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.

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Separated from her adult children and grieving her husband’s death in the war, she started a job packing boxes in a warehouse, making just enough to cover rent for her own apartment and bills.

Antoinette has been relying on the Supplemental Nutrition Assistance Program, formerly known as food stamps, for her weekly grocery trips.

But now, just as life is starting to stabilize, she will have to deal with a new setback.

President Donald Trump’s massive budget law, which Republicans call the One Big Beautiful Bill Act, slashes $187 billion — or nearly 20% — from the federal budget for SNAP through 2034. And separate from any temporary SNAP stoppages due to the federal shutdown, the law cuts off access completely for refugees and other immigrant groups in the country lawfully. The change was slated to take effect immediately when the law was signed in July, but states are still awaiting federal guidance on when to stop or phase it out.

For Antoinette, 51, who did not want her last name used for fear of deportation and likely persecution in her native country, the loss of food aid is dire.

“I would not have the means to buy food,” she said in French through a translator. “How am I going to manage?”

Throughout its history, the U.S. has admitted into the country refugees like Antoinette, people who have been persecuted, or fear persecution, in their homelands due to race, religion, nationality, political opinions, or membership in a particular social group. These legal immigrants typically face an in-depth vetting process that can start years before they set foot on U.S. soil.

Once they arrive — often with little or no means — the federal government provides resources such as financial assistance, Medicaid, and SNAP, outreach that has typically garnered bipartisan support. Now the Trump administration has pulled back the country’s decades-long support for refugee communities.

The budget law, which funds several of the president’s priorities, including tax cuts to wealthy Americans and border security, revokes refugees’ access to Medicaid, the state-federal health insurance program for people with low incomes or disabilities, starting in October 2026.

But one of the first provisions to take effect under the law removes SNAP eligibility for most refugees, asylum seekers, trafficking and domestic violence victims, and other legal immigrants. About 90,000 people will lose SNAP in an average month as a result of the new restrictions narrowing which noncitizens can access the program, according to the Congressional Budget Office.

“It doesn’t get much more basic than food,” said Matthew Soerens, vice president of advocacy and policy at World Relief, a Christian humanitarian organization that supports U.S. refugees.

“Our government invited these people to rebuild their lives in this country with minimum support,” Soerens said. “Taking food away from them is wrong.”

Not Just a Handout

The White House and officials at the United States Department of Agriculture did not respond to emails about support for the provision that ends SNAP for refugees in the One Big Beautiful Bill Act.

But Steven Camarota, director of research for the Center for Immigration Studies, which advocates for reduced levels of immigration to the U.S., said cuts to SNAP eligibility are reasonable because foreign-born people and their young children disproportionately use public benefits.

Still, Camarota said, the refugee population is different from other immigrant groups. “I don’t know that this would be the population I would start with,” Camarota said. “It’s a relatively small population of people that we generally accept have a lot of need.”

Federal, state, and local spending on refugees and asylum seekers, including food, health care, education, and other expenses, totaled $457.2 billion from 2005 to 2019, according to a February 2024 report from the Department of Health and Human Services. During that time, 21% of refugees and asylum seekers received SNAP benefits, compared with 15% of all U.S. residents.

In addition to the budget law’s SNAP changes, financial assistance given to people entering the U.S. by the Office of Refugee Resettlement, a part of HHS, has been cut from one year to four months.

The HHS report also found that despite the initial costs of caring for refugees and asylees, this community contributed $123.8 billion more to federal, state, and local governments through taxes than they received in public benefits over the 15 years.

It’s in the country’s best interest to continue to support them, said Krish O’Mara Vignarajah, president and CEO of Global Refuge, a nonprofit refugee resettlement agency.

“This is not what we should think about as a handout,” she said. “We know that when we support them initially, they go on to not just survive but thrive.”

Food Is Medicine

Food insecurity can have lifelong physical and mental health consequences for people who have already faced years of instability before coming to the U.S., said Andrew Kim, co-founder of Ethnē Health, a community health clinic in Clarkston, an Atlanta suburb that is home to thousands of refugees.

Noncitizens affected by the new law would have received, on average, $210 a month within the next decade, according to the CBO. Without SNAP funds, many refugees and their families might skip meals and switch to lower-quality, inexpensive options, leading to chronic health concerns such as obesity and insulin resistance, and potentially worsening already serious mental health conditions, he said.

After her husband was killed in the Democratic Republic of Congo, Antoinette said, she became separated from all seven of her children. The youngest is 19. She still isn’t sure where they are. She misses them but is determined to build a new life for herself. For her, resources like SNAP are critical.

From the conference room of New American Pathways, the nonprofit that helped her enroll in benefits, Antoinette stared straight ahead, stone-faced, when asked about how the cuts would affect her.

Will she shop less? Will she eat fewer fruits and vegetables, and less meat? Will she skip meals?

“Oui,” she replied to each question, using the French for “yes.”

Since arriving in the U.S. last year from Ethiopia with his wife and two teen daughters, Lukas, 61, has been addressing diabetes-related complications, such as blurry vision, headaches, and trouble sleeping. SNAP benefits allow him and his family to afford fresh vegetables like spinach and broccoli, according to Lilly Tenaw, the nurse practitioner who treats Lukas and helped translate his interview.

His blood sugar is now at a safer level, he said proudly after a class at Mosaic Health Center, a community clinic in Clarkston, where he learned to make lentil soup and balance his diet.

“The assistance gives us hope and encourages us to see life in a positive way,” he said in Amharic through a translator. Lukas wanted to use only his family name because he had been jailed and faced persecution in Ethiopia, and now worries about jeopardizing his ability to get permanent residency in the U.S.

Hunger and poor nutrition can lower productivity and make it hard for people to find and keep jobs, said Valerie Lacarte, a senior policy analyst at the Migration Policy Institute.

“It could affect the labor market,” she said. “It’s bleak.”

More SNAP Cuts To Come

While the Trump administration ended SNAP for refugees effective immediately, the change has created uncertainty for those who provide assistance.

State officials in Texas and California, which receive the most refugees among states, and in Georgia told KFF Health News that the USDA, which runs the program, has yet to issue guidance on whether they should stop providing SNAP on a specific date or phase it out.

And it’s not just refugees who are affected.

Nearly 42 million people receive SNAP benefits, according to the USDA. The nonpartisan Congressional Budget Office estimates that, within the next decade, more than 3 million people will lose monthly food dollars because of planned changes — such as an extension of work requirements to more people and a shift in costs from the federal government to the states.

In September, the administration ended a key report that regularly measured food insecurity among all U.S. households, making it harder to assess the toll of the SNAP cuts.

The USDA also posted on its website that no benefits would be issued for anyone starting Nov. 1 because of the federal shutdown, blaming Senate Democrats. The Trump administration has refused to release emergency funding — as past administrations have done during shutdowns — so that states can continue issuing benefits while congressional leaders work out a budget deal. A coalition of attorneys general and governors from 25 states and the District of Columbia filed a lawsuit on Oct. 28 contesting the administration’s decision.

Cuts to SNAP will ripple through local grocery stores and farms, stretching the resources of charity organizations and local governments, said Ted Terry, a DeKalb County commissioner and former mayor of Clarkston.

“It’s just the whole ecosystem that has been in place for 40 years completely being disrupted,” he said.

Muzhda Oriakhil, senior community engagement manager at Friends of Refugees, an Atlanta-area nonprofit that helps refugees resettle, said her group and others are scrambling to provide temporary food assistance for refugee families. But charity organizations, food banks, and other nonprofit groups cannot make up for the loss of billions of federal dollars that help families pay for food.

“A lot of families, they may starve,” she said.

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But while the result seemed foretold, the debate was far from unanimous.

The Advisory Committee on Immunization Practices, or ACIP, met at a satellite campus of the Centers for Disease Control and Prevention because the agency’s headquarters were still smashed up from a deadly gun attack last month by a man who said the covid vaccine had made him depressed and suicidal.

Health and Human Services Secretary Robert F. Kennedy Jr. has made it clear he wants the panel to change the CDC’s childhood immunization schedule, which establishes, sometimes with legal authority, which vaccines are to be mandated, paid for, and administered by states, insurers, and doctors across the country.

Kennedy fired the 17-member panel in June and has so far restocked it with 12 people, including outspoken critics of vaccination. On Sept. 18, the new panel’s discussions reflected its thin expertise and ignorance of how the vaccination schedule came to be. Scientific questions answered decades ago were asked as if they were brand-new.

“We are rookies,” said biostatistician Martin Kulldorff, the committee’s chair, noting many “technical issues that we might not grasp as of yet.”

Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, watched the telecast anxiously.

“It reminds me when as children we would have a mock United Nations meeting,” he said. “This would be like that, except we would have actually made decisions for the United Nations.”

Kennedy’s CDC accomplished what 30 years of public health attempts to fight anti-vaccine sentiment hadn’t: a head-to-head comparison of evidence and arguments. But while the winner was clear in the eyes of most experts, some doubted the result would be good.

“The whole purpose of the people on this committee is to circulate these old recycled anti-vax talking points,” said Sean O’Leary, a professor of pediatrics at the University of Colorado who previously was a liaison from the American Academy of Pediatrics to ACIP. On Friday morning, he said, a colleague had a mother in his practice who refused the measles, mumps, and rubella vaccine “because she heard something bad in the news about it last night.”

Until now, public health owned places like ACIP, while vaccine foes and skeptics dominated social media. At this meeting, the skeptics had moved onto public health’s turf — where sometimes flimsy arguments and expertise were exposed.

Pharmacist Hillary Blackburn, for example, asked why children needed two measles, mumps, and rubella shots. ACIP began recommending a second shot in 1989 during a deadly measles outbreak. The two-shot regimen provided more than 95% immunity and led to the virtual elimination of measles from the United States. This year under the Trump administration more than 1,400 cases have been reported, mostly in unvaccinated people.

In one noteworthy gaffe, ACIP member Retsef Levi, a Massachusetts Institute of Technology operations management professor, misinterpreted data from a graph showing declines in hepatitis B in the United States since the 1980s. While rates had fallen in older groups, Levi said, cases in babies hadn’t declined substantially since 2005, when he inaccurately said a birth dose was first recommended.

“Where’s the argument to vaccinate even younger children at all,” he said. “Where is the benefit?”

In fact, the recommendation for a newborn shot began in 1991 and was reinforced and expanded in 2005. The first generation of hepatitis B-vaccinated babies are well into their 30s now.

“As time goes on,” CDC scientist Adam Langer patiently explained, “the people who benefited from the change in policy at the very beginning of the policy are moving into different age groups.”

Kulldorff, Levi, and committee member Evelyn Griffin, a gynecologist, also suggested that vaccines shouldn’t be recommended unless they are tested in placebo trials, which would require certain children not to be vaccinated — a practice considered unethical.

Kulldorff began the meeting defiantly. He did not mention the CDC shooting, but disparaged former agency officials Kennedy had forced out and challenged nine former CDC directors to a debate.

He also asked if anyone in the audience would eat a hot dog laced with thimerosal, the mercury-containing preservative the committee banned from influenza vaccines at its last meeting. (No one has ever offered thimerosal as a condiment, but years of study showed the minuscule amounts in vaccines did no harm).

At the June meeting, HHS censored a CDC appraisal of thimerosal while inviting an anti-vaccine activist to present an error-filled criticism of the substance. But on Sept. 18 the panel got what looked like straight science from CDC professionals.

As the committee prepared to debate ending a 34-year-old ACIP recommendation for babies to get a dose of the hepatitis B vaccine at birth, CDC career scientists Langer and John Su presented evidence of the vaccine’s safety and benefits.

Langer also laid out the history of the fight against hepatitis B — including the failed effort to control the disease by vaccinating people most at risk, including people who use drugs, sex workers, and pregnant women who tested positive for the virus. Years of trial and error showed that in the U.S., at least, it was necessary to vaccinate newborns to really knock down the disease.

Levi, who frequently mentions the vaccination status of his own six children, challenged the idea that a healthy baby from a “normal” household — one with no history of drug use or prostitution — needed the vaccine.

Cody Meissner, one of three panel members who put up a spirited defense of the status quo in the hepatitis debate, noted that when it comes to vaccination campaigns, “the more we try and define a target group to vaccinate, the less successful we are.” Meissner, a Dartmouth College professor, has published studies of vaccines and the diseases they fight since the 1970s.

Long-observed tropes of vaccine skepticism were abundant on the first day of the meeting. Levi praised a 2004 study from Guinea-Bissau, an outlier that suggested that babies, especially females, were more likely to die if they got a hepatitis B shot. Other panelists said the study, performed in a poor country with high infant mortality where children got an outdated vaccine, wasn’t relevant. But more studies were needed in general, Levi said. “We sit here with very lousy evidence,” he said.

Nurse Vicky Pebsworth of the National Vaccine Information Center, which opposes all vaccine mandates, frequently brought her own selective research into the meeting. She read off the names of studies other panelists hadn’t received to back her arguments that vaccines under discussion were not safe.

But while “too many, too soon” is a common anti-vaccine refrain, Judith Shlay from the National Association of County and City Health Officials, which had a nonvoting chair at the meeting, used it to support the current schedule. She pointed out that the panel’s debate over a combination measles, mumps, rubella, and varicella shot for children would result in a separate shot for the virus that causes chickenpox, adding to the number of inoculations on the childhood schedule.

“Some parents want to have fewer injections,” she said.

With an 8-3 vote at the end of the day, the committee nonetheless recommended separate vaccinations for MMR and chickenpox.

Everyone seemed puzzled about what had transpired with an ensuing vote on whether the Vaccines for Children Program, which pays for more than half of childhood vaccinations, should respond to ACIP’s new recommendation. The panel revoted on the issue on Sept. 19.

Nor could anyone provide a clear answer as to what prompted the committee’s discussion and planned vote on the birth dose of hepatitis B vaccine, since there was no new evidence suggesting any harm from it.

Two of Kennedy’s senior aides, both vaccine skeptics, pushed the hepatitis B discussion onto the ACIP schedule, according to testimony at a Sept. 17 Senate hearing by former CDC chief medical officer Debra Houry, who resigned to protest administration policies.

ACIP member Robert Malone, who has claimed that mRNA vaccines are dangerous, said hepatitis B was on the agenda because it is given to newborns at birth and of special concern to parents newly awakened to vaccine doubt. He appeared to nod off during a CDC staff presentation on the safety of the hepatitis B shot.

Vaccination of babies has always triggered parents. The 19th-century poet Alexander Hope Hume described evil vaccinators who turned “the rosy darling” who “crows with glee” into “a wailing infant” whose every vein “ferments with poison.”

The agenda item was not really about the merit of the hepatitis B vaccine, Malone acknowledged.

“The signal that is prompting this is not one of safety; it’s one of trust,” he said.

But in the end, the committee reconsidered what would have been its first drastic move to reverse a successful U.S. vaccination campaign. It postponed its vote on the hepatitis B birth dose.

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“We’re going to take care of the sickest patients first,” Margo, a family medicine physician, said.

It’s not like there was space on that June afternoon anyway. A small monitor on the wall pulsed with the vitals of current patients, who filled the ER. An ambulance idled outside in the South Texas heat with a patient waiting for a bed to open up.

“Everybody shows up here,” Margo said. “When you’re overwhelmed and you’re overrun, there’s only so much you can do.”

Starr County, a largely rural, Hispanic community on the southern U.S. border, made headlines in 2024 when it voted Republican in a presidential election for the first time in more than a century. Immigration and the economy drove the flip in this community, where roughly a third of the population falls below the poverty line.

Now, recent actions by the Trump administration and the GOP-controlled Congress have triggered a new concern: the inability of doctors, hospitals, and other health providers to continue to care for uninsured patients. It’s a fear not only in Starr County, which has one of the highest uninsured rates in the nation. Communities across the U.S. with similarly high proportions of uninsured people could struggle as additional residents lose health coverage.

About 14 million fewer Americans are expected to have health insurance in a decade due to President Donald Trump’s new tax-and-spending law, which Republicans dubbed the One Big Beautiful Bill Act, and the pending expiration of enhanced subsidies that slashed the price of Affordable Care Act plans for millions of people. The new law also limits programs that send billions of dollars to help those who care for uninsured people stay afloat.

“You can’t disinsure this many people and not have, in many communities, just a collapse of the health care system,” said Sara Rosenbaum, founding chair of the Department of Health Policy and Management at George Washington University’s Milken Institute School of Public Health.

“The future is South Texas,” she said.

KFF Health News is examining the impact of national health care policy changes on uninsured people and their communities. Though the Trump administration told KFF Health News it is making “a historic investment in rural health care,” people who treat low-income patients, as well as researchers and consumer advocates, say recent policy decisions will make it harder for people to stay healthy. Doctors, hospitals, and clinics that make up the health care safety net could lose so much money they must close their doors, some of them warn.

“Because the patient’s bill is not going to get paid,” said Joseph Alpert, editor-in-chief of The American Journal of Medicine and a professor of medicine at the University of Arizona. “Uninsured patients stress the health care system.”

Starr County shows how this dynamic unfolds.

Primary care doctors in the county serve an average of just under 3,900 people each, nearly three times the U.S. average.

Margo, the family physician, said because so many people lack insurance and there are so few places to seek care, many residents treat the ER as their first stop when they’re sick.

In many cases, they have neglected their health, making them sicker and more expensive to treat. And federal law requires ERs at hospitals in the Medicare program to stabilize or transfer patients, regardless of their ability to pay.

That leaves Margo and his team to practice what he described as “disaster medicine.”

“They come in with chest pain or they stop breathing. They collapse. They’ve never seen a doctor,” Margo said. “They’re literally dying.”

Health Systems in ‘Survival Mode’

When people are uninsured or on Medicaid, they tend to rely on a safety net of doctors, hospitals, clinics, and community health centers, which offer services free of charge or absorb getting reimbursed at lower rates than they do treating patients on commercial insurance.

Those providers’ financial situations can often be precarious, leading them to rely on myriad federal supports. The Trump administration’s cuts to health care and Medicaid in the name of eliminating “waste, fraud, and abuse” have many concerned they won’t weather the additional financial strain.

Trump’s new law funds his priorities, like extending tax cuts that mainly benefit wealthier Americans and expanding immigration enforcement. Those costs are covered in part by a nearly $1 trillion reduction in federal health spending for Medicaid within the next decade and changes to the ACA, such as requiring additional paperwork and shortening the time for people to sign up.

Many Republicans have argued Medicaid has gotten too large and strayed from the state-federal program’s core mission of covering those with low incomes and disabilities. And the GOP has fought to roll back the ACA since its passage.

Kush Desai, a spokesperson for the White House, said projections from the nonpartisan Congressional Budget Office about how many people could lose health insurance are an “overestimate.” He did not provide an estimate the administration sees as more accurate.

Supporters of the “One Big Beautiful Bill” say those who need health coverage can still get it if they meet new requirements such as working in exchange for Medicaid coverage.

And Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said even with the legislation, Medicaid spending will grow, just not as quickly.

The budget law won’t cause “the sky to fall,” Cannon said. “The inefficient providers should be shutting down.”

A recent survey from AMGA, formerly the American Medical Group Association, which represents health systems across the country, found nearly half of rural facilities could close or restructure due to Medicaid cuts. Nearly three-quarters of respondents said they anticipated layoffs or furloughs, including of front-line clinicians.

Public health departments, which often fill gaps in care, also face federal funding cuts that have reduced their capacity. In South Texas’ Cameron County, the health department has eliminated nearly a dozen positions, said agency head Esmer Guajardo. In neighboring Hidalgo County, the health department has laid off more than 30 people, said Ivan Melendez, who helps oversee its operations.

In July, the Texas Department of State Health Services canceled Operation Border Health, a massive annual event that last year provided free health services to nearly 6,000 South Texas residents.

Gateway Community Health Center in Laredo, a border city north of the Rio Grande Valley, is in “survival mode,” with about a third of patients already lacking insurance and even more who will struggle to afford health care if the ACA subsides aren’t renewed, said David Vasquez, its director of communications and public affairs. The center is looking for other forms of funding to avoid layoffs or cuts to services, and its expansion and hiring plans are on hold, Vasquez said.

That downsizing is happening as more people lose health insurance and need free or reduced-cost care.

Esther Rodriguez, 39, of McAllen has been out of work for two years and her husband makes $600 a week working in construction. Neither of them has health insurance.

Medicaid covered the bills for the births of her five children. Now, she depends on a mobile health clinic run by a local medical school, where she can pay out-of-pocket for routine checkups and drugs to control her Type 2 diabetes. If she needed more care, Rodriguez said, she would go to the ER.

“You have to adapt,” she said in Spanish.

‘Death by a Thousand Cuts’

People’s inability to pay results in uncompensated care, or services that hospitals, doctors, and clinics don’t get paid for, which, under an earlier version of the megabill, was projected to increase by $204 billion over the next decade, according to the Urban Institute, a nonprofit think tank.

But the Trump administration is also cutting other support that helped offset the cost of care for people who can’t pay. The new law caps federal programs that many health providers for low-income people have come to depend on, especially in rural areas, to shore up their budgets. These include taxes on hospitals, health plans, and other providers that states use to help fund their Medicaid programs. Such provider taxes are a “financial gimmick,” Desai said.

While the law creates a temporary $50 billion fund to support rural doctors and hospitals, that’s a little over a third of estimated Medicaid funding losses in rural areas, according to KFF, a health information nonprofit that includes KFF Health News. Desai called the analysis “flawed.”

Any loss in revenue could spell financial ruin, especially for small rural hospitals, said Quang Ngo, president of the Texas Organization of Rural & Community Hospitals Foundation.

“It’s kind of like death by a thousand cuts,” he said. “Some will probably not make it.”

And the hits could keep coming. The Trump administration’s budget request for the coming fiscal year calls for cuts to multiple rural health programs operated through the Health Resources and Services Administration. Desai said the spending law’s investment in rural health “dwarfs” the cuts.

In February, the Trump administration announced funding cuts of 90% to the ACA navigator program, which helps people find health insurance. That program has been “historically inefficient,” Desai said.

In December 2023, nearly 3 million of Texas’ uninsured were eligible for ACA subsidies, Medicaid, or the Children’s Health Insurance Program, according to Texas 2036, a public policy think tank.

Maria Salgado spends her workdays tabling at community events, dropping off flyers at doctors’ offices, and holding one-on-one meetings with clients of MHP Salud, a nonprofit that connects residents to Medicaid and ACA coverage.

She worried funding cuts would really set the organization’s efforts back: “A lot of community members here, they’re going to be left behind,” said Salgado, a community health worker, or promotora.

Chris Casso, a primary care physician who grew up in McAllen and now practices there, held back tears as she described treating patients who have put off seeing a doctor because of an inability to pay, only to have their preventable conditions deteriorate.

She worries about the future of her community as physician shortages worsen, potentially leaving few providers to treat uninsured people.

“It’s heartbreaking,” she said, sitting in a small back room in her office in a suburban strip mall, wedged between a Kohl’s and a Shoe Carnival. “These are hardworking people,” she said. “They try their best to take care of themselves.”

Casso said her own sister, who worked as a medical biller in a physician’s office, couldn’t afford health insurance. She delayed care and died at age 45 of complications from diabetes and heart disease. Casso worries the future will find more people in similar situations.

“Our population is going to suffer,” she said. “It’s going to be devastating.”

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“Vamos a atender primero a los pacientes más graves”, dijo Margo, que es médica de familia.

De todas formas, esa tarde de junio no quedaba espacio disponible. Un pequeño monitor en la pared mostraba los signos vitales de los pacientes que ya llenaban la sala de emergencias. Y afuera, bajo el calor del sur de Texas, una ambulancia esperaba a que se liberara una cama para el paciente que había traído.

“Aquí viene todo el mundo”, dijo Margo. “Pero cuando estás abrumado y sobrepasado, hay un límite a lo que puedes hacer”.

El condado de Starr, una comunidad rural y mayoritariamente hispana en la frontera sur de Estados Unidos, fue noticia en 2024 al votar, por primera vez en más de un siglo, por un candidato republicano en una elección presidencial.

La inmigración y la economía fueron los temas que impulsaron el cambio político en esta comunidad, donde aproximadamente un tercio de la población vive bajo la línea de la pobreza.

Ahora, las medidas que adoptaron recientemente la administración Trump y el Congreso controlado por el Partido Republicano han despertado una nueva preocupación: la creciente dificultad para que médicos, hospitales y otros proveedores de salud puedan seguir atendiendo a personas sin seguro médico.

Este es un temor que va más allá del condado de Starr, una localidad que tiene una de las tasas más altas de población sin seguro del país. Comunidades de todo Estados Unidos que tienen números similares de personas sin seguro podrían verse en serios problemas a medida que más residentes pierden su cobertura médica.

Se calcula que, en 10 años, 14 millones de personas se quedarán sin seguro médico en Estados Unidos como consecuencia de la ley fiscal y de presupuesto del presidente Donald Trump, a la que los republicanos llaman One Big Beautiful Bill Act.

A esto se agrega la eliminación de los subsidios extraordinarios que redujeron el costo de los planes a partir de la Ley de Cuidado de Salud a Bajo Precio (ACA).

La nueva ley también limita programas que otorgan miles de millones de dólares a los hospitales y clínicas que atienden a personas sin seguro, lo que complica aún más su supervivencia.

“No se puede dejar sin cobertura a tanta gente sin que, en muchas comunidades, el sistema de salud colapse”, afirmó Sara Rosenbaum, presidenta y fundadora del Department of Health Policy and Management de la George Washington University’s Milken Institute School of Public Health.

“El futuro es el sur de Texas”, pronosticó.

KFF Health News está examinando el impacto de los cambios en la política nacional de salud en las personas sin seguro y sus comunidades.

Aunque la administración Trump respondió a KFF Health News que está haciendo “una inversión histórica en la atención médica rural”, quienes tratan a pacientes de bajos ingresos, así como investigadores y defensores de los consumidores, aseguran que las recientes decisiones políticas harán más difícil que las personas permanezcan saludables.

Algunos médicos, hospitales y clínicas que conforman la red de seguridad sanitaria han advertido que podrían perder tanto dinero que se verían obligados a cerrar.

“Porque la factura del paciente no se va a pagar”, dijo Joseph Alpert, editor en jefe de The American Journal of Medicine y profesor de Medicina en la Universidad de Arizona. “Los pacientes sin seguro saturan el sistema de salud”, añadió.

El condado de Starr es un ejemplo de esta situación.

Los médicos de atención primaria del condado reciben algo menos de 3.900 personas cada uno, casi tres veces el promedio nacional.

Margo, la médica de familia, explicó que como hay tantas personas sin seguro y son tan pocos los lugares donde los atienden, cuando se sienten mal muchas van directamente a la sala de emergencias.

Además, muchos de esos pacientes han descuidado su salud y por eso llegan más enfermos y necesitan tratamientos más costosos. La ley federal exige que las salas de emergencia de los hospitales que participan en Medicare atiendan o transfieran a los pacientes, sin tomar en cuenta si pueden pagar o no.

Esto obliga a Margo y a su equipo a practicar lo que describió como “medicina de desastre”.

“Llegan con dolor en el pecho o no pueden respirar. Se desmayan. Nunca han visto a un médico”, dijo. “Están literalmente muriendo”.

Sistemas de salud en “modo de supervivencia”

Cuando alguien no tiene seguro o depende de Medicaid, suele recurrir a una red de seguridad sanitaria: médicos, hospitales, clínicas y centros comunitarios que ofrecen servicios gratuitos o reciben reembolsos muy bajos si se los compara con los seguros comerciales.

Estas instituciones muchas veces funcionan con un financiamiento muy precario y dependen de innumerables ayudas federales. Los recortes impulsados por la administración Trump, con el argumento de eliminar el “desperdicio, fraude y abuso”, generaron dudas respecto de si estos proveedores podrán soportar todavía mayor presión financiera.

La nueva ley de Trump financia las prioridades del gobierno. Entre ellas están la ampliación de los recortes fiscales que benefician principalmente a los estadounidenses de mayores ingresos y el refuerzo de los controles a los inmigrantes.

Esos costos se cubren en parte con una reducción de casi $1.000 millones en el gasto federal en salud para Medicaid durante la próxima década. Y, también, con cambios en los mercados de seguros establecidos por ACA, como la exigencia de trámites adicionales y la reducción de los plazos para inscribirse.

Muchos republicanos argumentan que Medicaid ha crecido demasiado y se ha desviado de su misión original de cubrir a personas de bajos recursos y con discapacidades. El Partido Republicano ha tratado de revertir ACA desde que se aprobó.

Kush Desai, vocero de la Casa Blanca, dijo que las proyecciones sobre cuántas personas podrían perder el seguro médico de la no partidista Congressional Budget Office son “exageradas”. No ofreció una cifra que la administración considere más precisa.

Los que apoyan la One Big Beautiful Bill aseguran que quienes necesitan cobertura médica pueden obtenerla si cumplen con los nuevos requisitos, como trabajar para recibir Medicaid.

Michael Cannon, director de estudios de políticas de salud del Cato Institute, un centro de pensamiento libertario, sostuvo que incluso con esta ley el gasto en Medicaid seguirá creciendo, aunque más lentamente.

“Los proveedores ineficientes deberían cerrar”, dijo Cannon. “La ley no provocará un colapso”, aseguró.

Una encuesta reciente de la AMGA, una asociación que representa a los sistemas de salud de todo el país y antes era conocida como American Medical Group Association, reveló que casi la mitad de los centros de salud rurales podrían cerrar o reestructurarse por los recortes de Medicaid.

Casi tres cuartas partes de los encuestados afirmaron que preveían despidos o licencias, incluso de profesionales de salud de primera línea.

Los departamentos de salud pública, que a menudo cubren las carencias en la atención médica, también se enfrentan a recortes en el financiamiento federal que redujeron su capacidad operativa.

En el condado de Cameron, al sur de Texas, el Departamento de Salud ha eliminado casi una docena de puestos, según afirmó su directora, Esmer Guajardo.

En el condado vecino de Hidalgo han despedido a más de 30 empleados, según Iván Meléndez, que colabora en la supervisión de la administración.

En julio, el Departamento de Servicios de Salud de Texas canceló  Operation Border Health, un multitudinario evento anual que el año anterior había brindado servicios de salud gratuitos a casi 6.000 residentes en el sur de Texas.

El Gateway Community Health Center, un centro de salud comunitario de Laredo, una ciudad fronteriza al norte del Valle del Río Grande, está en “modo de supervivencia”, según David Vásquez, su director de comunicaciones.

Aproximadamente un tercio de sus pacientes ya no tienen seguro médico, y muchos más tendrán dificultades para pagar la atención sanitaria si no se renuevan las subvenciones de ACA.

El centro está buscando otras formas de financiamiento para evitar despidos o recortes en los servicios, y ha suspendido todos los planes de expansión y contratación, agregó Vásquez.

Este achicamiento ocurre justo cuando más personas pierden su seguro y necesitan atención médica gratuita o a bajo costo.

Esther Rodríguez, de 39 años, residente de McAllen, lleva dos años sin empleo y su esposo gana $600 por semana trabajando en la construcción. Ninguno de los dos tiene seguro médico.

Medicaid cubrió los gastos del parto de sus cinco hijos. Ahora depende de una clínica móvil gestionada por una facultad de medicina local, donde debe pagar de su bolsillo las revisiones rutinarias y los medicamentos para controlar su diabetes tipo 2. Si necesitara más atención, dijo Rodríguez, iría a una sala de emergencias.

“Hay que saber adaptarse”, dijo.

Muerte por mil recortes

Que muchas personas no estén en condiciones de pagar genera una atención médica no remunerada, es decir, servicios por los que los hospitales, los médicos y las clínicas no reciben ningún pago. Estaba previsto, según una versión anterior del megaproyecto de ley, que esto aumentara en $204.000 millones durante la próxima década. La estimación es del Urban Institute, un grupo de expertos sin fines de lucro.

Pero la administración Trump también está recortando otras formas de ayuda que contribuían a compensar el costo de la atención médica de las personas que no pueden pagarla.

La nueva ley impone límites a programas federales que muchos prestadores de salud para personas de bajos ingresos han utilizado para equilibrar sus presupuestos, especialmente en áreas rurales.

Entre ellos se incluyen los impuestos a los hospitales, los planes de salud y otros proveedores que los estados utilizan para ayudar a financiar sus programas de Medicaid. Estos impuestos a los proveedores son un “truco financiero”, afirmó Desai.

Si bien la ley crea un fondo temporario de $50.000 millones para apoyar a médicos y hospitales rurales, esa cifra representa poco más de un tercio de las pérdidas estimadas en fondos de Medicaid en estas zonas, según la organización sin fines de lucro KFF.

Desai calificó el análisis como “defectuoso”.

Cualquier pérdida de ingresos podría suponer la ruina financiera, especialmente para los pequeños hospitales rurales, afirmó Quang Ngo, presidente de la Texas Organization of Rural & Community Hospitals Foundation.

“Es como si te fueran matando de a poquito con tantos recortes”, dijo. “Algunos probablemente no lo resistan”.

Todo indica que los golpes podrían continuar. La propuesta presupuestaria de la administración Trump para el próximo año fiscal contempla recortes a múltiples programas de salud rural ejecutados por la Health Resources and Services Administration (HRSA).

Desai aseguró que la inversión de la nueva ley en salud rural “supera por mucho” esos recortes.

En febrero, la administración Trump anunció un recorte del 90% al programa de navegadores de ACA, que ayuda a las personas a encontrar seguro médico.

Desai afirmó que ese programa ha sido “históricamente ineficiente”.

En diciembre de 2023, en Texas, casi tres millones de personas sin seguro médico reunían los requisitos para recibir subsidios de ACA, Medicaid o el Programa de Seguro Médico Infantil (CHIP), según Texas 2036, un grupo de expertos en políticas públicas.

María Salgado es una trabajadora de salud comunitaria, o promotora de salud, que pasa sus días laborales en eventos comunitarios, repartiendo volantes en consultorios médicos y reuniéndose con personas para ayudarlas a inscribirse en Medicaid o en planes de ACA a través de MHP Salud, una organización sin fines de lucro.

Salgado tiene miedo de que los recortes de fondos realmente frenen los esfuerzos de la organización: “Muchos miembros de nuestra comunidad van a quedar rezagados”, dijo.

Chris Casso, una médica de atención primaria que creció y ahora ejerce en McAllen, contuvo las lágrimas mientras hablaba de los pacientes que habían dejado de ir al médico porque no lo podían pagar, y eso había hecho que sus enfermedades prevenibles se volvieran más graves.

A Casso le preocupa el futuro de su comunidad, ya que se acentúa la escasez de médicos y podrían quedar pocos profesionales de salud para tratar a quienes han quedado sin cobertura.

“Parte el alma”, dijo, sentada en un pequeño cuarto detrás de su consultorio, ubicado en un centro comercial suburbano, entre una tienda Kohl’s y una Shoe Carnival. “Son personas muy trabajadoras”, afirmó. “Hacen todo lo posible para cuidarse”.

Casso contó que su propia hermana, que trabajaba como facturadora médica en un consultorio, no tenía seguro. Postergó la atención y murió a los 45 años por complicaciones de la diabetes y una enfermedad cardíaca. Casso teme que ese sea el destino de muchas otras personas en el futuro.

“Nuestra comunidad la va a pasar mal”, aseguró. “Va a ser un desastre”.

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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The Trump administration is making historic changes to federal food aid as part of its plan to “Make America Healthy Again.” But some nutrition experts warn recent cuts to funding and more stringent rules to qualify for the Supplemental Nutrition Assistance Program could do the opposite: Worsen food insecurity and push families toward cheaper, less nutritious options. 

KFF Health News senior correspondent Renuka Rayasam appeared on WAMU’s “Health Hub” on Sept. 3 to explain how these new policies are shaping what’s on American dinner plates. 

Taylor Cook 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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She found Forbes face down in the street in August 2023, two weeks before he had planned to move away from the empty storefronts, boarded-up houses, and poverty that make this one of the most troubled places in the nation.

Naketra Guy thought about how her son overcame losing his father at age 4 and was the glue of the family. She called him “humble” and “respectful,” a leader in the community and on the football field, where he shined.

Yet he could not outrun the grim statistics of his hometown. Bogalusa posts some of the worst health outcomes and poverty in Louisiana, a state that routinely ranks among the worst nationally in both. And Bogalusa has endured another indicator of poor public health: high levels of gun violence.

Since the beginning of the covid-19 pandemic, gun violence has shattered any sense of peace or progress here. Louisiana suffers the nation’s second-highest firearm death rate — and Bogalusa, a predominantly Black community with 10,000 residents, has seen dozens of shootings and a violent crime rate approaching twice the national average.

A nearby team refused to play football at Bogalusa High School in fall 2022, citing safety concerns.

Bogalusa’s mayor, Tyrin Truong, was elected in 2022 at age 23 on his promises to fix entrenched challenges: few youth programs and good jobs, and perpetual crime and blight.

“I ran for mayor because I got sick of seeing our city painted as mini-New Orleans,” he said, “due to the high levels of youth gun violence.”

In January, the Louisiana State Police arrested Truong, accusing him of soliciting a prostitute and participating in a drug trafficking ring that allegedly used illicit proceeds to buy firearms. He has said he is innocent. “I still haven’t been formally arraigned,” he told KFF Health News in late July, “and I haven’t been charged with anything.”

Every year tens of thousands of Americans — one every few minutes — are killed by gun violence on the scale of a public health epidemic.

Many thousands more are left to recover from severe injuries, crushing medical debt, and the mental health toll of losing loved ones.

Most headlines focus on America’s urban centers, but the numbers also reflect the growth of gun violence in places like Bogalusa, a pinprick of a town 75 miles north of New Orleans. In 2020, the gun violence death rate for rural communities was 40% higher than in large metropolitan areas, according to Johns Hopkins University.

Firearms are the No. 1 killer of children in the U.S., and no group suffers more than young Black people. More Black boys and men ages 15 to 24 in 2023 were killed in gun homicides than from the next 15 leading causes of deaths combined. Though overall U.S. homicides dropped sharply after the pandemic ended, adolescent gun deaths climbed even higher in the years after, according to research by Jonathan Jay, an associate professor in the School of Public Health at Boston University.

“It has all the markers of an epidemic. It is a major driver of death and disability,” Jay said. “Gun violence does not get the attention it deserves. It is underrecognized because it disproportionately impacts Black and brown people.”

Rather than bolstering efforts to save lives, federal, state, and local government officials have undermined them. KFF Health News undertook an examination of gun violence since the pandemic, a period when firearm death rates surged. Reporters reviewed government reports and academic research and interviewed dozens of health policy experts, activists, and victims or their relatives. They reviewed corporate earnings reports from gun manufacturers and data on the industry’s donations to politicians.

In polling published in 2023 by KFF, more than half of Americans said they or a family member had been impacted by gun violence such as by seeing a shooting or being threatened, injured, or killed with a gun.

American politicians and regulators have put in place laws and practices that have helped enrich firearm and ammunition manufacturers — which tout $91 billion in economic impact — even as gun violence has terrorized neighborhoods already damaged by white flight, systemic disinvestment, and other forms of racial discrimination.

President Donald Trump championed gun rights on the campaign trail and has received millions from the National Rifle Association, to whose members he promised, “No one will lay a finger on your firearms.” His administration has rolled back efforts under President Joe Biden to address the rise in gun violence.

Emboldened in his second term, Trump is pushing to allow more guns in schools, weaken federal oversight of the gun industry, override state and local gun laws, permit sales without background checks, and cut funding for violence intervention.

Trump ordered the attorney general to review all Biden administration actions that “purport to promote safety but may have impinged on the Second Amendment rights of law-abiding citizens.”

The Biden administration said “a historic spike in homicides” during the pandemic took its greatest toll on racially segregated and high-poverty neighborhoods.

Black youths in four major cities were 100 times as likely as white ones to experience a firearm assault, research showed. Gun suicides reached an all-time high, and for the first time the firearm suicide rate among older Black teens surpassed that of older white teens.

In Bogalusa, the pandemic gun violence spread fear. Among the victims killed were a 15-year-old attending a birthday party and a 24-year-old nationally known musician. Thirteen people were injured at a memorial for a man who himself had been shot. Residents said neighbors stopped sitting in their yards because of stray bullets.

Researchers say communities like Bogalusa endure a collective trauma that shatters their sense of safety. Two years after Forbes’ death, his mother says that when she leaves home her surviving children worry that she, too, might get shot.

Repercussions from the surge will last years, researchers said: Exposure to shootings increases risk for post-traumatic stress disorder, anxiety, suicide, depression, substance abuse, and poor school performance for survivors and those who live near them.

“We saw gun violence exposure go up for every group of children except white children, in the cities we studied,” Jay said. “Limits on government funding into gun violence research may stop us from ever knowing exactly why.”

Politics of Pain

The year before Forbes died in Bogalusa, Biden signed into law the Bipartisan Safer Communities Act, considered the most sweeping firearm legislation in decades.

In a matter of months, Trump has systematically dismantled key provisions.

Efforts to regulate guns have long proven ineffective against the power of political and business interests that fill the streets with weapons. In 2020, the number of guns manufactured annually in the U.S. hit 11.3 million, more than double a decade earlier, according to the federal government. In 2022, the United States had nearly 78,000 licensed gun dealers, more than its combined number of McDonald’s, Burger King, Wendy’s, and Subway locations, according to Everytown for Gun Safety, an advocacy group.

The Biden administration announced in 2021 it would attempt to reduce gun violence by adopting a “zero tolerance” policy toward firearm dealers who committed violations such as failing to run a required background check or selling to someone prohibited from buying a gun.

The federal Bureau of Alcohol, Tobacco, Firearms and Explosives, or ATF, which licenses gun dealers, has the authority to enforce laws meant to prevent illegal gun sales. In issuing an executive order, the Trump administration declared that, under Biden, the agency targeted “mom-and-pop shop small businesses who made innocent paperwork errors.”

From October 2010 to February 2022, the agency conducted more than 111,000 inspections, recommending revocation of a dealer’s license only 589 times, about 0.5% of cases, an inspector general’s report said. Even when it cited serious violations, the ATF rarely shut dealers down.

ATF leaders told the inspector general’s office that recommendations for license revocations increased after Biden’s zero-tolerance policy was implemented. In April, the Trump administration repealed it.

Surgeon General Vivek Murthy last year declared firearm violence a public health crisis. Within weeks of Trump’s inauguration, his administration removed the advisory. Of the 15 leading U.S. causes of death, firearm injuries received less research funding from the National Institutes of Health for each person who died than all but poisoning and falls, according to an analysis in 2024 by Brady, an anti-gun violence organization. Trump is trying to cut that funding, too.

Trump’s Department of Justice abruptly cut 373 grants in April for projects worth about $820 million, with a large share from gun violence intervention.

“We are going to lose a generation of community violence prevention folks,” said Volkan Topalli, a gun violence researcher at Georgia State University. “People are going to die, I’m sorry to say, but that is the bleak truth of this.”

Asked about its policies, the White House did not address questions about public health considerations around gun violence.

“Illegal violence of any sort is a crime issue, and President Trump has been clear since Day One that he is committed to Making America Safe Again by empowering law enforcement to uphold law and order,” White House spokesperson Kush Desai said.

Trump administration officials “want safer streets and less violence,” Topalli said. “They are hurting their cause.”

Garen Wintemute, an emergency medicine professor who directs the violence prevention program at the University of California-Davis, was among the first in the nation to consider guns and violence as a public health issue. He said race plays a significant role in perceptions about gun violence.

“People look at the demographic risk for firearm homicide and depending on the demographics of the people in the audience, I can see the transformation in their faces,” Wintemute said. “It’s like they’re saying, ‘Not my people, not my problem.’”

Eroding Gun Restrictions

Trump’s incursions against public health efforts to contain gun violence are backed by lobbying power.

Firearm industry advocacy groups made millions of dollars in political donations in recent years, mostly to conservative causes and Republican candidates. That includes $1.4 million to Trump, according to OpenSecrets, which tracks campaign finance data.

The assassination of civil rights icon the Rev. Martin Luther King Jr. helped lead to the passage of the federal Gun Control Act of 1968, which imposed stricter licensing rules and outlawed the sale of firearms and ammunition to felons.

While it remains the law of the land, over time, federal and state government actions have significantly weakened its protections.

Most states now allow people to carry concealed weapons without a permit or background check, even though research suggests the practice can increase the risk of firearm homicides.

In Louisiana, Democratic former Gov. John Bel Edwards, in office from 2016 to 2024, vetoed a bill that would have allowed people to carry concealed firearms without a permit.

Elected in 2023, Republican Gov. Jeff Landry signed a law to allow any person over age 18 to conceal-carry without a permit.

The Trump administration has created a task force to implement his executive order to end most gun regulations and which would allow more people with criminal convictions, including for domestic abuse, to own guns.

Figures vary, but some researchers estimate as many as 500 million guns circulate in the U.S. Sales reached record highs during the pandemic and publicly traded firearm and ammunition companies saw profits jump.

Donald Trump Jr. this summer joined the board of GrabAGun, an online gun retailer that went public in July under the stock ticker PEW. In a Securities and Exchange Commission filing, the company, which markets guns to people ages 18 to 44, cited “gun violence prevention and legislative advocacy organizations that oppose sales of firearms and ammunition” as threats to its sales growth.

Dave Workman, a gun rights advocate with the Second Amendment Foundation, said firearms are not to blame for the surge in pandemic shootings.

“Bad guys are going to do what bad guys are going to do regardless of the law,” Workman said. “Taking away gun rights is not going to reduce crime.”

David Yamane, a Wake Forest University sociology professor and national authority on guns, said the U.S. firearm debate is complex and the industry is often “painted with too broad a brush.”

Most guns will never be used to kill anyone, he said. Americans tend to buy more guns during times of unrest, Yamane added: “It’s part of the American tradition. Guns are seen as a legitimate tool for defending yourself.”

‘A Low Level of Hope’

Once called “the Magic City,” Bogalusa has become a grim symbol of deindustrialization.

Bogalusa emerged as Black people formed their own communities in the time of Jim Crow racial segregation at the turn of the 20th century.

Racism concentrated Black people in neighborhoods that became epicenters of poor health, reflected in high rates of cancer, asthma, chronic stress, preterm births, pregnancy-related complications — and, over recent decades, firearm violence.

Thousands flocked to Bogalusa after the Great Southern Lumber Company built one of the world’s biggest sawmills, establishing Bogalusa as a company town. Racial tensions soon followed.

Members of the local Deacons for Defense and Justice gained national attention in the 1960s for protecting civil rights organizers from the Ku Klux Klan, a hate group that burned houses and churches, terrorizing and killing Black people.

As the mill changed hands over the decades, Bogalusa’s fortunes slid. In the mid-20th century, the population surpassed 20,000, but it is now about half that.

International Paper, a Fortune 500 company based in Tennessee, runs the mill as a containerboard factory, employing about 650 people. In 2021, the state announced incentives for the company that included a $500,000 tax break, saying the move would help bring “prosperity.”

Businesses remain boarded up along the main drag. Houses still bear damage from Hurricane Katrina, and many streets are eerily quiet.

Nearly 1 in 3 people in Bogalusa live in poverty — 2½ times the national average.

Bogalusa’s violent gun crime rate reached 646.1 per 100,000 people in 2022, higher than Louisiana’s and 1.7 times the national one, according to the nonprofit Equal Justice USA, citing FBI Uniform Crime Reporting data.

In many rural towns across the South, “there is a level of desperation that is more apparent” than in other parts of the U.S., said Luke Shaefer, a University of Michigan professor of social justice and public policy.

“They don’t have the same infrastructure to have robust social services. People are like, ‘What are my life chances?’” Shaefer said. “People feel like there is nothing that can be done. There is a low level of hope.”

Missed Opportunities

Mayor Truong lamented the violence in Bogalusa after Forbes was killed, writing on Facebook, “When are we as a community going to come together and decide enough is enough?”

The federal government had offered one path forward.

The Biden administration provided billions of dollars to local governments through the American Rescue Plan Act during the pandemic. Biden urged them to deploy money to community violence intervention programs, shown to reduce homicides by as much as 60%.

A handful of cities seized the opportunity, but most did not. Bogalusa has received $4.25 million in ARPA funds since 2021. None appears to have gone toward violence prevention.

The Louisiana legislative auditor, Michael Waguespack, found that Bogalusa used nearly $500,000 for employee bonuses, which his report said may have violated state law. In some cases, the report says, payments were not tied to work performed.

Bogalusa officials did not respond to a public records request from KFF Health News seeking detailed information about its ARPA money.

Former Mayor Wendy O’Quin-Perrette, who served from 2015 through early 2023, told Waguespack in a June 2024 letter that the city used ARPA money to improve streets and pay the bonuses. “We would not have done it without being sure it was allowed,” she said.

O’Quin-Perrette did not respond to requests for comment.

In a 2023 letter to Waguespack, O’Quin-Perrette’s successor, Truong, wrote that Bogalusa officials didn’t know how the federal money was spent. When he took office, Truong alleged, officials discovered “tens of thousands of dollars of checks and cash” stashed “in various drawers and on desks” in city offices.

Truong defended his stewardship of ARPA funds, saying that about $1 million remained when he assumed office but that the money was needed for more urgent sewer infrastructure repairs. “I wish we could have invested more, invested any money in gun violence prevention efforts,” he said.

In an interview, Truong said the city has been “intentional” about bringing down gun violence, including through a summer jobs program. He pointed to statistics that show homicides decreased from nine in 2022 to two in 2024. “If you keep them busy, they won’t have time to do anything else,” he said.

Asked about his January arrest, Truong said he has political enemies.

“I’m the only Democrat in a very red part of the state, and, you know, I’ve made a lot of changes at City Hall, and that ticks people off,” Truong told KFF Health News. He said that he ended long-standing city contracts with local businesspeople. “When you’re shaking up power structures, you become a target.”

Josie Alexander, a Louisiana-based senior strategist for Equal Justice USA, said city officials missed an opportunity when they didn’t use ARPA funds for gun violence prevention. “The sad thing is people here can now see that money was coming in,” she said. “But it just wasn’t used the way it needed to be.”

‘Too Much Trouble Here’

Truong said the city is still reeling from the pandemic spike in violent crime. He said he was at Bogalusa High School’s homecoming football game in 2022 when one teen shot another. Shots rang out, Truong said, and he grabbed his 3-month-old son and “laid in the bleachers.”

“It’s not a foreign topic to hardly anybody in town, whether you’ve heard the gunshots in the distance, whether you have attended a funeral of somebody who passed due to gun violence,” he said. Many still grapple with trauma.

In December 2022, Khlilia Daniels said, she hosted a birthday party for her teenage niece, praying no one would bring a gun.

The hosts checked guests for weapons, she said.

Yet gunfire erupted, Daniels said. Three teens were shot, including 15-year-old Ronié Taylor, who died, according to police.

“When someone you know is killed, you never forget,” said Daniels, 32, who held Taylor until emergency responders arrived.

Tajdryn Forbes was planning his future when he was killed, likely because of a dispute that started on social media over lyrics in a rap song, Guy said.

In a Facebook post in January, Bogalusa police said they had arrested someone in connection with Forbes’ killing. Authorities had previously announced the arrest of a teen in connection with the homicide.

Forbes had been a high school football standout, like his late father, Charles Forbes Jr., who played semipro. When Forbes scored a touchdown, he would look to the sky to honor his dad.

The school praised Forbes for his senior baseball season in a social media post: “This young man makes a difference on our campus and on the field with his strong character.”

When hopes for a college football scholarship did not pan out, Forbes worked as a deckhand for a marine transportation company. He saved money, looking forward to moving to Slidell, a suburb of New Orleans.

“He would always say, ‘There’s too much trouble here’” in Bogalusa, Guy recalled.

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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