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

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

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

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

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

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

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

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

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But months of intense back pain eventually landed her in the emergency room, where a doctor suggested that Hunter might have multiple myeloma. Hunter’s first question was, “What is that?”

Multiple myeloma is a cancer that develops in bone marrow plasma cells, crowding out healthy blood cells and damaging the bones. It is one of the most common blood cancers — and the most diagnosed among African Americans. The mortality rate from multiple myeloma also is higher among African American patients than white people, with a number of studies showing that, in addition to disease biology, societal factors such as socioeconomic status and lack of access to health insurance or medical services delay timely diagnoses.

A belated diagnosis is what happened to Hunter, a Black woman in Montgomery, Alabama. She said her primary care doctor dismissed a recommendation from her endocrinologist to refer her to a hematologist after finding high protein counts in her blood. Then, she said, he also refused to order a bone marrow biopsy after the ER doctor suggested she might have multiple myeloma. Fed up, she said, she found a new doctor, got tested, and learned she indeed had the disease.

Monique Hartley-Brown, a multiple myeloma researcher at the Dana-Farber Cancer Institute in Boston, said Hunter’s experience is fairly common, particularly among Black patients who live in underserved communities.

“On average, patients see their primary doctor three times before being accurately diagnosed,” Hartley-Brown said. “The delay from symptom onset to diagnosis is even longer for Black Americans. Meanwhile, the disease is wreaking havoc — causing fractures, severe anemia, fatigue, weight loss, kidney problems.”

Black and Hispanic patients are also less likely to receive the newest therapies, according to the Multiple Myeloma Research Foundation, and, when they do, they are more likely to do so later in the course of their disease than white patients. An analysis published in 2022 of racial and ethnic disparities in multiple myeloma drug approval trials submitted to the FDA concluded that Black patients made up only 4% of participants despite being roughly 20% of those living with the disease.

Now, even though significant progress has been made in understanding the biology of multiple myeloma and how to treat it, those racial gaps may grow larger amid federal cuts to cancer research and the backlash against diversity and inclusion efforts. While few multiple myeloma experts were willing to talk on the record about the impact of the funding cutbacks, Michael Andreini, president and CEO of the Multiple Myeloma Research Foundation, has written that cuts to the National Institutes of Health and its National Cancer Institute put future innovations at risk.

“Even before these potential cuts, funding for myeloma lagged behind,” he wrote before the cuts were finalized. “The myeloma specific budget has decreased significantly. Myeloma is almost 2% of all cancers, yet receives less than 1% of the NCI’s budget.”

The disease is already hard to diagnose. Because multiple myeloma is usually diagnosed when a patient is over 65 (African Americans tend to be diagnosed five years younger, on average), common symptoms such as lower back pain and fatigue are often chalked up to just getting older.

That’s what happened to Jim Washington of Charlotte, North Carolina. He was 61 when excruciating hip pain brought his regular tennis games to a sudden stop.

“I figured I’d done something to injure myself,” Washington said. “But I’d been playing tennis all my life, and this pain was different from anything I’d ever felt before.”

Washington was fortunate to have a concierge doctor and premium health insurance. In quick succession, he underwent X-rays that revealed a lesion on his spine and received a referral to an oncologist, who identified a cancerous tumor. A subsequent biopsy and blood tests confirmed he had multiple myeloma.

Washington had weeks of high-dose chemotherapy, followed by what is known as an autologous stem cell transplant, which used his own stem cells to regrow healthy blood cells in his body. It was a grueling process that ultimately left him with a clean bill of health. For the next several years, his doctors monitored him closely, including conducting an annual bone marrow biopsy.

Before treatment, he said, myeloma had infiltrated 60% of his blood cells. The stem cell transplant brought those levels down to zero. After about five years, however, his multiple myeloma level had crept back up to 10% and required more treatment.

But Washington had closely followed the latest research and believed he had reason to be optimistic. The FDA had approved the first CAR T-cell therapy for multiple myeloma in 2021.

Hartley-Brown said the lack of Black patients in multiple myeloma drug approval trials raises concerns about whether the trial results are equally applicable to the Black population and may help explain why treatment advances have been less effective in Black patients.

She cited multiple causes for the low trial participation rate, including historical distrust of the medical establishment and a lack of available clinical trials. “If you are living in an underserved or underrepresented area, the hospital or community doctor may not have clinical trials available, or that patient may have limitations getting to that location affiliated with the clinical trial,” she said.

Washington, a Black patient, appears to have avoided this trap, having benefited from the latest treatments both times. In January, he began six weeks of chemotherapy with a three-drug combination of Velcade, Darzalex, and dexamethasone before undergoing CAR T-cell therapy.

For that, doctors collected Washington’s T cells, a type of white blood cell, and genetically modified them to better recognize and destroy the cancer cells before reinfusing them into his body. He didn’t require hospitalization post-transplant and could do daily blood draws at home. His energy levels were much higher than during his first treatment.

“I’ve been in a very privileged position,” Washington said. “The prognosis is very positive, and I’m feeling good about where I am at this point.”

Hunter, too, considers herself lucky despite receiving a delayed diagnosis. After her diagnosis in January 2017, she underwent five months of immunotherapy with a three-drug combination (Revlimid, Velcade, and dexamethasone) followed by a successful stem cell transplant and two weeks in the hospital. She has been in remission since July 2017.

Hunter, now a support group co-leader and patient advocate, said that stories like Washington’s and her own provide hope despite the research cuts.

In the eight years since her treatment, she said, she’s seen the thinking around multiple myeloma — long described as a treatable but incurable disease — begin to shift as a growing subset of patients remain disease-free for many years. She said she has even met people living with the disease for 30 years.

“The word ‘cure’ is now being heard,” Hunter said.

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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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Un poste naranja y una señal de “¡Atención!” al costado de una carretera marcan el lugar donde está enterrado un cable de fibra óptica.

“Tienen necesidades de atención médica, pero carecen de las habilidades digitales necesarias”, dijo Waiters, quien trabaja como navegadora digital para una organización sin fines de lucro de Alabama. Su trabajo ha consistido en regalar computadoras y tabletas, a la vez que imparte clases sobre cómo usar internet para el trabajo y necesidades personales, como el banco y la salud. “Es como un espacio extraño”.

Esas historias ahora tienen un sabor agridulce.

Wakers forma parte de una red de navegadores digitales en todo el país, cuyo trabajo para acercar a otros al mundo digital se financió, en parte, a través de un programa federal de $2.750 millones que canceló abruptamente su financiación esta primavera.

La suspensión se produjo después de que el presidente Donald Trump publicara en su plataforma Truth Social que la Ley de Equidad Digital era inconstitucional y prometiera “¡no más ayudas a la conciencia pública basadas en la raza!”.

La ley detalla exactamente a quiénes debería beneficiar el dinero, incluyendo hogares de bajos ingresos, residentes mayores, algunas personas en cárceles, estadounidenses de zonas rurales, veteranos y miembros de minorías raciales o étnicas.

Políticos, investigadores, bibliotecarios y defensores afirmaron que la desfinanciación del programa, junto con otros cambios en las iniciativas federales de banda ancha, pone en peligro los esfuerzos para ayudar a los residentes rurales y desfavorecidos a participar en la economía moderna y llevar una vida más saludable.

“Se podían ver vidas cambiando”, dijo Sam Helmick, presidente de la Asociación Americana de Bibliotecas, recordando cómo ayudaron a abuelos en Iowa a consultar recetas médicas en línea o a trabajadores despedidos de fábricas a llenar solicitudes de empleo.

La Ley de Equidad Digital forma parte de la amplia ley de infraestructura de 2021, que incluyó $65.000 millones para construir infraestructura de internet de alta velocidad y conectar a millones de personas sin acceso a internet.

Este año, el Congreso impulsó una vez más un enfoque moderno para ayudar a los estadounidenses, exigiendo a los líderes estatales que priorizaran las tecnologías nuevas y emergentes a través de su Programa de Transformación de la Salud Rural, de $50.000 millones.

Un análisis de KFF Health News reveló que casi 3 millones de personas a lo largo del país viven en zonas con escasez de profesionales médicos y donde los servicios modernos de telesalud suelen ser inaccesibles debido a las malas conexiones a internet.

El análisis reveló que en unos 200 condados, principalmente rurales, donde persisten las zonas sin cobertura, los residentes viven con mayor riesgo de enfermedad y mueren antes, en promedio, que las personas del resto del país. El acceso a internet de alta velocidad se encuentra entre una serie de factores sociales, como la alimentación y una vivienda segura, que ayudan a las personas a llevar una vida más saludable.

“Internet proporciona esta capa adicional de resiliencia”, afirmó Christina Filipovic, quien dirige la investigación de una iniciativa del Institute for Business in the Global Context de la Universidad de Tufts. En 2022, el grupo de investigación descubrió en 2022 que el acceso a internet de alta velocidad se correlacionaba con una menor mortalidad por covid-19, especialmente en áreas metropolitanas.

Durante la pandemia de covid, los legisladores federales lanzaron un programa de subsidios financiado por la ley de infraestructura. Esta ayuda, denominada Programa de Conectividad Asequible, buscaba conectar a más personas con sus trabajos, escuelas y médicos. En 2024, el Congreso no renovó la financiación del programa de subsidios, que había inscrito a unos 23 millones de hogares de bajos ingresos.

Este año, el secretario de Comercio de Estados Unidos, Howard Lutnick, renovó y retrasó la iniciativa de construcción de la ley de infraestructura —conocida como Programa de Equidad, Acceso e Implementación de Banda Ancha (BEAD)— tras anunciar planes para reducir las cargas regulatorias. Más de 40 estados y territorios han presentado propuestas finales para extender internet de alta velocidad a zonas desatendidas bajo las nuevas directrices de la administración, según un panel del Departamento de Comercio.

En mayo, la financiación de la Ley de Equidad Digital se canceló pocos días después de la publicación de Trump en Truth Social. Si bien muchos estados recibieron fondos para planificar sus programas en 2022, la siguiente ronda de financiación, destinada a que los estados y las agencias implementaran los planes, se había otorgado en gran medida, pero no distribuido.

En cambio, los reguladores federales, incluida la Administración Nacional de Telecomunicaciones e Información (NTI), la agencia federal que supervisa la implementación de la Ley de Equidad Digital, notificaron a los beneficiarios que las subvenciones serían canceladas.

Se crearon y administraron con “preferencias raciales inconstitucionales”, según la carta.

En Phoenix, Arizona, las autoridades se enteraron en enero de que la ciudad recibiría $11,8 millones para aumentar el acceso a internet y enseñar alfabetización digital, pero recibieron un correo electrónico el 20 de mayo indicando que todas las subvenciones, “excepto las destinadas a Entidades Nativas”, habían sido canceladas.

“Es una pena”, declaró la alcaldesa de Phoenix, la demócrata Kate Gallego. El dinero, afirmó, habría ayudado a 37.000 residentes a obtener acceso a internet.

En julio, los líderes demócratas de Georgia enviaron una carta a Lutnick y al entonces administrador interino de la NTIA, Adam Cassady, reclamando la restitución de los fondos, señalando que el recorte federal ignora la intención del Congreso y vulnera la confianza pública.

La creadora de la ley, la senadora Patty Murray (demócrata por Washington), declaró durante una conferencia de prensa en línea en mayo que los gobernadores republicanos de 2024 apoyaron la ley y su financiación cuando cada estado promocionó la finalización de sus planes de equidad digital requeridos y solicitó recursos.

“No puedo creer que no haya gobernadores republicanos que se unan a nosotros para luchar contra esto”, declaró Murray, y agregó que “la otra vía es a través de los tribunales”.

Los 50 estados desarrollaron planes de equidad digital luego de meses de grupos focales, encuestas y períodos de consulta pública. La directora de Equidad Digital de la NTIA, Angela Thi Bennett, durante una entrevista en agosto de 2024 con KFF Health News, afirmó que la “participación comunitaria deliberada” de los líderes federales y estatales para brindar banda ancha a las comunidades desatendidas fue “la mayor demostración de democracia participativa que nuestro país haya visto jamás”.

No fue posible contactar con Thi Bennett para que comentara sobre este artículo. El voceru de la NTIA, Stephen Yusko, afirmó que la agencia “no podrá atender” una solicitud de entrevista con Thi Bennett y no respondió a las preguntas para este artículo.

Caroline Stratton, directora de investigación del Instituto Benton para la Banda Ancha y la Sociedad, afirmó que la financiación de la ley permitió a los estados dotar de personal a sus oficinas; identificar programas de internet de alta velocidad existentes, incluyendo los que operan en otras agencias estatales; y crear planes para subsanar las deficiencias.

“Esto motivó a la gente a investigar”, explicó Stratton, para ver si las agencias del estado ya estaban trabajando en planes de mejora de la salud y para preguntarse si el trabajo en banda ancha podría contribuir y “ayudar activamente a mejorar la situación”.

Las solicitudes de subvenciones estatales incluían objetivos para promover el acceso a la atención médica. En Mississippi, el plan consiste en una iniciativa para mejorar la salud de la universidad estatal y otra agencia, explicó Stratton.

Si bien los estados debían crear programas que ayudaran a poblaciones específicas cubiertas, algunos modificaron el lenguaje o agregaron subcategorías para incluir a otras poblaciones. El plan de Colorado incluía a inmigrantes y a personas sin hogar.

“En todos los estados, hay una pérdida”, afirmó Angela Siefer, directora ejecutiva de la Alianza Nacional para la Inclusión Digital. La organización sin fines de lucro, que recibió casi $26 millones para colaborar con organizaciones de todo el país, pero no recibió fondos, presentó una demanda el 7 de octubre para obligar a Trump y al gobierno a distribuir el dinero.

“La brecha digital no ha terminado”, declaró Siefer.

La subvención de la organización se había planificado para apoyar a los navegadores digitales en 11 estados y territorios, incluyendo a Waiters. Su empleador, la organización sin fines de lucro Community Service Programs of West Alabama, esperaba recibir una subvención de $1,4 millones.

En los últimos dos años, Waiters dedicó horas a recorrer las carreteras rurales de Alabama para llegar a los residentes. Ha distribuido 648 dispositivos (computadoras portátiles, tabletas y tarjetas SIM) y ha ayudado a cientos de clientes mediante 117 clases de habilidades digitales de dos horas en bibliotecas, centros para personas mayores y programas de desarrollo laboral en Tuscaloosa, Alabama, y sus alrededores.

Personas de “todas las razas, edades y niveles económicos” que no “encajaban en nuestra típica categoría minoritaria” recibieron ayuda gracias a su trabajo, afirmó Waiters. Dijo que Trump y su administración deberían saber “cómo se ve realmente la situación para la gente a la que sirvo”.

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“They have health care needs, but they don’t have the digital skills,” said Waiters, who is a digital navigator for an Alabama nonprofit. Her work has involved giving away computers and tablets while also teaching classes on how to use the internet for work and personal needs, like banking and health. “It’s like a foreign space.”

Those stories are now bittersweet.

Waiters is part of a network of digital navigators across the country whose work to bring others into the digital world was, at least in part, propped up by a $2.75 billion federal program that abruptly canceled funding this spring. The halt came after President Donald Trump posted on his Truth Social platform that the Digital Equity Act was unconstitutional and pledged “no more woke handouts based on race!”

The act lists exactly whom the money should benefit, including low-income households, older residents, some incarcerated people, rural Americans, veterans, and members of racial or ethnic minority groups. Politicians, researchers, librarians, and advocates said defunding the program, along with other changes in federal broadband initiatives, jeopardizes efforts to help rural and underserved residents participate in the modern economy and lead healthier lives.

“You could see lives change,” said Sam Helmick, president of the American Library Association, recalling how they helped grandpas in Iowa check prescriptions online or laid-off factory workers fill out job applications.

The Digital Equity Act is part of the sweeping 2021 infrastructure law, which included $65 billion to build high-speed internet infrastructure and connect millions without access to the internet.

This year, Congress once again pushed for a modern approach to help Americans, mandating that state leaders prioritize new and emerging technologies through its $50 billion Rural Health Transformation Program.

A KFF Health News analysis found that nearly 3 million people in America live in areas with shortages of medical professionals and where modern telehealth services are often inaccessible because of poor internet connections. The analysis found that in about 200 mostly rural counties where dead zones persist, residents live sicker and die earlier on average than people in the rest of the country. Access to high-speed internet is among a host of social factors, like food and safe housing, that help people lead healthier lives.

“The internet provides this extra layer of resilience,” said Christina Filipovic, who leads the research for an initiative of the Institute for Business in the Global Context at Tufts University. The research group found in 2022 that access to high-speed internet correlated with fewer covid deaths, particularly in metro areas.

During the covid-19 pandemic, federal lawmakers launched a subsidy program paid for by the infrastructure law. That aid, called the Affordable Connectivity Program, aimed to connect more people to their jobs, schools, and doctors. In 2024, Congress did not renew funding for the subsidy program, which had enrolled about 23 million low-income households.

This year, U.S. Commerce Secretary Howard Lutnick revamped and delayed the infrastructure law’s construction initiative — known as the Broadband Equity, Access, and Deployment Program, or BEAD — after announcing plans to reduce regulatory burdens. More than 40 states and territories have submitted final proposals to extend high-speed internet to underserved areas under the administration’s new guidelines, according to a Commerce Department dashboard.

In May, the Digital Equity Act’s funding was terminated within days of Trump’s Truth Social post. While many states in 2022 had received money to plan their programs, the next round of funding, designated for states and agencies to implement the plans, had largely been awarded but not distributed.

Instead, federal regulators — including the National Telecommunications and Information Administration, the federal agency overseeing implementation of the Digital Equity Act — notified recipients that the grants would be terminated. The grants were created and administered with “unconstitutional racial preferences,” according to the letter.

In Phoenix, officials learned in January that the city was slated to get $11.8 million to increase internet access and teach digital literacy, but they received an email May 20 stating that all grants, “except for grants to Native Entities,” had been terminated. “It’s a shame,” said Phoenix Mayor Kate Gallego, a Democrat. The money, she said, would have helped 37,000 residents get internet access.

Georgia’s Democratic leaders in July sent a letter to Lutnick and NTIA’s then-acting administrator, Adam Cassady, urging reinstatement of the money, noting that the federal cut ignores congressional intent and violates public trust.

The act’s creator, Sen. Patty Murray (D-Wash.), said during an online press conference in May that Republican governors in 2024 supported the law and its funding when each state touted completing its required digital equity plans and asked for resources.

“I cannot believe there aren’t Republican governors out there that are going to join with us to fight back on this,” Murray said, adding “the other way is through courts.”

All 50 states developed digital equity plans after months of focus groups, surveys, and public comment periods. NTIA Digital Equity Director Angela Thi Bennett, during an August 2024 interview with KFF Health News, said the “intentional community engagement” by federal and state leaders to deliver broadband to unserved communities was “the greatest demonstration of participatory democracy our country has ever seen.”

Thi Bennett could not be reached for comment on this article. NTIA spokesperson Stephen Yusko said the agency “will not be able to accommodate” a request for an interview with Thi Bennett and did not respond to questions for this article.

Caroline Stratton, a research director at the Benton Institute for Broadband & Society, said the act’s funding allowed states to staff offices; identify existing high-speed internet programs, including those operating within other state agencies; and create plans to fill the gaps.

“This sent folks out looking,” Stratton said, to see whether agencies in the state were already working on health improvement plans and to ask whether the broadband work could contribute and “actively help move the needle.”

State grant applications included goals to promote health care access. In Mississippi, the plan consists of the state university and another agency’s health improvement plan, Stratton said.

While states were required to create programs that would help specific covered populations, some states modified the language or added subcategories to include other populations. Colorado’s plan included immigrants and “individuals experiencing homelessness.”

“In every state, there’s a loss,” said Angela Siefer, executive director of the National Digital Inclusion Alliance. The nonprofit, which was awarded nearly $26 million to work with organizations nationwide but did not receive any funds, filed a lawsuit Oct. 7 seeking to force Trump and the administration to distribute the money.

“The digital divide is not over,” Siefer said.

The nonprofit’s grant had been planned to support digital navigators in 11 states and territories, including Waiters. Her employer, the nonprofit Community Service Programs of West Alabama, expected to receive a $1.4 million grant.

In the past two years, Waiters spent hours driving the roads of rural Alabama to reach residents. She has distributed 648 devices — laptops, tablets, and SIM cards — and helped hundreds of clients through 117 two-hour digital skills classes at libraries, senior centers, and workplace development programs in and around Tuscaloosa, Alabama.

People of “all races, of all ages, of all financial backgrounds” who did not “fit into our typical minority category” were helped through her work, Waiters said. Trump and his administration should know, she said, “what it actually looks like for the people I serve.”

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Algunos de estos centros de salud comunitarios podrían verse obligados a reducir personal médico y administrativo, y hasta servicios. Algunos incluso podrían llegar a cerrar. Sus defensores advierten que esto podría aumentar la presión sobre las salas de emergencia de los hospitales, que ya están saturadas de pacientes.

“Este es el peor momento en todos los años que llevo trabajando en atención médica”, dijo Jim Mangia, presidente y director ejecutivo de St. John’s Community Health, una red de 28 clínicas que atiende a más de 144.000 pacientes en los condados de Los Ángeles, Riverside y San Bernardino, en California. “Estamos enfrentando recortes federales y recortes extremos a nivel estatal que van a afectar los servicios”.

St. John’s y otros centros de salud calificados a nivel federal ofrecen atención primaria y una amplia gama de otros servicios sin costo o a precios ajustados a los ingresos de cada paciente. A nivel nacional, atienden a cerca de 34 millones de personas en las zonas más desatendidas del país.

Los fondos federales provienen de dos fuentes principales, ambas actualmente bajo presión: subvenciones otorgadas en parte a través del Community Health Center Fund, federal, y de reembolsos por la atención brindada a pacientes mediante programas como Medicaid, que ofrece cobertura médica a personas de bajos ingresos o con discapacidades.

A Medicaid lo financian de manera conjunta los estados y el gobierno federal.

En los últimos tiempos, el Congreso ha aprobado esos fondos con cuentagotas. En marzo, los legisladores extendieron las subvenciones hasta el 30 de septiembre. Ese dinero expiró después de que el Congreso, controlado por los republicanos, no aprobara una ley de financiación, lo que ha provocado un cierre parcial del gobierno.

Defensores de los centros enfatizan que se necesita un financiamiento a largo plazo para poder planificar con mayor certeza, idealmente a través de un fondo multianual.

Los centros de salud recibieron $4.400 millones en subvenciones a comienzos de 2024. La National Association of Community Health Centers está presionando para que se asignen al menos $5.800 millones anuales durante dos años, con el fin de mantener los centros plenamente operativos.

La red de seguridad que representan los centros de salud “enfrenta múltiples capas de desafíos”, dijo Vacheria Keys, vicepresidenta de políticas y asuntos regulatorios de la asociación.

La nueva ley de gasto público que los republicanos llaman “One Big Beautiful Bill Act” implicará recortes significativos a Medicaid, lo que impone otra amenaza importante para estos centros.

En 2023, Medicaid representó el 43% de los $46.700 millones en ingresos totales de los centros de salud.

Defensores advierten que los pagos reducidos de Medicaid agravarán la brecha entre el financiamiento disponible y los costos operativos.

También se necesita financiación para programas de desarrollo de personal, para apoyar la prestación de servicios de salud, ya que los centros enfrentan dificultades para contratar y retener trabajadores, dijo Feygele Jacobs, directora del Geiger Gibson Program in Community Health de la Universidad George Washington.

Los primeros centros de este tipo se abrieron en lugares como Massachusetts en la década de 1960. Históricamente, el Congreso los ha financiado con apoyo bipartidista, con algunos obstáculos menores.

La crisis actual comenzó cuando la administración Trump congeló la ayuda nacional a través de un memorando emitido en enero, lo que impidió que algunos centros recibieran subvenciones ya aprobadas. Como resultado, algunos centros cerraron o se fusionaron en estados como Virginia.

Los próximos recortes también llegarán justo cuando los pacientes enfrenten nuevas demandas y desafíos. Entre los cambios en Medicaid incluidos en la ley fiscal y de gasto del presidente Donald Trump se encuentra el requisito de que los beneficiarios reporten sus horas de trabajo u otras actividades comunitarias para poder conservar su cobertura.

Mientras tanto, los subsidios más generosos que la administración Biden y el Congreso habían aprobado para ayudar a los consumidores a pagar los planes médicos adquiridos en los mercados de seguros bajo la Ley de Cuidado de Salud a Bajo Precio (ACA) están programados para expirar a fin de año.

Si el Congreso no los renueva, algunos costos de los consumidores aumentarán dramáticamente.

Una de las razones del cierre del gobierno es que los demócratas quieren extender esos subsidios, que protegen a los consumidores del aumento en los costos del seguro. El proyecto de ley de financiación de los republicanos no incluía la extensión; los líderes republicanos en el Congreso dicen que ese tema debe tratarse por separado.

“Los consumidores van a necesitar más apoyo que nunca”, dijo Jacobs, quien advirtió que los recortes a Medicaid y el fin de los subsidios mejorados podrían “dejar a muchas personas sin cobertura”.

El 90% de los pacientes de los centros comunitarios de salud tienen ingresos del doble del nivel federal de pobreza o menos, y el 40% son hispanos.

“Estamos recibiendo 300 llamadas por día de pacientes preocupados por su cobertura”, comentó Mangia, de St. John’s.

Los republicanos no están atacando directamente a los centros, aunque sí respaldaron los recortes a Medicaid que afectarán sus finanzas. Muchos argumentan que el gasto en Medicaid se ha disparado y que reducir su crecimiento hará que el programa sea más sostenible.

Apoyo estatal y local

Mientras abogan por un financiamiento federal más estable, los centros también están buscando el respaldo de sus comunidades y gobiernos locales.

Algunos estados ya tomaron medidas al finalizar sus presupuestos anuales. Connecticut, Minnesota, Illinois y Massachusetts asignaron fondos a los centros. Maryland, Oregon y Wisconsin también ofrecieron apoyo.

La pregunta del millón es cuánto tiempo durará ese dinero.

Mientras algunos estados aumentaron su apoyo a los centros, otros están tomando la dirección contraria. Anticipando el impacto de los recortes a Medicaid, estados como California hicieron sus propios recortes al programa.

La oficina del gobernador de California, Gavin Newsom, así como la Administración de Recursos y Servicios de Salud federal, no respondieron a las solicitudes de comentarios.

En Los Ángeles, Mangia dijo que una posible solución es trabajar con aliados a nivel del condado, y señaló que el condado de Los Ángeles tiene unos 10 millones de habitantes.

“Podemos imponernos un impuesto para aumentar el financiamiento de los servicios de salud”, dijo.

Los líderes de los centros están formando una coalición que, “esperan”, incluya a los principales actores del sistema de salud del condado: centros comunitarios, clínicas, hospitales, médicos, planes de salud, sindicatos. El objetivo: iniciar el proceso para presentar una iniciativa ciudadana que permita a los votantes decidir si quieren aprobar un impuesto destinado a financiar a los centros de salud.

“Estamos aprendiendo que el gobierno federal y el estatal no son confiables cuando se trata de garantizar la financiación continua de los servicios de salud”, dijo Mangia.

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Hsu, a board-certified general surgeon, was one of six out-of-state doctors who joined the Atlanta Goals Aesthetics & Plastic Surgery center during the pandemic. The surgeons received temporary licenses to practice in Georgia, which state officials granted in response to the sudden need for more medical personnel to address the covid-19 outbreak — even though the center specialized in elective cosmetic surgeries, such as Brazilian butt lifts, or BBLs, and liposuction, paid for in cash or on credit.

The Atlanta center announced its opening in March 2021 as an expansion of New York-based Goals Aesthetics & Plastic Surgery, which markets “precision body contouring” for about a dozen surgery clinics in eight states, promising patients a “dream body in just one visit.”

But the Atlanta center’s early days were marred by allegations of substandard patient care. Court records show that at least 20 women filed medical malpractice lawsuits against the facility, or its owner and surgeons. Hsu was named as a defendant in seven suits filed against the Atlanta center, more than any other physician there. An eighth patient sued Hsu alleging negligence in an operation he performed at a Goals office in New York.

Hsu did not respond to requests for comment. Goals declined to comment. Both have denied any negligence.

Cosmetic surgery chains across the country are attracting patients by promising “minimally invasive” operations to reshape their bodies or get rid of stubborn fat — even helping arrange outside financing for people who can’t pay up front. Hundreds of thousands of patients are undergoing such procedures each year, and plastic surgeons can make more than $500,000 each year in one of the highest-paid specialties in American medicine.

An investigation by KFF Health News found that lawsuits filed by injured patients have trailed the industry’s growth, in some cases alleging that surgeons lacked adequate training, had histories of malpractice lawsuits, or had faced disciplinary action by state medical licensing boards — yet crossed into another state and kept practicing.

In the Atlanta lawsuits, Goals has denied any negligence and won dismissal of several of them because patients had signed papers agreeing to outside arbitration — which requires them to resolve disputes privately and outside the court system.

Yet Goals argued in a separate contract dispute that several of its Atlanta surgeons, including Hsu, were indeed prone to problems — either because they lacked adequate training or had troubled pasts, including investigations by state medical licensing boards into misconduct, court records show. One of Hsu’s Atlanta patients said in a separate lawsuit that she suffered in pain for over a year because a piece of a scalpel was left inside her body after a BBL and liposuction.

In a June 2023 court filing in that contract dispute, Goals blamed the problems on a medical staffing firm — Barton Associates, a private equity-owned firm in Massachusetts — it said failed to do adequate background checks on the doctors it supplied. Barton denied the allegations and said it met all terms of the contract.

No public database exists to help patients learn the full practice histories of physicians, including cosmetic surgeons. And patients are largely left on their own to decipher which certificates hanging on a surgeon’s wall, or ballyhooed in web advertising, signify appropriate training and which do not. Disputes among medical specialty groups over whose members are the best qualified to perform cosmetic operations — and deliver the best results — add to the confusion.

No government agency tracks injuries or other complication rates at clinics offering cosmetic surgery or any other type of operations. And in many jurisdictions, including Georgia, gaining access to court records — a possible red flag for spotting problems — is laborious and costly.

Charleetra Hornes, 52, who lives in the Atlanta suburbs and is suing the Goals center for medical malpractice, said she knew nothing of its alleged early troubles and chose the company because its advertising promised “minimal downtime” for recovery and that she would remain awake during the operation.

She said she paid $6,650 for a “double BBL,” in which fat is suctioned from the stomach, purified, and injected into the buttocks and hips to create what Goals calls a “natural-looking enhancement.”

Goals went ahead with her surgery on July 2, 2022, even though she had tested positive for covid that day, according to the suit. Hornes alleged that two days before the surgery Goals assigned her to surgeon Thomas Shannon, who has worked for Goals in Georgia and Texas.

Though staff gave her pills to manage the discomfort, Hornes said, she suffered “excruciating pain” during the procedure, according to the suit.

That night, she spiked a fever that sent her to the emergency room. She spent two weeks in the hospital recovering from injuries, including a “severe burn on her side,” according to the suit.

“I’ve been disfigured and burned up, and it’s not fair,” she said in an interview.

In June 2024, Hornes sued Shannon, the Goals center, and Barton Associates, alleging malpractice. On Sept. 2, a Georgia judge dismissed Shannon from the case, ruling that Hornes failed to serve him with the complaint in Texas before the statute of limitations ran out. He did not respond to requests for comment. 

In a separate order issued on the same day, the judge also dismissed the other defendants, citing the statute of limitations issue and that Hornes had previously signed an arbitration agreement. Some cosmetic surgery chains and other medical practices ask patients to sign such agreements. 

Hornes wishes she had learned more about the Atlanta surgery center, instead of accepting what she calls its “flashy” come-ons. “I wish I would have taken it more seriously,” she said in an interview, “because it was life-altering.”

Useful Tools

KFF Health News identified more than 200 lawsuits filed against multistate cosmetic surgery companies, mostly over the past seven years, including cases involving a dozen deaths, using databases of court records.

Lawsuits by themselves don’t prove wrongdoing. Many cases are settled under confidential terms that keep critical details under wraps. Yet medical authorities and most physician licensing boards regard malpractice cases and settlements as a useful tool for detecting possible patterns of substandard health care that may harm patients.

Court files show that surgeons who were sued numerous times for malpractice — and in some cases disciplined by state medical boards for misconduct — have managed to get hired by cosmetic surgery chains.

Goals, owned by physician Sergey Voskin, has contracted with eight surgeons with three or more malpractice cases filed against them, including in the Atlanta area, court records allege. Gerald Hickson, founding director of the Vanderbilt Center for Patient and Professional Advocacy and an expert on medical malpractice issues, called that number of suits a “warning” of possible problems, despite their outcome.

Earlier this year, a Pennsylvania woman identified in court filings as “P.C.” sued Goals, Voskin, and surgeon Peter Driscoll, alleging Driscoll came on board despite an “extensive history of malpractice allegations, licensing suspensions and discipline” in Texas and California, according to medical board records cited in the suit. Companies hiring doctors have ready access to the nonpublic National Practitioner Data Bank, which details disciplinary problems in a doctor’s past. But it’s not clear from court records whether anybody made these standard background checks. Goals did not respond to a request for comment.

The suit also accuses Goals of consumer fraud for touting its surgeons as “double if not triple board certified plastic surgeons.” According to the complaint, Driscoll was board-certified by the American Board of Otolaryngology, a specialty that focuses on treatment and surgery of head and neck areas. Driscoll is no longer certified in the specialty, according to the American Board of Medical Specialties website.

The woman alleges that Driscoll sexually harassed her and made “unwanted and unwelcome sexual contact” during a BBL procedure in June 2022 at a Goals office in New Jersey. 

According to the suit, staff members overheard Driscoll watching pornography in an office bathroom multiple times, but Goals did not terminate him at the time. New Jersey’s State Board of Medical Examiners suspended Driscoll’s license in February 2023 related to the incident, and the woman’s lawsuit is pending in federal court in New Jersey. Goals and Voskin have denied the allegations in the suit and filed a motion to dismiss or compel arbitration of the case. Driscoll, who has not filed a response with the court, could not be reached for comment.

Performance Issues Not ‘Disqualifying’

Other cosmetic surgery chains have faced multiple malpractice actions targeting surgeons or other health care providers who staff their clinics, court records show.

The surgeon roster at Mia Aesthetics, a Miami-based chain that operates 13 cosmetic surgery offices nationwide, lists four doctors with three or more malpractice actions since 2020, court records show.

Nearly a dozen injured patients have filed lawsuits criticizing the credentials of doctors and nurse practitioners affiliated with Belle Medical, including the family of a 70-year-old Utah woman with five children who died in the car two days after liposuction as her husband rushed her from home to a hospital, according to court records.

Her husband alleges he called Belle Medical’s office the day after the procedure to say his wife was having difficulty breathing and heart palpitations and couldn’t walk more than a short distance, which the lawsuit argued were “textbook symptoms of pulmonary embolism, or blood clot in the lung.” According to the suit, nobody at Belle Medical advised the family to seek immediate medical care. An autopsy found she died from “bilateral pulmonary emboli,” according to the suit.

Backed by Peterson Partners, a Utah private equity and investment firm, Belle Medical operates in Utah, Idaho, and Oklahoma, offering liposuction and other cosmetic surgery. Neither Belle Medical nor Peterson Partners responded to requests for comment. In court filings, Belle Medical has argued that its medical providers are independent contractors who are solely responsible for any procedures they perform.

Private equity-backed Sono Bello, the largest of the cosmetic surgery chains with more than 100 locations nationwide, has defended more than a dozen lawsuits alleging the company contracted with inadequately trained doctors or practitioners previously disciplined by medical licensing boards. In May 2023, Ohio’s medical board revoked the license of a Sono Bello contract surgeon after three of her patients died, two of them following procedures at a Sono Bello office in the Cleveland area, according to medical board records.

Robert Centeno, Sono Bello’s medical director for the East region, told KFF Health News that many surgeons have past performance issues, which he called “not, in fact, disqualifying.”

“The vast majority of our colleagues are extremely professional and committed to their profession,” he said in an interview. “And while there may be a momentary lapse or issue with their practice, most of our surgeons take those sanctions, take that counseling, that advice, and improve their practices and go on to be very, very productive members of the medical community.”

Asked about malpractice lawsuits filed against the company, Centeno said that Sono Bello has “performed over 300,000 procedures to date,” which he described as “more procedures for more patients completed safely than anyone else in the industry. It would be natural and understandable to know that at some point during that process, that a patient has actually sued us,” Centeno said.

‘Unable To Perform’

In early 2020, as the pandemic slowed business in New York City, Goals sought to expand to Atlanta — a hot market for its BBLs. In a PR Newswire release, Goals promised patients “amazing contours” and boasted of having “some of the most experienced, and aesthetically forward surgeons in the industry.” BBLs and liposuction make up 95% of its business, marketed to mostly Black and Hispanic women, Goals owner Voskin testified in a deposition filed this year in the Driscoll case. Many Atlanta patients suing the company paid roughly $6,000 to $8,000 for their surgeries, court records show.

Goals initially staffed the Atlanta center through Barton Associates. Many hospitals and medical offices rely on such firms to find temporary doctors and other staff. Under the deal, Barton charged Goals $1,400 for each procedure and paid about $600 of that to the surgeon, according to Goals’ court filings.

In 2023, Barton sued Goals in a Massachusetts court, alleging it was owed $487,000 in fees. Goals admitted that it “temporarily ceased payment” to Barton. But it fired back with a counterclaim accusing Barton of failing to check the qualifications and backgrounds of surgeons as required by the agreement.

Goals named five surgeons Barton sent to the center, including Hsu, and pointed to the spate of malpractice cases in Atlanta to bolster its argument.

Goals said it “became immediately apparent” that another surgeon was “fundamentally unable to perform his duties.” The surgeon was “abrasive, vulgar and could not conduct himself in accordance with reasonable professional standards that were expected in a medical workplace,” according to Goals’ counterclaim.

A second surgeon Barton presented as “highly skilled” turned out to have “an extensive history of complaints about his professional conduct” in two other states, according to the counterclaim.

Barton and Goals settled the case and counterclaim in April 2024 under confidential terms. Barton did not respond to requests for comment. Barton denied Goals’ allegations in earlier court filings and said that it “complied fully” with the terms of its contract with the surgery company.

In its counterclaim, Goals argued that shortly after Hsu joined the staff in 2021, it learned he had “multiple issues” in California and “was about to lose his medical license as a result,” according to a court filing.

Goals provided “significant legal and other assistance” to keep that from happening and Hsu “required substantial training in order to do acceptable work on patients,” the company argued in court filings.

Seven women filed malpractice suits in 2023 alleging they sustained injuries from BBLs and liposuction Hsu performed at the Atlanta office between mid-February 2021 and the end of June 2021, court records show. Barton, the staffing firm, also is a defendant in these cases and has denied wrongdoing. Hsu has denied wrongdoing in the cases and sought to enforce arbitration agreements. 

Hsu’s emergency Georgia medical license, approved in January 2021, expired in April 2022, state records show. Hsu is licensed in New York and California, where he has also worked for Goals.

Two suits accuse Hsu of leaving a piece of metal inside the bodies of women, a calamity patient safety experts believe should never occur.

In one Atlanta case, a patient who alleged she had experienced constant pain since her surgery at Goals in 2021 said she discovered why more than a year later when a chest X-ray ordered after a car crash showed a piece of scalpel blade in her upper abdomen, according to her court filings. The action against Hsu and Barton Associates was settled early this year, court records show.

In the second case, a New Jersey woman who had a BBL at Goals’ Harlem office in New York City in February 2022 alleged she overheard Hsu say in the operating room that he had “left something inside of her,” which turned out to be a metal liposuction cannula tip that had broken off in her stomach. A judge dismissed her lawsuit due to an arbitration clause. She filed a notice of appeal, but the case was settled in August.

The California medical board’s investigation of Hsu ended in October 2023 with a settlement and disciplinary order. The state accused him of “repeated negligent acts” in treating six patients dating to 2016, including three people who died. None involved cosmetic surgery like his work at Goals.

The board revoked his license but stayed the action and imposed a four-year probation, tacking on a $24,000 penalty to cover costs of the investigation. The order also required Hsu to find a practitioner to help oversee his practice and prohibits him from serving on any on-call panel for general surgery. In settling the case, Hsu did not admit any wrongdoing.

Goals has featured Hsu in a TikTok video, and boasts on its website that he is a “highly skilled surgical specialist,” who provides “top-notch surgical care.”

Fellowship Training

How much training cosmetic surgery chains demand of surgeons varies, judging by physician service contracts obtained by KFF Health News through court filings. Some contracts simply require that the doctor hold a valid state medical license, while others specify that a doctor “represents” that they are qualified to perform cosmetic surgery and have not been disciplined by licensing boards or been hit with major malpractice awards.

Sono Bello takes a different route. The company sponsors a six- to eight-week training course for surgeons, which it calls a “fellowship,” and posts details online.

Sono Bello accepts applicants from more than half a dozen surgical specialties and focuses its training on liposuction and a type of tummy tuck procedure called AbEX.  

Court records show that Sono Bello has defended at least a dozen lawsuits from patients who argued some surgeons lacked sufficient training or had other problems, or alleged they were misled by some advertising that described surgeons who completed the fellowship as “board certified plastic surgeons.”

Sono Bello’s credentialing process came under attack in a 2023 malpractice lawsuit filed by Shirley Webb, a 79-year-old Nevada woman who spent months in hospitals and rehabilitation care recovering from sepsis after a tummy tuck and liposuction performed by surgeon Charles Kim in Las Vegas in December 2022.  

Kim, a colorectal surgeon, took the Sono Bello fellowship from July 2022 to October 2022, court records show. In a deposition, Kim, who is board-certified in general surgery, stated that Sono Bello knew he had been disciplined by Nevada’s state medical licensing board for alleged malpractice in which a patient he operated on died. Kim paid a $4,000 fine and received a letter of reprimand in settling the medical board case without admitting wrongdoing.

Kim also testified in the medical malpractice case that Sono Bello was aware he had previously settled four medical malpractice cases, court records show. Christopher Chung, Sono Bello’s chief medical officer, said the company verified that Kim’s state medical license and other credentials “were up to date and in good standing” before it hired him. “We reviewed his surgical log, which detailed the voluminous and complex surgeries he had performed at the hospital where he was then employed, and received positive references from his employer and other surgeons,” Chung said in an emailed statement.

A medical expert hired by Webb’s legal team opined that Sono Bello’s use of the term “fellowship” is deceptive because the program is not accredited, or recognized by any subspecialty certifying board, professional society, or hospital. A medical fellowship is typically a training program that lasts at least a year. “We strongly disagree with the suggestion that our website is misleading. We accurately state that our physicians are board-certified surgeons — because they are,” Sono Bello spokesperson Mark Firmani said in response.

In her lawsuit, Webb testified that Sono Bello’s advertisements on television and online led her to believe the company employed only board-certified plastic surgeons.

Had she been told of Kim’s background in advance, “I wouldn’t have had the surgery done,” Webb testified in a 2024 deposition. 

The parties settled the suit early this year under confidential terms.

Have you had liposuction, a “Mommy Makeover,” a tummy tuck, a Brazilian butt lift, or another type of cosmetic surgery? We’d like to hear about your experience. Click here to contact our reporting team.

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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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Under federal law, public schools must provide children with disabilities a “free appropriate public education,” to give them the same opportunity to learn as other kids.

The twins’ mother, Emma Miller, and tens of thousands of other parents in the U.S. have elevated complaints to the Education Department alleging that schools and states have ignored mistreatment of their children. Those complaints are in limbo as President Donald Trump’s administration has set about dismantling the federal agency.

Trump once mocked a reporter with a disability. Earlier this year, Health and Human Services Secretary Robert F. Kennedy Jr.’s inaccurate remarks about people with autism were criticized as perpetuating offensive stereotypes.

Now people like Miller are worried their children will be left behind.

“I want justice for my twins, and to sound the alarm so other special needs children are not suffering or being deprived,” said Miller, 53, who lives with her twins in Wake Forest, North Carolina.

The Education Department, which was created in 1979 and helps oversee schools and colleges in the U.S., has the authority to protect students from discrimination based on race, sex, religion, or disability. Its Office for Civil Rights investigates allegations at schools and negotiates corrective actions.

As the school year begins, families throughout the country are unsure what authority will be left to intervene on their behalf if the office is shuttered, said Hannah Russell, an advocate who works with parents in North Carolina trying to obtain educational services for their children with disabilities.

“Without the Department of Education there is no accountability,” said Russell, a former special education teacher. “Everybody is scared.”

Miller described her twins as her “miracle babies” who survived despite each weighing 1 pound at birth. Danielle Price spent the first five months of her life in a neonatal intensive care unit, and her brother, Devon, the first seven months.

She has spent years fighting for them, repeatedly taking on local and state school officials. But even when she notched victories, she said, her children did not get the help they were promised.

Miller said her children are high-functioning and verbal. She said they could have thrived academically if the school system had given them proper services.

“My children have suffered,” Miller wrote in a complaint she filed in September 2024. “The most vulnerable group of children [is] being denied a basic education.”

‘Unusual and Unprecedented’

Miller says her daughter began to self-harm after classmates teased and tormented her and staff secluded her away from her bullies. The Wake County Public School System assigned Devon to a classroom with an instructional assistant who was not a licensed teacher, a violation of policy, according to state documents.

Last year, Miller filed a complaint against Wake County schools with the federal Office for Civil Rights. She alleged the district did not reevaluate her kids to determine their special education needs, did not respond for months to her records requests, and retaliated against her by wrongly withdrawing the twins from the school district.

Wake County schools violated policy when staff did not address the effects of bullying on Danielle, says an April 2024 letter from the North Carolina Department of Public Instruction.

The school system’s education plan for Danielle “was not appropriate considering the student’s unmet social-emotional needs, which resulted in the student’s increased anxiety,” the letter says.

State officials concluded in June 2024 that the school system failed to develop, review, and revise an education plan for Devon, assigned him to a teacher assistant instead of a licensed teacher, and did not provide technology that could help him learn, according to documents.

While the decisions validated Miller’s concerns, she said that the district continues to violate her children’s rights and that the state is now ignoring her pleas for help.

“No one is taking responsibility,” she told KFF Health News. “It has been a nightmare.”

But after she appealed to the federal government last year, the Education Department sent her a letter in March saying it would not look into the complaint.

For decades, parents and advocates for people with disabilities have said the system makes it difficult for them to win against school districts, because the process is often time-consuming, confusing, and, if a family hires a lawyer, expensive. Now they say families could soon face even bigger hurdles.

On March 11, the day the Education Department sent Miller’s denial letter, the agency announced it was firing nearly half its 4,133 employees. Education Secretary Linda McMahon said the move was “a significant step toward restoring the greatness of the United States education system.”

Officials shuttered seven of the 12 regional offices of the agency’s Office for Civil Rights, leaving a skeleton staff to investigate thousands of complaints filed each year, according to attorneys and advocates for the disabled.

Trump, acting on a campaign promise to shrink the federal government, later signed an executive order to eliminate the Education Department, which he said had failed children and built a bloated bureaucracy.

The president instructed officials to “return authority over education to the States and local communities while ensuring the effective and uninterrupted delivery of services, programs, and benefits on which Americans rely.”

Parents and advocacy groups say that would allow local authorities to police themselves at a time when schools remain racially segregated, some selective colleges accept male applicants at higher rates than female applicants, and students with disabilities are struggling to recover academically from the covid pandemic, more so than their peers. Also, they note, the federal laws protecting disabled and disadvantaged children emerged because of state-level failures.

Under North Carolina law, children with disabilities should be reevaluated by schools every three years to help determine their individual needs. But Miller said Wake County officials for nearly a decade refused her requests to have her kids reevaluated. She said it finally happened in late 2024.

“I never expected getting an education for my children would be such a problem,” Miller said.

The Education Law Center, the NAACP, and other advocacy groups have sued to stop Trump’s plans, alleging the changes are illegal and pose a threat to the education of students from vulnerable groups. Some 20 states and the District of Columbia sued to halt the plan, but the Supreme Court ruled in July that the Trump administration could move ahead while the case proceeded through the courts.

Russell said she has heard North Carolina school districts are promising to provide accommodations for students with disabilities, such as extra time on tests.

But families who cannot afford to hire an attorney could find themselves at a disadvantage when disagreements arise over services that cost districts more money, Russell said.

The Trump administration has decimated the Office for Civil Rights’ ability to properly investigate a backlog of thousands of complaints, said Robert Kim, who leads the Education Law Center.

The office reported receiving nearly 23,000 complaints in fiscal 2024, the highest number ever. About 8,400, or 37%, involved allegations of disability discrimination.

Black children and those with disabilities may suffer the worst consequences, since they disproportionately face harsh discipline at school, including physical restraint and isolation in seclusion rooms, Kim said.

The Education Department says children with disabilities make up 14% of students but 75% of those secluded and 81% of those physically restrained.

Black children constitute about 15% of students but 42% of those who are mechanically restrained using a device or equipment.

“Something unusual and unprecedented is happening,” Kim said about what he sees as a shift in the federal government’s responsibility to keep children safe and provide a high-quality education.

The Education Department’s press office declined an interview request for this story in an unsigned email that was copied to agency officials Madison Biedermann, Savannah Newhouse, Julie Hartman, and Ellen Keast.

White House spokesperson Kush Desai did not respond to a request for comment.

In a July statement, McMahon said her agency is performing all of its duties: “We will carry out the reduction in force to promote efficiency and accountability and to ensure resources are directed where they matter most — to students, parents, and teachers.”

‘Nothing but Problems’

Danielle and Devon Price entered 10th grade at Wake Forest High School in August. Their mother said she is uncertain what will happen to them.

Danielle wants to go to college, but her math skills are at a fourth-grade level, school records show.

Like many youths with autism, Danielle struggles with changes in routine, and her mother said she became despondent when school officials repeatedly changed her classes to keep her away from a boy who bullied her. Soon after that, Danielle started to self-harm, Miller said, adding that her daughter receives intensive therapy.

“It has been nothing but problems” with Wake County schools, she said. “It is like no one cares.”

Wake County school officials declined to answer questions about Miller’s complaints, citing privacy laws.

In a written statement, district spokesperson Matthew Dees said that “the school district has worked hard to reach agreement with Ms. Miller on many issues” and remedied complaints that were substantiated.

“The district disputes the remaining allegations in the various complaints she has raised, including the many accusations against various staff,” Dees added.

Under federal law, parents have 180 days from the time of the last alleged violation to file a complaint with the Education Department. Miller submitted her complaint Sept. 12, 2024, exactly 180 days after she says her twins were last denied a “free appropriate public education.”

But the Office for Civil Rights said that was too late. Officials declined to waive the time limit for Miller, who had asked for an exception, according to its March denial letter.

She said she spent months fighting with Wake County school officials and did not turn to federal government sooner because she hoped she could resolve the issues locally.

Miller fears for her children’s future unless something changes at school.

“I’m a single parent, and one day I won’t be here,” she said. “My kids are going to be adults soon, yet my son doesn’t know how to read and write. I’m like, ‘Wow.’ There really is no help here.”

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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A July ruling by a three-judge panel of the 9th U.S. Circuit Court of Appeals upheld California’s right to mandate that every course doctors take to remain licensed must address how bias contributes to poorer health outcomes for racial and ethnic minorities. The ruling against the nonprofit Do No Harm and Los Angeles ophthalmologist Azadeh Khatibi amounts to a victory for California as it fights the Trump administration and right-leaning advocacy and legal groups’ attacks on perceived “wokeness.”

In August, the Pacific Legal Foundation, which represents Do No Harm and Khatibi, asked that a panel of 11 appellate judges reconsider what attorney Caleb Trotter characterized as a “very clearly wrong” decision. Trotter, a senior attorney for the Pacific Legal Foundation, expects the court’s response in October. If the appeal fails, he said, his firm would likely appeal to the U.S. Supreme Court. At stake, legal scholars say, is the latitude of states to prescribe educational content, including health equity training, for licensed professionals.

“The general recent tenor of the Supreme Court’s First Amendment jurisprudence has been very speech protective, so that we would like our odds with, of course, the understanding that any attempt to get the Supreme Court to take your case is a long shot,” Trotter said.

Erwin Chemerinsky, dean of the University of California-Berkeley law school, described the chances of the Supreme Court taking the case as “very unlikely” and the appellate ruling as “clearly correct” in affirming the state’s authority to impose course requirements.

California began requiring implicit-bias training for physicians in 2022. From 2019 through July 2022, five other states enacted legislation mandating the training. California is the only state that requires it to be included in every course involving direct patient care.

In enacting the law, the legislature found that bias contributed to health care disparities and persisted regardless of other factors influencing care. Black women, for example, are often prescribed less pain medication than white women with the same complaints and are three to four times as likely as white women to die of pregnancy-related causes.

Bias does influence clinical care and contribute to health care disparities, a 2022 report concluded. Implicit-bias training, however, might have no impact and might even worsen care, the report noted.

Do No Harm and Khatibi alleged that California’s law violated their First Amendment rights. Khatibi acknowledges that unconscious bias might prejudice how clinicians treat patients. But the Los Angeles ophthalmologist does not believe she should be forced to carve out time to talk about it in a class she might teach on, for example, ocular tumors.

“The government is mandating doctors endorse a specific ideology or priority instead of science,” she said. “I believe government should not mandate or compel the speech of doctors.”

The three-judge appellate panel disagreed. No one is forcing Khatibi to teach state-accredited continuing education, the panel wrote in its opinion affirming a lower court’s decision that the state had the right to mandate the training. The judges found that the curriculum requirement constitutes government speech and, therefore, is not subject to free-speech protections.  

The complaint against the California medical board does not dispute the state’s authority to require physicians to learn about unconscious prejudices. Instead, it argues the state has no right to demand that all teachers discuss bias in every continuing medical education class. California physicians must take at least 50 hours of continuing education every two years. Private institutions offer the courses, and physicians generally teach them.

Rep. Sydney Kamlager-Dove (D-Calif.), who wrote the bill when she was a member of the state Assembly, defended it. “By connecting every provider to consistent and evolving training, we can help close these gaps and provide more equitable care,” she said.

The Medical Board of California declined to comment.

Ashutosh Bhagwat, a UC Davis School of Law distinguished professor, said the state has a right to require implicit-bias training, although he disagrees that the training constitutes government speech. He sees it as private, but not compelled, speech because Khatibi and other instructors need only include a discussion of implicit bias if they want their classes to qualify for state licensing credit.

He likened the requirement to that of an accredited private school having to teach math. “Doesn’t matter if you don’t want to teach math. Doesn’t matter if you don’t believe in math,” he said. “You have to teach math.”

Bhagwat sees Khatibi’s case as “very weak.” But he said he could not predict anything the Supreme Court, with its six-justice conservative majority, might do.

“If Khatibi wins in the Supreme Court, or at any level, then chaos reigns because now every single requirement in any licensure that says you must teach this to qualify for continuing education is up for grabs,” he said.

Trotter fears the opposite outcome. If allowed to stand, the implicit-bias training mandate could be extended to continuing education for 50 trades and professions in California alone, he said. “Then all kinds of governments based on all kinds of views can start requiring private speakers to say all kinds of things that, depending on where you are, are going to be controversial in all different kinds of ways,” he said.

While Khatibi’s lawsuit and others like it have had little success in the courts, said Joan Williams, a distinguished professor emerita at UC Law-San Francisco, they have chilled the creation of laws deemed “woke” or those favoring diversity, equity, and inclusion, known as DEI.

“There’s been this huge attack on DEI, and it’s been extraordinarily effective in creating regulatory risk such that people are apprehensive and self-editing because they don’t want to put a target on their backs,” said Williams, who directs the Equality Action Center.

Still, some supporters of bias training say California could refine its approach. Cristina Gonzalez, an internist and a New York University Grossman School of Medicine professor, designs and evaluates interventions to help recognize, prevent, and repair clinicians’ prejudices. She described implicit-bias training as “a science” and California’s approach as misguided because it requires all instructors, regardless of their knowledge of implicit bias, to teach the material.

Finger-wagging and blaming in implicit-bias training can lead doctors to become defensive and avoid patients, but done correctly, by experts, it does work, Gonzalez said. “The messaging has to be, ‘You’re not a bad person,’” she said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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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