At this decades-old psychiatric hospital on the edge of the Tennessee River, an intense storm could submerge the building in 11 feet of water, cutting off all roads around the facility, according to a sophisticated computer simulation of flood risk.

Aurora, a young woman who was committed to Peninsula as a teenager, said the hospital sits so close to the river that it felt like a moat keeping her and dozens of other patients inside. KFF Health News agreed not to publish her full name because she shared private medical history.

“My first feeling is doom,” Aurora said as she watched the simulation of the river rising around the hospital. “These are probably some of the most vulnerable people.”

Covenant Health, which runs Peninsula Hospital, said in a statement it has a “proactive and thorough approach to emergency planning” but declined to provide details or answer questions.

Peninsula is one of about 170 American hospitals, totaling nearly 30,000 patient beds from coast to coast, that face the greatest risk of significant or dangerous flooding, according to a months-long KFF Health News investigation based on data provided by Fathom, a company considered a leader in flood simulation. At many of these hospitals, flooding from heavy storms has the potential to jeopardize patient care, block access to emergency rooms, and force evacuations. Sometimes there is no other hospital nearby.

Much of this risk to hospitals is not captured by flood maps issued by the Federal Emergency Management Agency, which have served as the nation’s de facto tool for flood estimation for half a century, despite being incomplete and sometimes decades out of date. As FEMA’s maps have become divorced from the reality of a changing climate, private companies like Fathom have filled the gap with simulations of future floods. But many of their predictions are behind a paywall, leaving the public mostly reliant on free, significantly limited government maps.

“This is highly concerning,” said Caleb Dresser, who studies climate change and is both an emergency room doctor and a Harvard University assistant professor. “If you don’t have the information to know you’re at risk, then how can you triage that problem?”

The deadliest hospital flooding in modern American history occurred 20 years ago during Hurricane Katrina, when the bodies of 45 people were recovered from New Orleans’ Memorial Medical Center, including some patients whom investigators suspected were euthanized. More flooding deaths were narrowly avoided one year ago when helicopters rescued dozens of people as Hurricane Helene engulfed Unicoi County Hospital in Erwin, Tennessee.

Rebecca Harrison, a paramedic, called her children from the Unicoi roof to say goodbye.

“I was scared to death, thinking, ‘This is it,’” Harrison told CBS News, which interviewed Unicoi survivors as part of KFF Health News’ investigation. “Alarms were going off. People were screaming. It was chaos.”

The investigation — among the first to analyze nationwide hospital flood risk in an era of warming climate and worsening storms — comes as the administration of President Donald Trump has slashed federal agencies that forecast and respond to extreme weather and also dismantled FEMA programs designed to protect hospitals and other important buildings from floods.

When asked to comment, FEMA said flooding is a common, costly, and “under appreciated” disaster but made no statement specific to hospitals. Spokesperson Daniel Llargués defended the administration’s changes to FEMA by reissuing an August statement that dismissed criticism as coming from “bureaucrats who presided over decades of inefficiency.”

Alice Hill, an Obama administration climate risk expert, said the Trump administration’s dismissal of climate change and worsening floods would waste billions of dollars and endanger lives.

In 2015, Hill led the creation of the Federal Flood Risk Management Standard, which required that hospitals and other essential structures be elevated or incorporate extra flood protections to qualify for federal funding.

FEMA stopped enforcing the standard in March.

“People will die as a result of some of the choices being made today,” Hill said. “We will be less prepared than we are now. And we already were, in my estimation, poorly prepared.”

‘Flood Risk Is Everywhere’

The KFF Health News investigation identified more than 170 hospitals facing a flood risk by comparing the locations of more than 7,000 facilities to peer-reviewed flood hazard mapping provided by Fathom, a United Kingdom company that simulates flooding in spaces as small as 10 meters using laser-precision elevation measurements from the U.S. Geological Survey.

Hospitals were determined to have a significant risk if Fathom’s 100-year flood data predicted that a foot or more of water could reach a considerable portion of their buildings, excluding parking garages, or cut off road access to the hospital. A 100-year flood is an intense weather event that has roughly a 1% chance of occurring in any given year but can happen more often.

The investigation found heightened flood risks at large trauma centers, small rural hospitals, children’s hospitals, and long-term care facilities that serve older and disabled patients. At least 21 are critical access hospitals, with the next-closest hospital 25 miles away, on average.

Flooding threatens dozens of hospitals in coastal areas, including in Florida, Louisiana, Texas, and New York. Farther inland, flooding of rivers or creeks could envelop other hospitals, particularly in Appalachia and the Midwest. Even in the sun-soaked cities and arid expanses of the American West, storms have the potential to surround some hospitals with several feet of pooling water, according to Fathom’s data.

These findings are likely an undercount of hospitals at risk because the investigation overlooked pockets of potential flooding at some hospitals. It excluded facilities like stand-alone ERs, outpatient clinics, and nursing homes.

“The reality is that flood risk is everywhere. It is the most pervasive of perils,” said Oliver Wing, the chief scientific officer at Fathom, who reviewed the findings. “Just because you’ve never experienced an extreme doesn’t mean you never will.”

Dresser, the ER doctor, said even a small amount of flooding can shut down an unprepared hospital, often by interrupting its power supply, which is needed for life-sustaining equipment like ventilators and heart monitors. He said the most vulnerable hospitals would likely be in rural areas.

“A lot of rural hospitals are now closing their pediatric units, closing their psychiatry units,” Dresser said. “In a financially stressed situation, it can be hard to prioritize long-term threats, even if they are, for some institutions, potentially existential.”

Urban hospitals can face dangerous flooding, too. Fathom’s data predicts 5 to 15 feet of water around neighboring hospitals — Kadlec Regional Medical Center and Lourdes Behavioral Health — that straddle a tiny creek in Richland, Washington.

By Fathom’s estimate, a 100-year flood could cause the nearby Columbia River to spill over a levee that protects Richland, then loosely follow the creek to the hospitals. Some of the deepest flooding is estimated around Lourdes, which was built on land the U.S. Army Corps of Engineers set aside in 1961 as a “ponding and drainage easement.”

At the time, this land was supposed to be capable of storing enough water to fill at least 40 Olympic-size swimming pools, according to military documents obtained through the Freedom of Information Act. A mental health facility has occupied this spot since the 1970s.

Both Kadlec and Lourdes said in statements that they have disaster plans but did not answer questions about flooding. Tina Baumgardner, a Lourdes spokesperson, said government flood maps show the hospital is not in a 100-year flood plain.

This is not uncommon. Of the more than 170 hospitals with significant flood risk identified by KFF Health News, one-third are located in areas that FEMA has not designated as flood hazard zones.

Sometimes the difference is stark. For example, at Ochsner Choctaw General in Alabama — the only hospital for 30 miles in any direction — FEMA maps suggest a 100-year flood would overflow a nearby creek but spare the hospital. Fathom’s data predicts the same event would flood most of the hospital with 1 to 2 feet of water, including the ER and the helicopter pad.

Ochsner Health did not answer questions about flooding preparations at Choctaw General.

FEMA flood maps were launched in the ’60s as part of the National Flood Insurance Program to determine where insurance is required and building codes should include flood-proofing. According to a FEMA statement, the maps show only a “snapshot in time” and are not intended to predict where flooding will or won’t happen.

FEMA spokesperson Geoff Harbaugh said the agency intends to modernize its maps through the Future of Flood Risk Data initiative, which will enable the agency to “better project flood risk” and give Americans “the information they need to protect their lives and property.”

The program was launched by the first Trump administration in 2019 but has since received sparse public updates. Harbaugh declined to provide a detailed update or timeline for the program.

Chad Berginnis, executive director of the Association of State Floodplain Managers, said it is unknown whether FEMA is still trying to upgrade its maps under Trump, as the agency has cut off communications with outside flooding experts.

“There has been not a single bit of loosening of what I’m calling the FEMA cone of silence,” Berginnis said. “I’ve never seen anything like it.”

Floods are expected to worsen as a warming climate fuels stronger storms, drenching areas that are already flood-prone and bringing a new level of flooding to areas once considered lower risk.

The National Oceanic and Atmospheric Administration has said that 2024 was the warmest year on record — more than 2 degrees Fahrenheit higher than the 20th-century average. Scientists across the globe have estimated that each degree of global warming correlates to a 4% increase in the intensity of extreme rainfall.

“Warmer air can hold more moisture, so this leads us to experience heavier downpours,” said Kelly Van Baalen, a sea level rise expert at the nonprofit Climate Central. “A 100-year flood today could be a 10-year flood tomorrow.”

Intensifying storms raise concerns about Peninsula Hospital, which has operated for decades mere feet from the Tennessee River but has no known history of flooding.

Peninsula spokesperson Josh Cox said the river is overseen by the Tennessee Valley Authority, which uses dams to manage water levels and generate electricity. Estimates provided by the TVA suggest the dams could keep Peninsula dry even in a 500-year flood.

Fathom, however, said its flood simulation accounts for the dams and stressed that a large enough storm could drop more rain than even the TVA could control. These predictions are echoed by another flood modeling firm, First Street, which also says an intense storm could cause more than 10 feet of flooding in the area around Peninsula.

“It’s a hospital right on the banks of a major American river,” said Wing, the Fathom scientist. “It just isn’t conceivable that such a location is risk-free.”

Jack Goodwin, 75, a retired TVA employee who has lived next to Peninsula for three decades, said he was confident the dams could protect the area. But after reviewing Fathom’s predictions, Goodwin began to research flood insurance.

“Water can rise quickly and suddenly, and the destruction is tremendous,” he said. “Just because we’ve never seen it here doesn’t mean we won’t see it.”

‘All the Elements of a Real Disaster’

One year ago, as Hurricane Helene carved a deadly path across Southern Appalachia, Angel Mitchell was visiting her ailing mother at Unicoi County Hospital in the tiny town of Erwin, Tennessee.

Swollen by Helene, the nearby Nolichucky River spilled over its banks and around the hospital, which was built in a flood plain. Staff tried to bar the doors, Mitchell said, but the water got in, trapping her and others inside. The lights went out. People fled to the roof, where the roar of rushing water nearly drowned out the approach of rescue helicopters, Mitchell said.

Ultimately, 70 people from the hospital, including Mitchell and her mother, were airlifted to safety on Sept. 27, 2024. The hospital remains closed, and the company that owns it, Ballad Health, has said its reopening is uncertain.

“Why allow something — especially a hospital — to be built in an area like that?” Mitchell told CBS News. “People have to rely on these areas to get medical help, and they’re dangerous.”

Beyond Unicoi, KFF Health News identified 39 inland hospitals — including 16 in Appalachia — that Fathom predicts could flood when nearby rivers, creeks, or drainage canals overspill their banks, even in storms far less intense than Helene.

For example, in the Cumberland Mountains of southwestern Virginia, a 100-year flood is projected to cause Slate Creek to engulf Buchanan General Hospital in more than 5 feet of water.

Near the Great Lakes in Erie, Pennsylvania, LECOM Medical Center and Behavioral Health Pavilion could become flooded by a small drainage creek that is less than 50 feet from the front door of the ER.

Neither Buchanan nor LECOM responded to questions about flooding or preparations.

And in West Virginia’s capital of Charleston, where about 50,000 people live at the junction of two rivers in a wide and flat valley, a single storm could potentially flood five of the city’s six hospitals at once, along with schools, churches, fire departments, and other facilities.

“I hate to say it,” said Behrang Bidadian, a flood plain manager at the West Virginia GIS Technical Center, “but it has all the elements of a real disaster.”

At the largest hospital in Charleston, CAMC Memorial Hospital, Fathom predicts that the Kanawha River could bring as much as 5 feet of flooding to the ER. Across town, the Elk River could surround CAMC Women and Children’s Hospital, cutting off all exits.

And in the center of the city, where the overflowing rivers are predicted to merge, Thomas Orthopedic Hospital could be besieged by more than 10 feet of water on three sides.

WVU Medicine, which owns Thomas Orthopedic Hospital, did not respond to requests for comment.

CAMC spokesperson Dale Witte said the hospital system is aware of its flood risk and has prepared by elevating electrical infrastructure and acquiring flood-proofing equipment, like a deployable floodwall. CAMC also regularly revises and drills its disaster plans, Witte said, although he added that hospitals there have never been tested by a real flood.

Shanen Wright, 48, a lifelong Charleston resident who lives near CAMC Memorial, said many in the city have little worry about flooding in the face of more immediate problems, like the opioid epidemic and the decline of manufacturing and mining.

Tugboats and coal barges sail past his neighborhood as if they were cars on his street.

“It’s not to say it’s not a possibility,” he said. “I’m sure the people in Asheville and the people in Texas, where the floods took so many lives, they probably didn’t see it coming either.”

‘The Water Is Coming’

Despite wide scientific consensus that climate change fuels more dangerous weather, the Trump administration has taken the position that concerns about global warming are overblown. In a speech to the United Nations in September, Trump called climate change “the greatest con job ever perpetrated on the world.”

The Trump administration has made deep staff and funding cuts to FEMA, NOAA, and the National Weather Service. At FEMA, the cuts prompted 191 current and former employees to publish a letter in August warning that the agency is being dismantled from within.

Daniel Swain, a University of California climate scientist, said the administration’s rejection of climate change has left the nation less prepared for extreme weather, now and in the future.

“It’s akin to enforcing malpractice scientifically,” Swain said. “Imagine making a medical decision where you are not allowed to look at 20% of the patient’s vital signs or test results.”

Under Trump, FEMA has also taken actions critics say will leave the nation more vulnerable to flooding, specifically:

• FEMA disbanded the Technical Mapping Advisory Council, which had repeatedly pushed the agency to modernize its flood maps to estimate future risk and account for the impacts of climate change.
• FEMA canceled its Building Resilient Infrastructure and Communities program, which provided grants to help communities and vital buildings, including hospitals, protect themselves from floods and other natural disasters.
• And after stopping enforcement early this year, FEMA intends to rescind the Federal Flood Risk Management Standard, which was designed to harden buildings against future floods and save tax dollars in the long run.

Berginnis, of the Association of State Floodplain Managers, said the administration’s unwillingness to prepare for climate change and worsening storms would result in a dangerous and costly cycle of flooding, rebuilding, and flooding again.

“The president is saying we are closed for business when it comes to hazard mitigation,” Berginnis said. “It bugs me to no end that we have to have reminders — like people dying — to show us why it’s important to make these investments.”

FEMA did not answer specific questions about these decisions. In the statement to KFF Health News, spokesperson Llargués touted the administration’s response to flooding in Texas and New Mexico and said FEMA had provided billions of dollars to help people and communities recover and rebuild. He did not mention any FEMA funding for protecting against future floods.

Few hospitals understand this threat more than the former Coney Island Hospital in New York City, which has suffered catastrophic flooding before and has prepared for it to come again.

Superstorm Sandy in 2012 forced the hospital to evacuate hundreds of patients. When the water receded, fish and a sea turtle were found in the building.

Eleven years later, the facility reopened as Ruth Bader Ginsburg Hospital, transformed by a FEMA-funded $923 million reconstruction project that added a 4-foot floodwall and elevated patient care areas and utility infrastructure above the first floor.

It is now likely one of the most flood-proofed hospitals in the nation.

But, so far, no storm has tested the facility.

Svetlana Lipyanskaya, CEO of NYC Health+Hospitals/South Brooklyn Health, which includes the rebuilt hospital, said the question of flooding is “not an if but a when.”

“I hope it doesn’t happen in my lifetime,” she said, “but frankly, I’d be surprised. The water is coming.”

Methodology

After Hurricane Helene made landfall a year ago, a raging river flooded a rural hospital in eastern Tennessee. Patients and employees were rescued from the rooftop. Floods have hit hospitals from New York to Nebraska to Texas in recent years. We wanted to determine how many other U.S. hospitals face similar peril. Ultimately, we found more than 170 hospitals at risk.

For this analysis, we used data from Fathom, a United Kingdom-based company that specializes in flood-risk modeling across the globe. To assess the United States’ vulnerability, Fathom uses sophisticated computer simulations and detailed terrain data covering the country. It accounts for environmental factors such as climate change, soil conditions, and many rivers and creeks not mapped by other sources. Fathom’s modeling has been peer-reviewed and used by insurance companies, the World Bank, the Nature Conservancy, and government agencies in Florida, Texas, and elsewhere. The Iowa Flood Center has validated Fathom’s U.S. data.

Through a data use agreement, Fathom shared its U.S. mapping data that predicts areas with at least a 1% chance of flooding in any given year. Fathom’s data estimates the effects of three main types of flooding: coastal, fluvial (from overflowing rivers, lakes, or streams), and pluvial (rainfall that the ground can’t absorb). The data also accounts for dams, reservoirs, and other structures that defend against floods.

To identify at-risk hospitals, we used a publicly available Department of Homeland Security database containing the GPS coordinates of more than 7,000 short-term acute, critical access, rehab, and psychiatric hospitals — basically any hospital with inpatient services. (DHS under the Trump administration has discontinued public access to the database, so data for hospitals and other infrastructure is no longer widely available.)

Using GPS coordinates as the centerpoint, we created a circle with a 150-yard radius around each hospital, which in most cases captured the building plus nearby grounds and access roads. We then mapped Fathom’s flood-risk data to see where it overlapped with these circles. We started by looking for hospitals where at least 20% of the circle’s area had a predicted flood depth of at least 1 foot. That gave us an initial list of more than 320 hospitals across the U.S.

From there, we visually inspected those hospitals using mapping software and Google Maps, both satellite and street view. We trimmed our list to only the hospitals where a considerable portion of the building or all access roads were predicted to have at least a foot of flooding.

If two hospitals were mapped to the same building — for instance, a small rehab facility within a large hospital — we counted only one hospital. We also excluded hospitals recently converted to nursing homes or for other uses.

We ended up with a list of 171 hospitals across the U.S. That is most likely an undercount. Some hospitals could still face significant impact from flooding that is not deep enough or widespread enough to fit our methodology. Our analysis also does not account for how flooding farther from a hospital could affect employees or patients. And it does not assess what steps hospitals may have already taken to prepare for severe weather events.

We also ran a spatial analysis comparing Fathom’s data with flood hazard maps from the Federal Emergency Management Agency, which in many cases are incomplete or haven’t been updated in years. We found that about a third of hospitals identified as flood risks by Fathom’s data did not overlap at all with FEMA’s 100- or 500-year hazard areas.

Fathom provided guidance and feedback as we developed our analysis.

CBS News correspondent David Schechter, photojournalist Chance Horner, and producer Aparna Zalani contributed to this report.

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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As in earlier hearings concerning Robert F. Kennedy’s performance as secretary of the Department of Health and Human Services, the focus was on Sen. Bill Cassidy (R-La.), who cast the deciding vote as HELP Committee chair to confirm Kennedy early this year. Since that vote, Cassidy has repeatedly expressed skepticism about Kennedy’s leadership.

Cassidy noted that when Kennedy swore in Monarez on July 31, he extolled her “unimpeachable scientific credentials.” Less than a month later, she was fired. “What happened?” Cassidy said. “Turmoil at the top of the nation’s top public health agency is not good for the health of the American people.”

Monarez said she came into the job aligned with Kennedy’s goals of improving America’s health and was open to changing the policies and structures at the CDC. She wasn’t ready to compromise her scientific judgment, however.

“I could have kept the office, the title, but I would have lost the one thing that cannot be replaced: my integrity,” she said.

Monarez said that at an Aug. 25 meeting, Kennedy demanded she fire senior scientists and agree to approve all changes in vaccine policy put forward by the new members of the Advisory Committee on Immunization Practices. In June, Kennedy fired its members and replaced them with a smaller group that includes leading opponents of the U.S. vaccination program.

When Monarez refused both requests, she said, Kennedy told her to resign. She refused, and the White House fired her, she said.

Kennedy, in testimony this month, denied he’d made the ultimatums and said Monarez had lied. Republican senators repeated that claim at Wednesday’s hearing. Markwayne Mullin of Oklahoma said a recording of the Aug. 25 meeting contradicted Monarez’s account. But later in the hearing, Cassidy said that Mullin had retracted his statement, saying there was no such recording.

The hearing appeared to confirm reports that Kennedy intends to change the childhood vaccine schedule, moving initially against recommending a hepatitis B vaccination shortly after birth, a practice the CDC has supported for more than three decades.

The CDC recommends that children be vaccinated against 16 pathogens with about 25 shots, sprays, or oral vaccinations in their first two years of life. The vaccines protect kids against such diseases as influenza, measles, whooping cough, meningitis, diarrhea, chickenpox, cancer, and pneumonia. It’s up to states to decide which vaccinations are required for schoolchildren.

Sen. Lisa Blunt Rochester (D-Del.) noted that for decades universal vaccination of newborns for hepatitis B has reduced case rates of the disease among young people by 99%, as reported by KFF Health News. Sens. Ashley Moody (R-Fla.), Ed Markey (D-Mass.), and Cassidy (R-La.) asked about plans, first reported by KFF Health News, for ACIP to vote to recommend pushing the first dose of the hepatitis B vaccine from the hours after birth to age 4.

Cassidy, in closing the hearing, spoke gravely of the dangers of ending the hepatitis B dose for newborns. He noted that before 1991 as many as 20,000 babies would become infected with hepatitis B, often leading to liver disease and sometimes death. Today, fewer than 20 babies a year contract the virus from their mothers, he said.

“That is an accomplishment to make America healthy again, and we should stand up and salute the people that made that decision,” he said.

Asked by reporters after the hearing whether the American public should have confidence in the advisory committee if it votes to delay the hepatitis B dose for newborns, he replied, “No.”

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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KFF Health News video producer Hannah Norman spoke with Stephanie Hastings, a physician and an assistant program director at the Cambridge Health Alliance, and Malini Nijagal, an OB-GYN and a clinical professor at the University of California-San Francisco.

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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That is the age at which the Affordable Care Act declares that young adults generally must get off their family’s plan and figure out their coverage themselves.

When the ACA was voted into law in 2010, what’s known as its dependent coverage expansion was immediately effective, guaranteeing health insurance to millions of young Americans up to age 26 who would otherwise not have had coverage.

But for years, Republicans have whittled away at the infrastructure of the original ACA. Long gone is the requirement to buy insurance. Plans sold in the ACA’s online insurance marketplaces have no stringent quality standards. Costs keep rising, and eligibility requirements and subsidies are moving targets.

The erosion of the law has now created an “insurance cliff” for Americans who are turning 26 and don’t have a job that provides medical coverage.

Some, scared off by the complexity of picking a policy and by the price tags, tumble over the edge and go without insurance in a health system where the rate for an emergency room visit can be thousands, if not tens of thousands, of dollars.

Today, an estimated 15% of 26-year-olds go uninsured, which, according to a KFF analysis, is the highest rate among Americans of any age.

If they qualify, young adults can sign up for Medicaid, the federal-state program for Americans with low incomes or disabilities, in most but not all states.

Otherwise, many buy cheap subpar insurance that leaves them with insurmountable debt following a medical crisis. Others choose plans with extremely limited networks, losing access to longtime doctors and medicines.

They often find those policies online, in what has become a dizzyingly complicated system of government-regulated insurance marketplaces created by the ACA.

The marketplaces vary in quality from state to state; some are far better than others. But they generally offer few easily identifiable, affordable, and workable choices.

“The good news is that the ACA gave young people more options,” said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration.

“The bad news is the good stuff is hidden in a minefield of really bad options that’ll leave you broke if you get sick.”

(Ethan Evans)

(Maxwell Frost)

Publicly funded counselors called “navigators” or “assisters” can help insurance seekers choose a plan. But those programs vary by state, and often customers don’t realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.

In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees lose their insurance, according to the Congressional Budget Office.

Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.

In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.

Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he “didn’t make enough to justify having health insurance” and has reluctantly gone without it.

Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents’ plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.

Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother’s plan until he turned 26, he said.

Now 28, he is insured through his federal job.

“The ACA was groundbreaking legislation, including the idea that every American needs health care,” he said. “But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss.”

Why 26?

Back in 2010, the decision to make 26 the cutoff age for staying on a parent’s insurance was “kind of arbitrary,” recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.

“My kids were young , and I was trying to imagine when my child would be an adult.”

Before that time, children were often kicked off family plans at much younger ages, typically 18.

The Obama administration’s idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn’t have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.

But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.

Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.

“You’re scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?’” he recalled. “It feels like it’s nearly impossible to make a good choice in this scenario.”

(Elizabeth Mathis)

(Kayla Anderson)

Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.

More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a KFF Health News data investigation found. Few have the reserves to pay it off.

The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.

Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, “drowning” in texts and phone calls offering plans of uncertain and unregulated quality. “It never ends,” said Herne, 27.

Young Invincibles, an advocacy group representing young adults, runs its own “navigator” program to help young people choose health insurance plans.

“We hear the frustration,” said Martha Sanchez, the group’s former director of health policy and advocacy. “Twenty-six-year-olds have had negative experiences in a process that’s become really complex. Many throw up their hands.”

Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a “really scary” year after he turned 26.

“Every time he got in the car, I thought, ‘What if?’” Mathis said.

The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It’s a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.

But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.

“Technically, we gambled in the right direction,” Mathis said. “But I don’t feel like we’ve won.”

The Affordability Problem

The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.

But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, without insurance.

Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.

Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university’s insurance premiums were more than $5,000 annually.

But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.

“People tell you to think ahead, but I didn’t think that meant six months,” she said.

(Daisy Creager)

(Madeline Nelkin)

(Valeria Chávez)

When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.

She looked for a health care plan but found it hard to understand the marketplace. (She didn’t know there were navigators who could help.) Now she can’t afford her medicine or see her endocrinologist.

“I’m tired all the time,” Hughes said. “My cycles are not regular anymore at all. When I do get one, it’s debilitating.” She is hoping a new job will provide insurance later this year.

Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.

Over 30% of people ages 18 to 29 said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.

The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.

Many companies, which say they can’t afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.

Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.

In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.

As she left the first of those jobs, her husband’s endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.

After a few months, they bought a marketplace plan, but it was expensive and “didn’t cover a lot,” she said.

When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn’t start until the end of her first month of employment. The couple would be uninsured for a few weeks.

A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.

“I think I’ve done everything right,” Creager said. “So why am I in a position where the health insurance available to me doesn’t cover what I need, or I can barely afford my premiums, or worse, at times I don’t even have it?”

Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn’t schedule until after she would be off her family’s insurance plan.

Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. “There’s this impending terror of, ‘What am I going to do?’” she recalled.

(One day before she turned 26, her father’s company agreed to keep her on his plan for six more months, if he paid higher premiums.)

The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation’s authors had hoped. The “job lock” tying insurance to employment has long plagued the United States workforce.

Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.

Experts agree that the marketplaces need stronger regulation.

In 2023, the federal government defined clearer standards for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.

Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an “easy pricing” option or a “standard plan.”

Most plans on the marketplaces don’t meet these criteria. Federal and state regulators had long planned to cull such “noncompliant” plans, gradually — fearing that doing so too quickly would scare insurers away from participating.

But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it’s far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.

There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.

If the subsidies expire, premiums are likely to rise sharply for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.

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Companies don’t have to tell the FDA about those decisions, and they don’t have to list all ingredients on their product labels. Instead, companies can use broad terms such as “artificial flavors.”

In 1958, Congress mandated that before additives could be used in foods manufacturers had to prove they were safe and get FDA approval. However, Congress carved out an exception for substances “generally recognized as safe,” which came to be known simply as GRAS.

As conceived, GRAS promised regulatory relief for standard ingredients like salt, sugar, vinegar, and baking powder. Over time, “the loophole swallowed the law,” said a 2014 Natural Resources Defense Council report.

Health and Human Services Secretary Robert F. Kennedy Jr. wants to close or tighten the GRAS loophole. He has railed about the risks of food additives for years and has said he wants to end “the mass poisoning of American children.”

Whether changes come from the FDA or the food companies, it’s clear Americans are becoming more concerned about what they’re buying.

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Medicaid, the state-federal health insurance program for people with low incomes or disabilities, is integral to the U.S. health care system. It keeps hospitals and other providers afloat, provides a key source of federal funds to states, and helps provide health insurance to people who couldn’t otherwise afford it. More than 79 million people in the U.S. receive services from Medicaid or the closely related Children’s Health Insurance Program. 

KFF Health News correspondent Sam Whitehead discusses Medicaid’s history and role in the U.S. health system.

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Then Valle began to suspect water from her well was making her sick.

“Even if everything is organic, it doesn’t matter, if the water underground is not clean,” Valle said.

This year, researchers found worrisome levels of chemicals called PFAS in her well water. Exposure to PFAS, a group of thousands of compounds, has been linked to health problems including cancer, decreased response to vaccines, and low birth weight, according to a federally funded report by the National Academies of Sciences, Engineering, and Medicine. Valle worries that eating food from her farm and drinking the water, found also to contain arsenic, are to blame for health issues she’s experienced recently.

The researchers suspect the toxic chemicals could have made their way into Valle’s water through nearby agricultural operations, which may have used PFAS-laced fertilizers made from dried sludge from wastewater treatment plants, or pesticides found to contain the compounds.

The chemicals have unexpectedly turned up in well water in rural farmland far from known contamination sites, like industrial areas, airports, and military bases. Agricultural communities already face the dangers of heavy metals and nitrates contaminating their tap water. Now researchers worry that PFAS could further harm farmworkers and communities of color disproportionately. They have called for more testing.

“It seems like it’s an even more widespread problem than we realized,” said Clare Pace, a researcher at the University of California-Berkeley who is examining possible exposure from PFAS-contaminated pesticides.

Stubborn Sludge

Concerns are mounting nationwide about PFAS contamination transferred through the common practice of spreading solid waste from sewage treatment across farm fields. Officials in Maine outlawed spreading “biosolids,” as some sewage byproducts are called, on farms and other land in 2022. A study published in August found higher levels of PFAS in the blood of people in Maine who drank water from wells next to farms where biosolids were spread.

Contamination in sewage mostly comes from industrial discharges. But household sludge also contains PFAS because the chemicals are prevalent in personal care products and other commonly used items, said Sarah Alexander, executive director of the Maine Organic Farmers and Gardeners Association.

“We found that farms that were spread with sludge in the ’80s are still contaminated today,” Alexander said.

The first PFAS, or perfluoroalkyl and polyfluoroalkyl substances, were invented in the 1940s to prevent stains and sticking in household products. Today, PFAS chemicals are used in anything from cookware to cosmetics to some types of firefighting foam — ending up in landfills and wastewater treatment plants. Known as “forever chemicals” because they don’t break down in the environment, PFAS are so toxic that in water they are measured in parts per trillion, equivalent to one drop in 20 Olympic-size swimming pools. The chemicals accumulate in the human body.

On Valle’s farm, her well water has PFAS concentrations eight times as high as the safety threshold the Environmental Protection Agency set this year for the PFAS chemical referred to as PFOS, or perfluorooctane sulfonate. It’s unclear whether the new drinking water standards, which are in a five-year implementation phase, will be enforced by the incoming Trump administration.

Valle’s well is one of 20 sites tested in California’s San Joaquin Valley and Central Coast regions — 10 private domestic wells and 10 public water systems — in the first round of preliminary sampling by UC-Berkeley researchers and the Community Water Center, a clean-water nonprofit. They’re planning community meetings to discuss the findings with residents when the results are finalized. Valle’s results showed 96 parts per trillion of total PFAS in her water, including 32 ppt of PFOS — both considered potentially hazardous amounts.

Hailey Shingler, who was part of the team that conducted the water sampling, said the sites’ proximity to farmland suggests agricultural operations could be a contamination source, or that the chemicals have become ubiquitous in the environment.

The EPA requires public water systems serving at least 3,300 people to test for 29 types of PFAS. But private wells are unregulated and particularly vulnerable to contamination from groundwater because they tend to be shallower and construction quality varies, Shingler said.

A Strain on the Water Supply

California already faces a drinking water crisis that disproportionately hits farmworkers and communities of color. More than 825,000 people spanning almost 400 water systems across the state don’t have access to clean or reliable drinking water because of contamination from nitrates, heavy metals, and pesticides.

California’s Central Valley is one of the nation’s biggest agricultural producers. State data shows the EPA found PFAS contamination above the new safety threshold in public drinking water supplies in some cities there: Fresno, Lathrop, Manteca, and others.

Not long after she moved, Valle started feeling sick. Joints in her legs hurt, and there was a burning sensation. Medical tests revealed her blood had high levels of heavy metals, especially arsenic, she said. She plans to get herself tested for PFAS soon, too.

“So I stopped eating [or drinking] anything from the farm,” Valle said, “and a week later my numbers went down.”

After that, she got a water filter installed for her house, but the system doesn’t remove PFAS, so she and her family continue to drink bottled water, she said.

In recent years, the pesticide industry has increased its use of PFAS for both active and “inert” ingredients, said David Andrews, a senior scientist of the Environmental Working Group, who analyzed pesticide ingredient registrations submitted to the EPA over the past decade as part of a recently published study.

“PFAS not only endanger agricultural workers and communities,” Andrews said, “but also jeopardize downstream water sources, where pesticide runoff can contaminate drinking supplies.”

California’s most concentrated pesticide use is along the Central Coast, where Valle lives, and in the Central Valley, said Pace, whose research found that possible PFAS contamination from pesticides disproportionately affects communities of color.

“Our results indicate racial and ethnic disparities in potential PFAS threats to community water systems, thus raising environmental justice concerns,” the paper states.

Spotty Solutions

Some treatment plants and public water systems have installed filtration systems to catch PFAS, but that can cost millions or even billions of dollars. California Gov. Gavin Newsom, a Democrat, signed laws restricting PFAS in textiles, food packaging, and cosmetics, a move the wastewater treatment industry hopes will address the problem at the source.

Yet the state, like the EPA, does not regulate PFAS in the solid waste generated by sewage treatment plants, though it does require monitoring.

In the past, biosolids were routinely sent to landfills alongside being spread on land. But in 2016, California lawmakers passed a regulation that requested operators to lower their organic waste disposal by 75% by 2025 to reduce methane emissions. That squeeze pushed facilities to repurpose more of their wastewater treatment byproducts as fertilizer, compost, and soil topper on farm fields, forests, and other sites.

Greg Kester, director of renewable resource programs at the California Association of Sanitation Agencies, said there are benefits to using biosolids as fertilizer, including improved soil health, increased crop yields, reduced irrigation needs, and carbon sequestration. “We have to look at the risk of not applying [it on farmland] as well,” he said.

Almost two-thirds of the 776,000 dry metric tons of biosolids California used or disposed of last year was spread this way, most of it hauled from wealthy, populated regions like Los Angeles County and the Bay Area to the Central Valley or out of state.

When asked if California would consider banning biosolids from agricultural use, Wendy Linck, a senior engineering geologist at California’s State Water Resources Control Board, said: “I don’t think that is in the future.”

Average PFAS concentrations found in California’s sampling of biosolids for PFAS collected by wastewater treatment plants are relatively low compared with more industrialized states like Maine, said Rashi Gupta, wastewater practice director at consulting firm Carollo Engineers.

Still, according to monitoring done in 2020 and 2022, San Francisco’s two wastewater treatment facilities produced biosolid samples with total PFAS levels of more than 150 parts per billion.

Starting in 2019, the water board began testing wells — and finding high levels of PFAS — near known sites of contamination, like airports, landfills, and industry.

The agency is now testing roughly 4,000 wells statewide, including those far from known contamination sources — free of charge in disadvantaged communities, according to Dan Newton, assistant deputy director at the state water board’s division of drinking water. The effort will take about two years.

Solano County — home to large pastures about an hour northeast of San Francisco — tested soil where biosolids had been applied to its fields, most of which came from the Bay Area. In preliminary results, consultants found PFAS at every location, including places where biosolids had historically not been applied. In recent years, landowners expressed reservations about the county’s biosolids program, and in 2024 no farms participated in the practice, said Trey Strickland, manager of the environmental health services division.

“It was probably a ‘not in my backyard’ kind of thing,” Strickland said. “Spread the poop somewhere else, away from us.”

Los Angeles County, meanwhile, hauls much of its biosolids to Kern County or out of state. Green Acres, a farm near Bakersfield and owned by the city of Los Angeles, has applied as much as 80,000 dry tons of biosolids annually, fertilizing crops for animal feed like corn and wheat. Concerned about the environmental and health implications, for more than a decade Kern County fought the practice until the legal battle ended in 2017. At the time, Dean Florez, a former state senator, told the Los Angeles Times that “it’s been a David and Goliath battle from Day One.”

“We probably won’t know the effects of this for many years,” he added. “We do know one thing: If it was healthy and OK, L.A. would do it in L.A. County.”

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