergency response, weakening its ability to protect lives, maintain continuity of care, and meet federal preparedness benchmarks,” Barsanti said.

As the most populous state, California receives the most money — nearly $29 million this year — as it struggles with a massive budget deficit and fights a running rhetorical battle with Trump administration officials. The funds go to the state’s public health department; the California Emergency Medical Services Authority, which coordinates the state’s emergency medical system; health care associations; and about 60 local entities. Los Angeles County, with more than a quarter of the state’s population, received an additional $11 million, and the University of California system got $1.2 million.

Neither the White House, the Administration for Strategic Preparedness and Response, which administers the program under the U.S. Department of Health and Human Services, nor the Office of Management and Budget responded to repeated requests for comment about the May proposal to cut the Hospital Preparedness Program.

The Administration for Strategic Preparedness and Response has seen an 81% reduction in employees over the past year, The New York Times reported. It’s by far the largest workforce reduction at HHS and part of the wider culling of federal workers under Trump.

Already, HHS has delayed the distribution of this year’s Hospital Preparedness Program funds by nearly three months. The funds were supposed to be available to states for use starting in July, but the bulk of the money was not released until late September. Health officials in the waning days of the Biden administration had wanted to quickly distribute the funds for the nation’s response to the H5N1 bird flu.

The months-long delay “is yet another example of how changes and uncertainty at the federal level threaten critical public health programs in New York state,” said Department of Health spokesperson Cadence Acquaviva. Despite health officials’ best efforts, “delays or elimination of funding places New Yorkers at significant risk in the event of a disaster or emergency,” Acquaviva said.

New York state received nearly $14 million, and New York City more than $9 million.

Illinois Department of Public Health spokesperson Jim Leach said the medical system needs the federal funds to prepare for natural and human-caused disasters of every sort, “regardless of the ebb and flow of any single disease.”

Illinois and Chicago received a combined $15 million from the preparedness program.

During emergencies, the state’s federally funded crisis response program “turns hundreds of Illinois hospitals, EMS, and other health care facilities into a single, coordinated system,” Leach said, adding it saves both lives and taxpayer dollars. “If there is a natural disaster or an infectious disease outbreak, a state would not be able to react quickly enough without the HPP funds.”

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He hasn’t forgotten the pile of hospital bills that awaited him after he had a seizure while tending to customers in his Austin, Texas, barbershop four years ago. Once doctors hurriedly removed the dangerous tumor growing on his brain, a weeklong hospital stay, months of therapy, and nearly $250,000 worth of medical expenses followed.

The coverage he has purchased for years through the Affordable Care Act marketplace covered most of those bills.

“That saved my ass,” said Cleveland, who owns three barbershops across the city.

Even with Cleveland’s monthly premiums expected to soar next year — from $560 to about $682 — he will still sign up for a plan that requires him to shell out $70 if he sees a doctor and 50% of the cost for any emergency room visits. Still, Cleveland is most worried about some of his employees, who might risk going without insurance once they see the high prices.

Small-business owners are among those who stand to lose the most should Congress let the additional, generous federal subsidies put in place during the covid-19 pandemic lapse. The looming change threatens not only their own coverage but also that of their employees, who often depend on marketplace coverage.

Whether to extend the enhanced ACA subsidies that cost taxpayers billions of dollars yearly poses a serious political conundrum for Republicans. After years of unified opposition to Obamacare, the party now faces pressure from one of its most loyal constituencies, small-business owners, who will bear the brunt of rising premiums if the subsidies disappear.

Most of the roughly 20 employees who work on Justin Miller’s 113-year-old family fruit farm in rural Northern California purchase coverage through the Obamacare marketplace.

He’s agonizing over what it could mean if health insurance through the marketplace becomes unaffordable for his employees. He fears they might consider leaving his farm for a job that comes with health coverage.

“Being a small-business owner, especially in a field like ours, where it is tough work and we really understand how hard everybody works, we have to look everybody in the eyes every day,” Miller said. “Knowing that they’re going to have to pay $4,000 or $5,000 more a year to stay on their insurance is a tough pill to swallow.”

Miller says he already pays a minimum wage of $22.50 and provides sick leave, vacation, retirement, and employee housing benefits.

Adding health insurance for his employees, he said, would be too costly to keep his farm in business.

GOP Pollsters Issue ACA Caution

About half of the 24 million people enrolled in Obamacare coverage are, or are employed by, small-business owners — a group that is more likely to vote Republican and overwhelmingly backed President Donald Trump in last year’s election. Farmers, dentists, real estate agents, and chiropractors are among the professions most represented among enrollees.

Even Trump’s own pollsters have found deep support for the Obamacare subsidies, warning that failing to extend them could cost Republicans in next year’s midterms.

A poll conducted last month by Republican pollster John McLaughlin found that a majority of independent voters would be less likely to vote for politicians who voted to let the enhanced tax credits expire.

Given that “approximately 4 million” people would lose coverage and premiums would “skyrocket by an average of 75%,” the poll also concluded that: “A candidate for congress who let the healthcare tax cuts expire would also be vulnerable to more pointed messages.”

Red States Benefited From the Subsidies

Some red states have seen Obamacare enrollment balloon since the federal government began offering extra help paying premiums in the form of more generous subsidies.

Texas and Florida have added 2.8 million enrollees each since 2020, far outpacing growth in most other states. Together, the two states now account for more than a third of marketplace enrollment nationally.

A small chorus of Republican lawmakers — up for reelection next year, mostly in competitive races — have proposed an extension of the subsidies, urging Democrats to vote to reopen the government while simultaneously pleading with House Speaker Mike Johnson to work out a bipartisan deal that doesn’t allow them to simply lapse.

At Cleveland’s barbershops in Austin, about a third of his 18 employees rely on Obamacare coverage. He’s talked to them about their health insurance options for next year but said many hadn’t started thinking about open enrollment, which began Nov. 1.

He’s worried they’ll be baffled once they see the new prices, which currently reflect what customers will pay next year without an extension of the extra subsidies.

“There’s a couple of my barbers that are going to go without, because they’re healthy and young, but I thought I was too when everything happened to me,” said Cleveland, now 47.

Republicans, meanwhile, remain wary of voting to extend the additional Obamacare subsidies, said Rodney Whitlock, a vice president at the McDermott+ consultancy who was a longtime congressional staffer and advises on health care policy.

No Republican voted for the extra subsidies when they were introduced in 2021 or continued in 2022. Approving them now, he said, is viewed by many as a band-aid that would temporarily help a program GOP leaders have long lambasted as problematic and too costly.

But, Whitlock noted, many in the party are coming to terms with how the subsidies might affect their changing constituencies. Nearly 6 in 10 Obamacare enrollees live in a Republican-held congressional district.

“Republicans are slowly starting to grasp that the lower third of income earners are their voters,” he said. “For the first time, I think they’re getting there. That battleship turns slowly.”

Rep. Marjorie Taylor Greene, a Georgia Republican who has firmly backed Trump, broke with her party last month, calling on the GOP to extend the subsidies. Greene said in an interview that rising health care costs are the “No. 1 issue” she hears about from people living in her district.

“I know a lot of small-business owners, like a family of four, and they’re paying $2,000 a month,” Greene said during the television interview, adding that rising deductibles make the insurance hardly functional for anything other than catastrophes.

She warned in another TV interview that “ignoring” the issue could be “very bad for midterms” next year.

Miller, the farmer who lives in a conservative district in Northern California, expects monthly health insurance premiums for himself, his wife, and two of his children to jump from $264 to $600. His deductibles and copayments are going up, too. He expects all these new expenses will still be on his mind when he goes to vote in the midterm elections next year, he said. Describing himself as an independent, Miller said he is frustrated that few American politicians talk about the type of universal health care coverage that’s available in other countries.

“I’m definitely voting for those that will protect the working American, regardless of party,” he said.

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Bynum, then in his second year of residency training as a family medicine physician, was wrapping up a long shift when he was called into an emergency delivery. To save the baby’s life, he used a vacuum device, which applies suction to assist with rapid delivery.

The baby emerged unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon afterward, Bynum retreated to an empty hospital room, trying to process his feelings about the unexpected complication.

“I didn’t want to see anybody. I didn’t want anybody to find me,” said Bynum, now an associate professor of family medicine at Duke University School of Medicine in North Carolina. “It was a really primitive response.”

Shame is a common and highly uncomfortable human emotion. In the years since that pivotal incident, Bynum has become a leading voice among clinicians and researchers who argue that the intense crucible of medical training can amplify shame in future doctors.

He is now part of an emerging effort to teach what he describes as “shame competence” to medical school students and practicing physicians. While shame can’t be eliminated, Bynum and his research colleagues maintain that related skills and practices can be developed to reduce the culture of shame and foster a healthier way to engage with it.

Without this approach, they argue, tomorrow’s doctors won’t recognize and address the emotion in themselves and others. And thus, they risk transmitting it to their patients, even inadvertently, which may worsen their health. Shaming patients can backfire, Bynum said, making them defensive and leading to isolation and sometimes substance use.

The U.S. political environment presents an additional obstacle. Health and Human Services Secretary Robert F. Kennedy Jr. and other top Trump administration health officials have publicly blamed autism, diabetes, attention-deficit/hyperactivity disorder, and other chronic issues in large part on the lifestyle choices of people with the conditions — or their parents. For instance, FDA Commissioner Marty Makary suggested in a Fox News interview that diabetes could be better treated with cooking classes than “just throwing insulin at people.”

Even before the political shift, that attitude was reflected at doctors’ offices as well. A 2023 study found that one-third of physicians reported feeling repulsed when treating patients with Type 2 diabetes. About 44% viewed those patients as lacking motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like feeling shame. We want to avoid it. It’s very uncomfortable,” said Michael Jaeb, a nurse at the University of Wisconsin-Madison, who has conducted a review of related studies, published in 2024. And if the source of shame is from the clinician, the patient may ask, “‘Why would I go back?’ In some cases, that patient may generalize that to the whole health care system.”

Indeed, Christa Reed dropped out of regular medical care for two decades, weary of weight-related lectures. “I was told when I was pregnant that my morning sickness was because I was a plus-size, overweight woman,” she said.

Except for a few urgent medical issues, such as an infected cut, Reed avoided health care providers. “Because going into a doctor for an annual visit would be pointless,” said the now 45-year-old Minneapolis-area wedding photographer. “They would only just tell me to lose weight.”

Then, last year, severe jaw pain drove Reed to seek specialty care. A routine blood pressure check showed a sky-high reading, sending her to the emergency room. “They said, ‘We don’t know how you’re walking around normal,’” she recounted.

Since then, Reed has found supportive physicians with expertise in nutrition. Her blood pressure remains under control with medication. She’s also nearly 100 pounds below her heaviest weight, and she hikes, bikes, and lifts weights to build muscle.

Savannah Woodward, a California psychiatrist, is among a group of physicians trying to bring attention to the detrimental effects of shame and develop strategies to prevent and mitigate it. While this effort is in the early stages, she co-led a session on the spiral of shame at the American Psychiatric Association’s annual meeting in May.

If physicians don’t acknowledge shame in themselves, they can be at risk of depression, burnout, sleeping difficulties, and other ripple effects that erode patient care, she said.

“We often don’t talk about how important the human connection is in medicine,” Woodward said. “But if your doctor is burned out or feeling like they don’t deserve to be your doctor, patients feel that. They can tell.”

In a survey conducted this year, 37% of graduating students reported feeling publicly embarrassed at some point in medical school. And nearly 20% described public humiliation, according to the annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, along with an almost “masochistic” work ethic, as Woodward described it. Then they’re run through a gantlet of exams and years of training, amid constant scrutiny and with patients’ lives on the line.

During training, physicians work in teams and make presentations to teaching faculty about a patient’s medical issues and their recommended treatment approach. “You trip over your words. You miss things. You get things out of order. You go blank,” Bynum said. And then shame creeps in, he said, leading to other debilitating thoughts, such as “‘I’m no good at this. I’m an idiot. Everyone around me would have done this so much better.’”

Yet shame remains “a crack in your armor that you don’t want to show,” said Karly Pippitt, a family medicine physician at the University of Utah who has taught medical students about the potential for shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “Heaven forbid that you act like you’re not capable or you show fear.”

When students are taught about shame, the goal is to help future physicians recognize the emotion in themselves and others, so they don’t perpetuate the cycle, Pippitt said. “If you felt shamed throughout your medical education, it normalizes that as the experience,” she said.

Above all, physicians-in-training can work to reframe their mindset when they receive a poor grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they’ve failed as a physician, they can focus on what they got wrong and ways to improve.

Last year, Bynum started teaching Duke physicians about shame competence, beginning with roughly 20 OB-GYN residents. This year, he launched a larger initiative with The Shame Lab, a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people across Duke’s Department of Family Medicine and Community Health, including faculty and residents.

This sort of training is rare among Duke OB-GYN resident Canice Dancel’s peers in other programs. Dancel, who completed the training, now strives to support students as they learn skills such as how to suture. She hopes they will pay that approach forward in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would following delivery. “I was too scared of how she was going to react to me,” he said.

“It was a little devastating,” he said, when a colleague later told him that the mother wished he had stopped by. “She had passed a message along to thank me for saving her baby’s life. If I had just given myself a chance to hear that, that would have really helped in my recovery, to be forgiven.”

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But in Louisiana this year, public health officials appeared to have not followed that playbook during the state’s worst whooping cough outbreak in 35 years.

Whooping cough, also called pertussis, is a highly contagious, vaccine-preventable disease that’s particularly dangerous for the youngest infants. It can cause vomiting and trouble breathing, and serious infections can lead to pneumonia, seizures, and, rarely, death.

Madison Flake, a pediatric resident in Baton Rouge, cared for a baby who was hospitalized during this year’s outbreak. Less than 2 months old, he was sent to the intensive care unit.

“He would have these bouts of very dramatic coughing spells,” Flake said. “He would stop breathing for several seconds to almost a minute.”

Infants are not eligible for their first pertussis vaccine until they are 2 months old, but they can acquire immunity if the mother is immunized while pregnant.

By late January, two babies had died in Louisiana.

But the Louisiana Department of Health waited two months to send out a social media post suggesting people talk to their doctors about getting vaccinated. The department took even longer to issue a statewide health alert to physicians, send out a press release, or hold a news conference.

That lag is not typical, according to Georges Benjamin, the executive director of the American Public Health Association.

“Particularly for these childhood diseases, we usually jump all over these,” said Benjamin, a physician who has led health departments in Maryland and Washington, D.C. “These are preventable diseases and preventable deaths.”

Because infectious diseases spread exponentially, if officials don’t alert the public quickly, they lose a key chance to prevent further infections, said Abraar Karan, an instructor at Stanford University who has worked on covid and mpox outbreaks.

“Time is perhaps one of the most important currencies that you have,” he added.

General Promotion of Vaccines Banned

Because pertussis vaccine immunity wanes over time, cases can ebb and flow. But in September 2024, Louisiana health officials started seeing a “substantial” increase in whooping cough cases, part of a national trend.

In late January, physicians at one Louisiana hospital warned their colleagues that two infants had died in the outbreak.

On Feb. 13, the state’s surgeon general, Ralph Abraham, sent a memo to staff ending the general promotion of vaccines and community vaccine events.

He sent that email a few hours after Robert F. Kennedy Jr., an anti-vaccine activist, won Senate confirmation as the new secretary of the U.S. Department of Health and Human Services.

Also that day, Abraham posted a public memo on the state health department’s website. In it, he said public health has overstepped with vaccine recommendations, driven by “a one-size-fits-all, collectivist mentality.” Abraham has called covid vaccines “dangerous” and been a vocal supporter of Kennedy.

Four days later, in response to a request from WVUE Fox 8 News in New Orleans, the Louisiana Department of Health in an email confirmed the deaths of two infants from whooping cough for the first time. WVUE published the news on Feb. 20.

But Louisiana’s health department sent out no alerts, according to a review of external and internal communications by NPR and KFF Health News.

Over the next month, two more infants were hospitalized for whooping cough, according to internal health department emails obtained through a public records request.

In March, after inquiries from NPR and KFF Health News about the growing number of pertussis cases, the department put out its first social media communications about the outbreak and offered interviews to other journalists.

Then on May 1 — at least three months after the second infant death — the health department issued what appears to be its first and so far only official alert to physicians. It put out its first press release the next day and then held a news conference about pertussis on May 14.

By then, 42 people had been hospitalized for whooping cough since the outbreak began, three-quarters of whom were not up to date on their whooping cough immunizations, according to the Louisiana Department of Health.

More than two-thirds of those hospitalized were babies under the age of 1.

Throughout the summer, pertussis cases continued to climb in Louisiana. But there were no further public communications from the state health department.

NPR and KFF Health News contacted the department for comment on Sept. 25. Emma Herrock, a spokesperson, did not answer specific questions about the lack of communications but referred to a Sept. 30 post on X by the state surgeon general.

In the post, Abraham said the department “consistently reported cases of pertussis and provided guidance to help residents stay protected” in 2025. He called the pertussis vaccine “one of the least controversial” and said he recommends it to his patients.

The X post included a year-by-year graphic of pertussis cases that omitted 2024 and 2025. The post also provided a more specific timeframe for when the infant deaths occurred — one in late 2024 and the other in early 2025.

A ‘Train Wreck’ of Cases

Louisiana should have started warning the public within days of the first infant’s death instead of waiting months, said Stanford’s Karan.

“At minimum,” he said, “it should be like heavy promotion of: ‘Hey, infants are at high risk. They get infected by people who have waning immunity. If you haven’t gotten vaccinated, get vaccinated. If you have these symptoms, get tested.’”

Deaths from a vaccine-preventable illness are tragic, but they can also serve as an opportunity to educate the public about the benefits of vaccines and try to save lives, said Joshua Sharfstein, a former Maryland health secretary and now a professor at the Johns Hopkins Bloomberg School of Public Health.

“The risk of pertussis is always there, but when you have two infant deaths it’s a really good opportunity to communicate that this is a real threat to the health of children,” Sharfstein said.

Karan said that by not acting more quickly, the Louisiana Department of Health may have set itself up for a worse outbreak.

“Because then what we see is this train wreck thereafter, of like an insanely large outbreak, a lot of hospitalizations,” he said.

The Outbreak Continued

As of Sept. 20, the most recent date for which data is available, Louisiana had counted 387 cases of whooping cough in 2025, according to the Centers for Disease Control and Prevention. In data going back to 1990, the previous high was 214 cases, in 2013.

Until the Sept. 30 post on X, the Louisiana Department of Health did not appear to put out any public communications about pertussis over the preceding four months, though hospitalizations continued and case levels surpassed the 2013 levels.

The health department should be responding aggressively and consistently, said Joseph Bocchini, the president of the Louisiana Chapter of the American Academy of Pediatrics.

Health officials should make sure “people are updated on a regular basis and reminded of what needs to be done,” he said. “Get your vaccines. Moms, if you’re pregnant, get vaccinated. And if you have a cough illness, see your doctor.”

Benjamin, with the American Public Health Association, said the ongoing goal of public health communication is to prevent the next hospitalization or death.

“The bottom line is, it’s not too late,” he said. “It’s not too late to be much more aggressive and proactive about dealing with pertussis.”

This article is from a partnership that includes WWNO, NPR, and KFF Health News.

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

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Bre Dolan, a 35-year-old resident of Hardy County, West Virginia, understands why. Throughout her childhood, when her dad had addiction and mental health crises, police officers were often the first ones to respond. Dolan calls them “good men and women” who “care about seeing their community recover.”

But she’s skeptical that they can mitigate the root causes of an addiction epidemic that has racked her home state for decades.

“Most of the busts that go down are addicts,” she said — people who need treatment, not prison.

Dolan’s father was one of them. And so was she.

Now 14 years into recovery, she’s been surprised to see many local officials spending opioid settlement money — an influx of cash from companies accused of fueling the overdose crisis — on police Tasers, cruisers, night vision gear, and more.

“How is that really tackling an issue?” Dolan said. “How will it help families battling addiction?”

Nationwide, more than $61 million in opioid settlement funds were spent on law enforcement-related efforts in 2024, according to a yearlong investigation by KFF Health News and researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction. That included initiatives that public health experts largely support, such as hiring social workers to accompany officers on overdose calls, as well as actions they’re more skeptical of, such as beefing up police arsenals.

Over nearly two decades, state and local governments are set to receive more than $50 billion in opioid settlement money, which is intended to be used to fight addiction. The settlement agreements even outlined suggested uses and established other guardrails to limit unrelated uses of the funds — as happened with the Tobacco Master Settlement Agreement of the 1990s.

But there’s still significant flexibility with these dollars, and what constitutes a good use to one person can be deemed waste by another.

To Stephen Loyd, an addiction medicine doctor who was once addicted to opioids and has served as an expert in several opioid lawsuits, some law enforcement expenses fall into that second category.

Drones and police officer salaries are not “in the spirit of what we wanted to use the money for when we were fighting for it,” Loyd said.

“People died for this money. Families were torn apart for this money. And to not spend it to try to make our system better, so that people don’t have to experience those losses going forward, to me, is unconscionable,” he said.

As part of this investigation, KFF Health News and its partners compiled the most comprehensive national database of opioid settlement spending to date, featuring more than 10,500 examples of how the money was used (or not) last year. The team filed public records requests, scoured government websites, and extracted expenditures, which were then sorted into categories, such as treatment or prevention. The findings include:

• Nearly $2.7 billion — that’s the amount states and localities spent or committed in 2024, according to public records. The lion’s share went to investments addiction experts consider crucial, including about $615 million to treatment, $279 million to overdose reversal medications and related training, and $227 million to housing-related programs for people with substance use disorders.
• Smaller, though notable, amounts funded law enforcement initiatives — such as creating a shooting range and tinting patrol car windows — and prevention programs that experts called questionable, such as putting on a fishing tournament.
• Some jurisdictions paid for basic government services, such as firefighter salaries.
• The money is controlled by different entities in each state, and about 20% of it is untrackable through public records.

This year’s database, including the expenditures and untrackable percentages, should not be compared with the one KFF Health News and its partners compiled last year, due to methodology changes and state budget quirks. The database cannot present a full picture because some jurisdictions don’t publish reports or delineate spending by year. What’s shown is a snapshot of 2024 and does not account for decisions in 2025.

Still, the database helps counteract the secrecy among some of those in charge of settlement money and confusion among those tracking it.

‘How My Population Would Like Me To Vote’

Dolan has seen intergenerational addiction up close. When her father was high, he sometimes kicked teenage Dolan out of the house with her toddler siblings. She started drinking early and progressed to other drugs, eventually landing in prison.

Although she managed to find recovery on her own, even landing a job as an EMT, she wants to make the path easier for others.

If settlement money were used to hire social workers or build family recovery programs, it could change the course of a kid’s life, she said.

“Maybe people could have helped my dad get into recovery and gave him therapy,” she said. “Anything could have happened.”

But many local officials say law enforcement is one of the few tools they have, especially in rural areas. And their constituents believe it’s effective.

“If the goal was treatment and prevention, it would have been better to throw [the money] into a big grant system and give it to treatment centers,” said Cris Meadows, city manager of Oak Hill, West Virginia, which paid more than $67,000 for a drone and surveillance cameras for its police department. “Unfortunately, local governments are really not set up to do that.”

Clarkdale, Arizona, Town Manager Susan Guthrie said her town bought nearly $15,000 worth of drones because they help with enforcement — such as recording crime scenes and conducting search-and-rescue operations — as well as education, when officers interact with kids at community events.

Similar perspectives nationwide have led to spending that includes:

• About $12,000 for rifle suppressors (also known as silencers) in Alexandria, Indiana.
• About $21,000 for Tasers in Mooresville, Indiana.
• About $49,000 to replace outdated body cameras and Tasers in Hardy County, West Virginia.
• Nearly $70,000 in Lewisburg, West Virginia, to add a police officer to the county’s drug task force, replace that officer locally, buy guns and vehicles, and tint car windows.

Several elected officials said their choices reflect local politics.

That’s “how my population would like me to vote,” Hardy County Commissioner Steven Schetrom said of his commission’s goal to spend about a quarter of its settlement money on law enforcement.

Mooresville Town Council President Tom Warthen told KFF Health News, “People have petitioned our government for less taxes but have never petitioned for less services” from the local police force. With federal and state budget cuts looming, the town must be resourceful, he said, adding that the Tasers were bought with a portion of settlement funds that have no restrictions.

After these purchases, an Indiana commission issued a list of law enforcement equipment that it cautioned against buying with restricted settlement dollars. California, Kansas, and Virginia have released similar lists.

Research backs those restrictions. Studies have shown that drug busts and arrests can exacerbate the overdose crisis. Officers responding to overdoses often arrest people, making people who use drugs fearful of calling 911 or seeking treatment through police.

In contrast, equipping police officers with overdose reversal medications has been shown to save lives. That’s a key component of an $18 million effort in Texas, the state with the highest percentage of reported law enforcement spending.

Police and Firefighter Salaries

Some places used settlement funds to maintain basic first responder services.

For example, Mantua Township, New Jersey, used about $79,000 to “offset police salary and wages” and, according to its public spending report, plans to do so annually. Township officials did not respond to requests for comment.

Los Angeles County allocated $1 million to cover a portion of firefighter salaries and benefits last year and estimates it will use another $1 million this year.

County fire department spokesperson Heidi Oliva said opioid funds were used to fill a budget gap until revenue kicked in from a new tax voters approved last November.

The use of funds was “appropriate,” she said in an email, because “the opioid crisis presents a significant burden to EMS response, from dispatch through arrival at hospitals, clinician mental health/burnout, and a variety of other factors.”

Using opioid money to replace other revenue is legal in most places. But it’s considered bad practice.

“I don’t want to see this money used to make up for stuff that would be paid for anyway,” said Daniel Busch, chair of the FED UP! Coalition, a national advocacy organization representing many parents who’ve lost children to addiction.

Settlement dollars are “the only financial representation from the governments and from the drug companies” of families’ losses, Busch said. To see that money used to maintain the status quo is “painful” and “distressing.”

Busch fears this practice will become more common as states grapple with federal budget cuts.

Already in New Jersey, lawmakers allocated $45 million in settlement funds to health systems to cushion against anticipated Medicaid losses — a move opposed by the state’s attorney general, opioid settlement advisory council, and advocates.

However, some states are taking proactive steps.

Colorado released guidance this year against such actions.

“These dollars can’t be part of budget games where we simply backfill existing programs,” state Attorney General Phil Weiser told KFF Health News. “We have to build on whatever we’re doing because it hasn’t been enough.”

Other states, such as Maine, Maryland, and Kentucky, are newly requiring local governments to report how they spend the money, which may make it easier to spot disputed practices. Officials in Delaware, Hawaii, Massachusetts, and Missouri said they expect to revamp their public reporting systems to increase transparency by early 2026.

In Mississippi, which produced no substantive public reports last year, the attorney general’s office has set up a website that will host spending information after Dec. 1.

Jennifer Twyman is anxious to see some positive changes.

“We have people literally dying on our sidewalks,” said the Louisville, Kentucky, advocate.

Twyman struggled with opioid misuse for 20 years and now works with Vocal-KY to end homelessness and the war on drugs. To her, any spending that doesn’t directly help people with addiction betrays the settlement’s purpose.

“It is the blood from many of my friends, people that I care deeply about,” she said. “That money could have been me, could have been my life.”

Read the methodology behind this project.

KFF Health News’ Henry Larweh; Shatterproof’s Kristen Pendergrass and Lillian Williams; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Samantha Harris, Isha Desai, Katibeth Blalock, Erin Wang, Olivia Allran, Connor Gunn, Justin Xu, Ruhao Pang, Jirka Taylor, and Valerie Ganetsky contributed to the database featured in this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team that worked on this report are not involved in those efforts.

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

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Advocates say the push burdens states with duplicative verification checks and could lead people to lose coverage just for missing paperwork deadlines. But the administrator of the Centers for Medicare & Medicaid Services, Mehmet Oz, said in a post on the social platform X on Oct. 31 that more than $1 billion “of federal taxpayer dollars were being spent on funding Medicaid for illegal immigrants” in five states and Washington, D.C.

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

It wasn’t clear from Oz’s statement or an accompanying video over what period the spending happened, and CMS spokespeople did not immediately respond to questions, either for an earlier version of this article or after Oz’s statement was posted.

Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, which covers low-income and disabled people, and the closely related Children’s Health Insurance Program. Those without legal status are ineligible for federally funded health coverage, including Medicaid, Medicare, and plans through the Affordable Care Act marketplaces.

Several states disputed Oz’s comments.

“Our payments for coverage of undocumented individuals are in accordance with state and federal laws,” said Marc Williams, a spokesperson for Colorado’s Department of Health Care Policy & Financing, which administers the state’s Medicaid program. “The $1.5 million number referenced by federal leaders today is based on an incorrect preliminary finding, and has been refuted with supporting data by our Department experts.”

He added: “It is disappointing that the administration is announcing this number as final when it is clearly overstated and the conversations are very much in the education and discussion phase.”

Illinois Medicaid officials blasted Oz’s comments.

“Once again, the Trump administration is spreading misinformation about standard uses of Medicaid dollars,” said Illinois Medicaid spokesperson Melissa Kula. “This is not a reality show, and there is no conspiracy to circumvent federal law and provide ineligible individuals with Medicaid coverage. Dr. Oz should stop pushing conspiracy theories and focus on improving health care for the American people.”

The Washington State Health Care Authority, which runs the state’s Medicaid program, was also blunt.

“The numbers Dr. Oz posted on social media today are inaccurate,” said spokesperson Rachelle Alongi. “We were very surprised to see Dr. Oz’s post, especially considering we continue to work with CMS in good faith to answer their questions and clear up any confusion.”

In August, CMS began sending states the names of people enrolled in Medicaid that the agency suspected might not be eligible, demanding state Medicaid agencies check their immigration status.

KFF Health News in October reached out to Medicaid agencies in 10 states. Five provided the approximate number of names they had received from the Trump administration, with expectations of more to come: Colorado had been given about 45,000 names, Ohio 61,000, Pennsylvania 34,000, Texas 28,000, and Utah 8,000. More than 70 million people are enrolled in Medicaid.

Most of those states declined to comment further. Medicaid agencies in California, Florida, Georgia, New York, and South Carolina refused to say how many names they were ordered to review or did not respond.

Oz said in his X post that California had misspent $1.3 billion on care for people not eligible for Medicaid, while Illinois spent $30 million, Oregon $5.4 million, Washington state $2.4 million, Washington, D.C., $2.1 million, and Colorado $1.5 million.

“We notified the states, and many have begun refunding the money,” he said. “But what if we had never asked?”

Washington, D.C.’s Medicaid director, Melisa Byrd, said CMS had identified administrative expenses for the district program that covers people regardless of immigration status that should not have been billed to the federal government and her agency has already fixed some of those areas. “We run a big program that is very complex and when mistakes or errors happen, we fix them,” she said.

The program plans to pay $654,014 back to CMS by mid-November.

All five states, plus Washington, D.C., are led by Democrats, and President Donald Trump didn’t win any of them in the 2024 election.

In recent days, Deputy Health and Human Services Secretary Jim O’Neill began posting pictures on X of people he said are convicted criminals living in the U.S. without authorization who had received Medicaid benefits.

O’Neill could not be reached for comment.

“We are very concerned because this seems, frankly, to be a waste of state resources and furthers the administration’s anti-immigrant agenda,” said Ben D’Avanzo, senior health advocacy strategist with the National Immigration Law Center, an advocacy group. “This duplicates what states already do,” he said.

As part of the administration’s crackdown on people in the U.S. without authorization, President Donald Trump in February directed federal agencies to take action to ensure they are not obtaining benefits in violation of federal law.

In June, advisers to Health and Human Services Secretary Robert F. Kennedy Jr. ordered CMS to share information about Medicaid enrollees with the Department of Homeland Security, drawing a lawsuit by some states alarmed that the administration would use the information for its deportation campaign against unauthorized residents.

In August, a federal judge ordered HHS to stop sharing the information with immigration authorities.

State Medicaid agencies use databases maintained by the Social Security Administration and Department of Homeland Security to verify enrollees’ immigration status.

If states need to go back to individuals to reverify their citizenship or immigration status, it could lead some to fall off the rolls unnecessarily — for example, if they don’t see a letter requesting paperwork or fail to meet a deadline to respond.

“I am not sure that evidence suggests there really is a need for this” extra verification, said Marian Jarlenski, a health policy professor at the University of Pittsburgh School of Public Health.

Oz made clear that the Trump administration disagrees.

“Whether willful or not, the states’ conduct highlights a terrifying reality: American taxpayers have been footing the bill for illegal immigrants’ Medicaid coverage, despite many Democrats and the media insisting otherwise,” Oz said in his X post.

In an August press release, CMS said it would ask states to verify eligibility for enrollees whose immigration status could not be confirmed via federal databases. “We expect states to take quick action and will monitor progress on a monthly basis,” the agency said.

Leonardo Cuello, a research professor at Georgetown University’s Center for Children and Families, called the CMS order to states “unprecedented” in the Medicaid program’s 60-year history.

He said the federal government may have been unable to verify certain individuals’ immigration status because names were misspelled or outdated, such as when a beneficiary is identified by their maiden instead of married name. The names may also include people helped by Emergency Medicaid, a program that covers the cost of hospital emergency services, including labor and delivery, for people regardless of immigration status.

“CMS is conducting pointless immigration status reviews for people whose hospital bills were paid by Emergency Medicaid,” Cuello said.

Oz noted in his post that federal law “does permit states to use Medicaid dollars for emergency treatment, regardless of patients’ citizenship or immigration status,” and that states can “legally build Medicaid programs for illegal immigrants using their own state tax dollars, so long as no federal tax dollars are used.”

The states Oz mentioned all run their own such programs.

The verification checks create an added burden for state Medicaid agencies that are already busy preparing to implement the tax and policy law Trump signed in July. The measure, which Republicans call the One Big Beautiful Bill Act, makes many changes to Medicaid, including adding a work requirement in most states starting by 2027. The law also requires most states to more frequently check the eligibility of many adult Medicaid enrollees — at least twice a year.

“I fear states may do unnecessary checks that create a burden for some enrollees who will lose health coverage who should not,” Cuello said. “It’s going to be a whole lot of work for CMS and states for very little pay dirt.”

Cuello said the effort may have “greater political value than actual value.”

Brandon Cwalina, a spokesperson for the Pennsylvania Department of Human Services, which runs Medicaid in the state, said the state already requires every Medicaid applicant to verify their citizenship or, where applicable, their eligible immigration status.

However, he said, the directive issued by CMS “constitutes a new process, and DHS is carefully reviewing the list in order to take appropriate actions.”

Oz did not name Pennsylvania, which Trump won in 2024, in his post.

If a lawful resident does not have a Social Security number, the state confirms their legal status by checking a database from Homeland Security, as well as verifying specific immigration documents, he said.

Other state Medicaid agencies said they also needed to regroup before reaching out to enrollees.

“Our teams just received this notice and are working through a process by which we will perform these reviews,” Jennifer Strohecker, then Utah’s Medicaid director, told a state advisory board in August.

Renuka Rayasam and Rae Ellen Bichell contributed reporting.

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

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Permanent changes to the Supplemental Nutrition Assistance Program are coming regardless of the outcome of at least two federal lawsuits that seek to prevent the government from cutting off November SNAP benefits. The lawsuits challenge the Trump administration’s refusal to release emergency funds to keep the program operating during the government shutdown.

A federal judge in Rhode Island ordered the government to use those funds to keep SNAP going. A Massachusetts judge in a separate lawsuit also said the government must use its food aid contingency funds to pay for SNAP, but gave the Trump administration until Nov. 3 to come up with a plan.

Amid that uncertainty, food banks across the U.S. braced for a surge in demand, with the possibility that millions of people will be cut off from the food program that helps them buy groceries.

On Oct. 28, a vanload of SpaghettiOs, tuna, and other groceries arrived at Gateway Food Pantry in Arnold, Missouri. It may be Gateway’s last shipment for a while. The food pantry south of St. Louis largely serves families with school-age children, but it has already exhausted its yearly food budget because of the surge in demand, said Executive Director Patrick McKelvey.

New Disabled South, a Georgia-based nonprofit that advocates for people with disabilities, announced that it was offering one-time payments of $100 to $250 to individuals and families who were expected to lose SNAP benefits in the 14 states it serves.

Less than 48 hours later, the nonprofit had received more than 16,000 requests totaling $3.6 million, largely from families, far more than the organization had funding for.

“It’s unreal,” co-founder Dom Kelly said.

The threat of a SNAP funding lapse is a preview of what’s to come when changes to the program that were included in the One Big Beautiful Bill Act that President Donald Trump signed in July take effect.

The domestic tax-and-spending law cuts $187 billion within the next decade from SNAP. That’s a nearly 20% decrease from current funding levels, according to the Congressional Budget Office.

The new rules shift many food and administrative costs to states, which may lead some to consider withdrawing from the program, which helped about 42 million people buy groceries last year. Separate from the new law, the administration is also pushing states to limit SNAP purchases by barring such things as candy and soda.

All that “puts us in uncharted territory for SNAP,” said Cindy Long, a former deputy undersecretary at the Department of Agriculture who is now a national adviser at the law firm Manatt, Phelps & Phillips.

The country’s first food stamps were issued at the end of the Great Depression, when the poverty-stricken population couldn’t afford farmers’ products. Today, instead of stamps, recipients use debit cards. But the program still buoys farmers and food retailers and prevents hunger during economic downturns.

The CBO estimates that about 3 million people will lose food assistance as a result of several provisions in the budget law, including applying work requirements to more people and shifting more costs to states. Trump administration leaders have backed the changes as a way to limit waste, to put more people to work, and to improve health.

This is the biggest cut to SNAP in its history, and it is coming against the backdrop of rising food prices and a fragile labor market.

The exact toll of the cuts will be difficult to measure, because the Trump administration ended an annual report that measures food insecurity.

Here are five big changes that are coming to SNAP and what they mean for Americans’ health:

1. Want food benefits? They will be harder to get.

Under the new law, people will have to file more paperwork to access SNAP benefits.

Many recipients are already required to work, volunteer, or participate in other eligible activities for 80 hours a month to get money on their benefit cards. The new law extends those requirements to previously exempted groups, including homeless people, veterans, and young people who were in foster care when they turned 18. The expanded work requirements also apply to parents with children 14 or older and adults ages 55 to 64.

Starting Nov. 1, if recipients fail to document each month that they meet the requirements, they will be limited to three months of SNAP benefits in a three-year period.

“That is draconian,” said Elaine Waxman, a senior fellow at the Urban Institute, a nonprofit research group. About 1 in 8 adults reported having lost SNAP benefits because they had problems filing their paperwork, according to a December Urban Institute survey.

Certain refugees, asylum-seekers, and other lawful immigrants are cut out of SNAP entirely under the new law.

2. States will have to chip in more money and resources.

The federal law drastically increases what each state will have to pay to keep the program.

Until now, states have needed to pay for only half the administrative costs and none of the food costs, with the rest covered by the federal government.

Under the new law, states are on the hook for 75% of the administrative costs and must cover a portion of the food costs. That amounts to an estimated median cost increase for states of more than 200%, according to a report by the Georgetown Center on Poverty and Inequality.

A KFF Health News analysis shows that a single funding shift related to the cost of food could put states on the hook for an additional $11 billion.

All states participate in the SNAP program, but they could opt out. In June, nearly two dozen Democratic governors wrote to congressional leaders warning that some states wouldn’t be able to come up with the money to continue the program.

“If states are forced to end their SNAP programs, hunger and poverty will increase, children and adults will get sicker, grocery stores in rural areas will struggle to stay open, people in agriculture and the food industry will lose jobs, and state and local economies will suffer,” the governors wrote.

3. Will the changes lead to more healthy eating?

The Trump administration, through its “Make America Healthy Again” platform, has made healthy eating a priority.

Health and Human Services Secretary Robert F. Kennedy Jr. has championed the restrictions on soda and candy purchases within the food aid program. To date, 12 states have received approval to limit what people can buy with SNAP dollars.

Federal officials previously blocked such restrictions, because they were difficult for states and stores to implement and they boost stigma around SNAP, according to a 2007 USDA report. In 2018, the first Trump administration rejected an effort from Maine to ban sugar-sweetened drinks and candy.

A store may decide that hassle isn’t worth participating in the program and drop out of it, leaving SNAP recipients fewer places to shop.

People who receive SNAP are no more likely to buy sweets or salty snacks than people who shop without the benefits, according to the USDA. Research shows that encouraging healthy food choices is more effective than regulating purchases.

When people have less money to spend on food, they often resort to cheaper, unhealthier alternatives that keep them sated longer rather than paying for more expensive food that is healthy and fresh but quick to perish.

4. How will SNAP cuts affect health?

Advocacy organizations working to end hunger in the nation say the cuts will have long-term health effects.

Research has found that kids in households with limited access to food are more likely to have a mental disorder. Similarly, food insecurity is linked to lower math and reading skills.

Working-age people with food insecurity are more likely to experience chronic disease. That long list includes high blood pressure, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

Those health issues come with costs for individuals. Low-income adults who aren’t on SNAP spend on average $1,400 more a year on health care than those who are.

About 47 million people lived in households with limited or uncertain access to food in 2023.

5. What does this mean for the nation’s food supply chain?

SNAP spending directly boosts grocery stores, their suppliers, and the transportation and farming industries. Additionally, when low-income households have help accessing food, they’re more likely to spend money on other needs, such as prescriptions or car repairs. All that means that every dollar spent through SNAP generates at least $1.50 in economic activity, according to the USDA.

A report by associations representing convenience stores, grocers, and the food industry estimated it could cost grocers $1.6 billion to comply with the new SNAP restrictions.

Advocates warn stores may pass the costs on to shoppers, or they may close.

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

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