ALBANY, Ga. — Belinda McLoyd has been thinking about peanut butter.

McLoyd, 64, receives a small monthly payment through the federal Supplemental Nutrition Assistance Program, previously known as food stamps.

“They don’t give you that much to work with,” she said. To fit her tight budget, she eats ramen noodles — high on sodium and low on nutrition — multiple times a week.

If she had more money, said McLoyd, who has been diagnosed with multiple sclerosis and heart problems, she’d buy more grapes, melons, chuck roast, ground turkey, cabbage, and turnip greens. That’s what she did when lawmakers nearly doubled her SNAP benefit during the pandemic.

But now that a GOP-led Congress has approved $186 billion in cuts to the food assistance program through 2034, McLoyd, who worked in retail until she retired in 2016, isn’t sure how she will be able to eat any healthy food if her benefits get reduced again.

McLoyd said her only hope for healthy eating might be to resort to peanut butter, which she heard “has everything” in it.

“I get whatever I can get,” said McLoyd, who uses a walker to get around her senior community in southwestern Georgia. “I try to eat healthy, but some things I can’t, because I don’t have enough money to take care of that.”

The second Trump administration has said that healthy eating is a priority. It released a “Make America Healthy Again” report citing poor diet as a cause of childhood illnesses and chronic diseases. And it’s allowing states — including Arkansas, Idaho, and Utah — to limit purchases of unhealthy food with federal SNAP benefits for the first time in the history of the century-old anti-hunger program.

President Donald Trump also signed a tax and spending law on July 4 that will shift costs to states and make it harder for people to qualify for SNAP by expanding existing work requirements. The bill cuts about 20% of SNAP’s budget, the deepest cut the program has faced. About 40 million people now receive SNAP payments, but 3 million of them will lose their nutrition assistance completely, and millions more will see their benefits reduced, according to an analysis of an earlier version of the bill by the nonpartisan Congressional Budget Office.

Researchers say SNAP cuts run counter to efforts to help people prevent chronic illness through healthy food.

“People are going to have to rely on cheaper food, which we know is more likely to be processed, less healthy,” said Kate Bauer, an associate professor of nutritional sciences at the University of Michigan School of Public Health.

“It’s, ‘Oh, we care about health — but for the rich people,’” she said.

About 47 million people lived in households with limited or uncertain access to food in 2023, according to the U.S. Department of Agriculture. The agency’s research shows that people living in food-insecure households are more likely to develop hypertension, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

The Trump administration counters that the funding cuts would not harm people who receive benefits.

“This is total fearmongering,” said White House spokesperson Anna Kelly in an email. “The bill will ultimately strengthen SNAP for those who need it by implementing cost-sharing measures with states and commonsense work requirements.”

McLoyd and other residents in Georgia’s Dougherty County, where Albany is located, already face steep barriers to accessing healthy food, from tight budgets and high rates of poverty to a lack of grocery stores and transportation, said Tiffany Terrell, who founded A Better Way Grocers in 2017 to bring fresh food to people who can’t travel to a grocery store.

More than a third of residents receive SNAP benefits in the rural, majority-Black county that W.E.B. Du Bois described as “the heart of the Black Belt” and a place “of curiously mingled hope and pain,” where people struggled to get ahead in a land of former cotton plantations, in his 1903 book, “The Souls of Black Folk.”

Terrell said that a healthier diet could mitigate many of the illnesses she sees in her community. In 2017, she replaced school bus seats with shelves stocked with fruits, vegetables, meats, and eggs and drove her mobile grocery store around to senior communities, public housing developments, and rural areas.

But cuts to food assistance will devastate the region, setting back efforts to help residents boost their diet with fruits, vegetables, and other nutritious food and tackle chronic disease, she said.

Terrell saw how SNAP recipients like McLoyd ate healthier when food assistance rose during the pandemic. They got eggs, instead of ramen noodles, and fresh meat and produce, instead of canned sausages.

Starting in 2020, SNAP recipients received extra pandemic assistance, which corresponded to a 9% decrease in people saying there was sometimes or often not enough food to eat, according to the Institute for Policy Research at Northwestern University. Once those payments ended in 2023, more families had trouble purchasing enough food, according to a study published in Health Affairs in October. Non-Hispanic Black families, in particular, saw an increase in anxiety, the study found.

“We know that even short periods of food insecurity for kids can really significantly harm their long-term health and cognitive development,” said Katie Bergh, a senior policy analyst on the food assistance team at the Center on Budget Policy and Priorities. Cuts to SNAP “will put a healthy diet even farther out of reach for these families.”

The Trump administration said it’s boosting healthy eating for low-income Americans through restrictions on what they can buy with SNAP benefits. It has begun approving state requests to limit the purchase of soda and candy with SNAP benefits.

“Thank you to the governors of Indiana, Arkansas, Idaho, Utah, Iowa, and Nebraska for their bold leadership and unwavering commitment to Make America Healthy Again,” said Health and Human Services Secretary Robert F. Kennedy Jr. in a press release about the requests. “I call on every governor in the nation to submit a SNAP waiver to eliminate sugary drinks — taxpayer dollars should never bankroll products that fuel the chronic disease epidemic.”

Although states have asked for such restrictions in the past, previous administrations, including the first Trump administration, never approved them.

Research shows that programs encouraging people to buy healthy food are more effective than regulating what they can buy. Such limits increase stigma on families that receive benefits, are burdensome to retailers, and often difficult to implement, researchers say.

“People make incredibly tough choices to survive,” said Gina Plata-Nino, the deputy director of SNAP at the Food Research & Action Center, a nonprofit advocacy group, and a former senior policy adviser in the Biden administration.

“It’s not about soda and candy,” she said. “It’s about access.”

Terrell said she is unsure how people will survive if their food benefits are further trimmed.

“What are we thinking people are going to do?” said Terrell of A Better Way Grocers, who also opened a bustling community market last year that sells fresh juices, smoothies, and wellness shots in downtown Albany. “We’ll have people choosing between food and bills.”

That’s true for Stephen Harrison, 22, whose monthly SNAP benefit supports him, along with his parents and younger brother. During the pandemic, he used the extra assistance to buy strawberries and grapes, but now he comes into A Better Way Grocers to buy an orange when he can.

Harrison, who is studying culinary arts at Albany Technical College, said his family budgets carefully to afford meals like pork chops with cornbread and collard greens, but he said that, if his benefits are cut, the family will have to resort to cheaper foods.

“I’d buy hot dogs,” he said with a shrug.

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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SHREVEPORT, La. — When Robert Smith met his future girlfriend in 2010, he wanted to take things slowly. For Smith, no relationship had been easy in the years since he was diagnosed with the human immunodeficiency virus, or HIV. People often became afraid when they learned his status, even running away when he coughed.

The couple waited months to have sex until Smith felt he could share his medical status. To prepare her, Smith said, he took his girlfriend to his job in HIV prevention at the Philadelphia Center, a northwestern Louisiana nonprofit that offers resources to people with HIV, which also provided him housing at the time.

Finally, he revealed the news: Smith was diagnosed with HIV in 1994 and started taking daily antiviral pills in 2006. The virus could no longer be detected in his blood, and he couldn’t transmit it to a sexual partner.

Smith said his girlfriend seemed comfortable knowing his status. When it came to sex, there was no hesitation, he said. But a couple of years later, when Smith wanted to break up, he said, her tone shifted.

“She was like, ‘If you try to leave me, I’m gonna put you in jail,’” recalled Smith, now 68. “At the time, I really didn’t know the sincerity of it.”

After they broke up, she reported him to the police, accusing him of violating a little-known law in Louisiana — a felony called “intentional exposure to HIV.” He disputed the allegations, but in 2013 accepted a plea deal to spend six months in prison on the charge. He had a few months left on parole from a past conviction on different charges, and Smith thought this option would let him move past the relationship faster. He didn’t realize the conviction would also land him on the state’s sex offender registry.

For nearly two decades, Smith had dealt with the stigma associated with having HIV; the registry added another layer of exclusion, severely restricting where he could live and work to avoid minors. Not many people want to hire a sex offender, he said. Smith has been told by the local sheriff’s office he’s not allowed to do simple things, like go to a public park or a high school football game, since the conviction.

“I’ve been undetectable for 15 years, but that law still punishes us,” Smith said.

Louisiana is one of 30 states with criminal penalties related to exposing or transmitting HIV. Most of the laws were passed in the 1980s during the emergence of the AIDS epidemic. Since then, several states have amended their laws to make them less punitive or repealed them outright, including Maryland and North Dakota this year.

But Louisiana’s law remains among the harshest. The state is one of five that may require people such as Smith to register as a sex offender if convicted, a label that can follow them for over a decade. And state lawmakers considered a bill to expand the law to apply to other sexually transmitted infections, then failed to pass it before the session ended.

Meanwhile, people with HIV also face the threat that federal funding cuts will affect their access to treatment, along with prevention efforts, supportive services, and outreach. Such strategies have proved to slow the HIV/AIDS epidemic, unlike the laws’ punitive approach.

The tax and domestic policy law previously known as the “One Big Beautiful Bill” will likely affect HIV-positive people enrolled in Medicaid by reducing federal support for Medicaid and restricting eligibility. About 40% of adults under 65 with HIV rely on Medicaid.

The Trump administration proposed in its fiscal 2026 budget request to eliminate HIV prevention programs at the Centers for Disease Control and Prevention and to cancel a grant that helps fund housing for people with HIV. The Ryan White HIV/AIDS program, the largest federal fund dedicated to supporting HIV-positive people, also faces cuts. The program serves more than half of the people in the U.S. diagnosed with HIV, including in Louisiana, according to KFF, a health information nonprofit that includes KFF Health News.

Public health officials maintain that state laws criminalizing HIV exposure hurt efforts to end the HIV epidemic. Epidemiologists and other experts on AIDS agree that the enforcement of such laws is often shaped by fear, not science. For example, in many states that criminalize HIV exposure, people living with HIV can face heightened criminal penalties for actions that can’t transmit the virus, such as spitting on someone. The laws further stigmatize and deter people from getting tested and treatment, undermining response to the epidemic, experts say.

At least 4,400 people in 14 states have been arrested under these laws, though data is limited and the actual number is likely higher, and the arrests aren’t decreasing, according to analyses by UCLA’s Williams Institute.

“ Some people think it’s an issue that’s gone away, and that simply isn’t the case,” said Nathan Cisneros, a researcher at the Williams Institute.

In Louisiana, a 2022 Williams Institute analysis found at least 147 allegations reported to law enforcement under the state’s HIV law from 2011 to mid-2022. Black people made up nearly three-quarters of the people convicted and placed on the sex offender registry. Most were Black men, like Smith. At the time of the analysis, Black people made up about two-thirds of HIV diagnoses in the state.

“ We see over and over that Black people are disproportionately affected by the HIV epidemic and disproportionately affected by policing and incarceration in the United States,” Cisneros said.

Nationally, other marginalized groups such as women, sex workers, the queer community, or people who overlap across more than one group are also disproportionately arrested and prosecuted under similar criminalization laws, Cisneros said.

Ensnared in the System

Louisiana’s law hinges on the requirement that if a person knows they have HIV, they must disclose their HIV status and receive consent before exposing someone to the virus.

Louisiana District Attorneys Association Executive Director Zach Daniels said these cases don’t come up often and can be difficult to prosecute. Daniels said the intimate nature of the cases can lead to little evidence in support of either side, especially if the accuser doesn’t contract HIV.

When it comes to talking about one’s sex life, Daniels said, “there are often no other witnesses, besides the two participants.”

Louisiana’s law is written so that “intentional exposure” can occur through “any means or contact.” That includes sex and needle-sharing, practices known to transmit the virus. But the language of the law is so broad that actions known not to transmit the virus — like biting or scratching — could be included, said Dietz, the statewide coordinator for the Louisiana Coalition on Criminalization and Health, an advocacy network founded by people living with HIV that has opposed the law.

The broad nature of the law creates opportunities for abuse, as the threat of being reported under the law can be used as a coercive tool in relationships, said Dietz, who goes by one name and uses they/them pronouns. Such threats, Dietz said, have kept people in abusive relationships and loomed over child custody battles. Dietz said they’ve supported people accused of exposing their children to HIV in ways that are not medically possible.

“ ‘Any means or contact’ could be just merely being around your kids,” they said.

The prosecutors’ organization still supports the law as a recourse for emergency responders who, in rare instances, come into contact with blood or syringes containing the virus. In one recent high-profile case in New Orleans, the law was used against a local DJ accused of knowingly transmitting HIV to several women without informing them of his status or using a condom.

The person accused of violating the law, not the accuser, must prove their case — that they disclosed their HIV status beforehand. Without a signed affidavit or tape recording, courts can end up basing their decisions on conflicting testimonies with little supporting evidence.

That’s what Smith alleged happened to him.

After his relationship ended, he said, he remembered being called into a meeting with his parole officer where a detective waited for him, asking about his former relationship and whether his girlfriend had known about his HIV status.

Smith said yes. But that’s not what she had told police.

Verite News could not find a working phone number for Smith’s former girlfriend but corroborated the story with the incident’s police report. His attorney at the time, a public defender named Carlos Prudhomme, said he didn’t remember much about the case, and court documents are sealed because it was a sex offense.

In court, it was her word against his. So when he was offered six months in prison instead of the 10-year maximum, he switched his plea from not guilty to guilty. But he said he didn’t know his new conviction would require him to register as a sex offender once he got out — worsening the stigma.

“When people see ‘sex offender,’ the first thing that comes to their mind is rape, child molester, predator,” Smith said. “This law puts me in a category that I don’t care to be in.”

He has tried to make the most of it, despite the expense of paying fees each year to reregister. After being rejected from jobs, he started a catering business and built a loyal clientele. But he said he’s still stuck living in a poorly maintained apartment complex primarily inhabited by sex offenders.

“I understand their strategy for creating this law to prevent the spread, but it’s not helping. It’s hurting; it’s hindering. It’s destroying people’s lives instead of helping people’s lives, especially the HIV community,” he said. “They don’t care about us.”

The Case for Reform

Since 2014, there has been a nationwide effort to update or repeal state laws that criminalize HIV nondisclosure, exposure, or transmission. A dozen states have changed their laws to align more closely with modern science, and four have gotten rid of them completely in hopes of reducing stigma and improving public health outcomes, according to the Center for HIV Law and Policy.

Sean McCormick, an attorney with the center, said these changes are influenced partly by a growing body of evidence showing the laws’ negative consequences.

McCormick said the laws offer a “clear disincentive” for people to get tested for HIV. If they don’t know their status, there’s no criminal liability for transmission or exposure.

A 2024 survey by Centers for Disease Control and Prevention and DLH Corp. researchers found that after California updated its HIV criminalization law in 2018, respondents were more likely to get tested. Meanwhile, survey respondents in Nevada, which still had a more punitive law on the books, were less likely to get tested.

There’s no one-size-fits-all solution, McCormick said. His center works with HIV-positive people across the country to determine what legislative changes would work best in their states.

Texas was the first to repeal its HIV law in 1994.

“As a person living with HIV in Texas, I’m deeply appreciative that we don’t have an HIV-specific statute that puts a target on my back,” said Michael Elizabeth, the public health policy director for the Equality Federation.

But Elizabeth points out that Texans living with HIV still face steeper penalties under general felony laws for charges such as aggravated assault or aggravated sexual assault after state courts in Texas equated the bodily fluids of a person with HIV with a “deadly weapon.”

Louisiana activists have pushed lawmakers in the state to amend the law in three ways: removing the sex offender registration requirement, requiring transmission to have occurred, and requiring clear intent to transmit the virus.

“Our strategy, as opposed to repeal, is to create a law that actually addresses the kind of boogeyman that they ostensibly created the law for: the person who successfully, maliciously, intentionally transmits HIV,” said Dietz with the Louisiana Coalition on Criminalization and Health.

In 2018, a bill to narrow the statute was amended in ways that expanded the law. For example, the updated law no longer had any definition of which actions “expose” someone to HIV.

In 2023, state lawmakers created a task force that recommended updating Louisiana’s law to align with the latest public health guidelines, limit the potential for unintended consequences, and give previously convicted people a way to clear their record.

Lawmakers in the state House pushed forward a bill this year to criminalize other sexually transmitted infections, including hepatitis B and the herpes simplex virus. That bill died in the Senate, but it spurred the creation of another legislative task force with a nearly identical mission to that of the first.

“ This state has no idea how closely we just dodged a bullet,” Dietz said.

In the meantime, the Louisiana coalition is helping Smith petition the state to take his name off the sex offender registry. Louisiana law allows people to petition to have their names removed from the registry after 10 years without any new sex crime convictions. Smith expects his case to be approved by the end of the year.

Despite the difficulty of the past 12 years, he said, he’s grateful for the chance to be free from the registry’s restrictions.

“It’s like a breath of fresh air,” Smith said. “I can do stuff that I wanted to do that I couldn’t. Like, go to a football game. Simple stuff like that, I’m going to be ready to do.”

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

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KFF Health News Nevada correspondent Jazmin Orozco Rodriguez discussed the potential impact of Medicaid cuts on rural hospitals on KNPR’s “State of Nevada” on July 17.

• Click here to hear Orozco Rodriguez on “State of Nevada.”
• Read Orozco Rodriguez’s “‘One Big Beautiful Bill’ Would Batter Rural Hospital Finances, Researchers Say.”

KFF Health News chief Washington correspondent Julie Rovner discussed Medicaid cuts in President Donald Trump’s megabill on WAMU’s “1A” on July 16. Rovner also discussed immigrant health coverage on MSNBC’s “Velshi” on July 13.

• Click here to hear Rovner on “1A.”
• Click here to watch Rovner on “Velshi.”

Céline Gounder, KFF Health News’ editor-at-large for public health, discussed how artificial food dyes can affect health on CBS News’ “CBS Mornings” on July 15. She also discussed how to prevent tick bites on CBS News’ “CBS Mornings” on July 11.

• Click here to watch Gounder discuss food dyes on “CBS Mornings.”
• Click here to watch Gounder discuss tick bite prevention on “CBS Mornings.”

KFF Health News chief rural correspondent Sarah Jane Tribble discussed the impact of Trump’s tax and spending bill on rural health on Ideastream Public Media’s “Sound of Ideas” on July 15.

• Click here to hear Tribble on “Sound of Ideas.”

KFF Health News senior correspondent Renuka Rayasam discussed Medicaid work requirements on WUGA’s “The Georgia Health Report” on July 11.

• Click here to hear Rayasam on “The Georgia Health Report.”

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

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In the wake of January’s deadly wildfires, Los Angeles County leaders are weighing a disaster registry intended to help disabled and senior residents get connected to emergency responders to bring them to safety during disasters.

County supervisors approved a feasibility study this spring for such a voluntary database. Supporters applauded the effort to give more notice and assistance to the more than 1 million county residents with some type of disability, such as cognitive impairment or limited mobility.

“If we know that people perish in these situations, what are our answers?” said Hilary Norton, who runs FASTLinkDTLA, a nonprofit focused on mobility issues. “This is the time for people to really understand the magnitude for people in need when things like this happen.”

Amid the increasing frequency of natural disasters across the U.S. — brought into sharp relief by the recent deadly floods in Texas — state and local governments from Oregon to North Carolina have turned to disaster registries to prioritize help for vulnerable residents when fires, hurricanes, and other environmental catastrophes strike. But while some politicians say these registries are a potential solution to a public health problem, many disability advocates see them as ineffective tools that give people a false sense of security because there is no guarantee of evacuation help.

“They’re described in a way that communicates that if you place your information in this registry and you will need assistance, they will be able to plan for it, so in a disaster you will be safer. And in reality, that is simply not the case,” said Maria Town, president and CEO of the American Association of People with Disabilities.

Town, who has cerebral palsy, had been in Houston for six months when Hurricane Harvey hit in 2017. Texas makes a free registry called the State of Texas Emergency Assistance Registry available to cities and counties to help them identify needs in their communities, but how or if they use it is up to them. Fewer than 5% of people who registered were contacted during Harvey, and even fewer got evacuation assistance, according to a 2023 study by the National Council on Disability, a federal agency that advises on disability policies and programs. The hurricane took 89 lives.

“I heard people say, ‘I thought I was safe. I registered,’” Town said of the calls she got during and after Harvey.

Neither the Texas Division of Emergency Management nor officials in Kerr County, the area hit hardest by the recent floods in Texas Hill Country, responded to questions about whether any accommodations were made for residents on the registry during the early July catastrophe.

Many registries, like Florida’s Special Needs Registry, expressly tell participants they still must make their own evacuation plans. The Florida Department of Health oversees the registry and, like in Texas, shares the information with local emergency management officials for their use. In North Carolina’s Rockingham County, individuals must apply to be on the registry, and inclusion is not guaranteed. The registry page for Jackson and Josephine counties in Oregon warns that it can take up to three months for residents’ information to be made available to rescue workers.

The National Council on Disability says registries are harmful. “They are ineffective and provide a false sense of security of future guaranteed assistance,” Nicholas Sabula, a spokesperson for the organization, said in a statement.

The California Governor’s Office of Emergency Services also “strongly discourages” using registries, saying they can deter people from making their own disaster plans and raise privacy concerns. Disability advocates have also cited privacy as a concern.

But Los Angeles politicians behind the registry effort insist they are worth looking into — at least a third of those who died in the Eaton Fire had issues that could affect their mobility and therefore their ability to flee in the face of disaster, according to a Los Angeles Times analysis. Anthony Mitchell Sr., an amputee in a wheelchair, and his 35-year-old son, Justin, who had cerebral palsy, were among the 18 people killed when the wildfire ripped through the Los Angeles County community of Altadena in January.

Further driving the initiative is the aging of L.A. County’s population: The California Department of Finance’s Demographic Research Unit has estimated that more than a quarter of Los Angeles County residents will be 60 or over by 2030 — about 2.5 million people.

Supervisor Kathryn Barger, who represents Altadena and proposed the registry study along with Supervisor Janice Hahn, “wants to drill down and explore its usefulness,” according to her communications director, Helen Chavez Garcia. Barger had not yet talked to the first responder community or had conversations about how emergency services would use the registry, according to Chavez Garcia.

Victoria Jump, an assistant director at the county’s Aging & Disabilities Department, is conducting the feasibility study — which she noted does not include cost estimates — and will make a recommendation to the Board of Supervisors this month on whether to support the project. The board will decide whether to move forward. Jump said she’s gotten largely positive feedback in more than a dozen community sessions.

It’s not the first time Los Angeles has considered and even implemented a disaster registry. The county maintained a voluntary disaster registry called Specific Needs Awareness Planning, but acknowledged in 2016 that the program did “not guarantee priority service to those who register” and had a “low return on investment.” It was discontinued, and registrants were migrated to a mass emergency alert system called Alert LA County.

“We’ve been through this before with the county. It didn’t work. It hasn’t worked around the country,” said Los Angeles resident June Kailes, a disability advocate who uses a power scooter.

Kailes sees what happened in the Eaton Fire as a problem with emergency planning, saying that the county needs to better understand how to offer people with disabilities emergency transportation. She pointed to Galen Buckwalter, a paralyzed Eaton Fire survivor who reportedly drove his motorized wheelchair a mile in the dark to evacuate when he realized it would be impossible for a ride-hailing service to pick him up given the conditions.

Norton, of the mobility nonprofit FASTLinkDTLA, said the registry needs to be about more than just collecting names of disabled residents. “No one wants to create false hope,” Norton said. “It’s an agreement to explore the possibilities. It’s that balance of asking now, in order to make sure in the next disaster they are not left behind.”

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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LISTEN: Federal law entitles patients to interpreters if they don’t have a strong grasp of English. KFF Health News correspondent Vanessa G. Sánchez appeared on WAMU’s “Health Hub” on July 9 to explain why some Trump administration policies are leaving patients fearful to ask for language services. 

Patients need to communicate clearly with their health care provider. But that’s getting more difficult for those in the U.S. who don’t speak English. 

Budget cuts by the Trump administration have left some providers scrambling to keep qualified medical interpreters. And an executive order designating English the official language of the United States has created confusion among providers about what services should be offered. 

Patients who don’t speak English are left afraid, and perhaps at risk for medical mistakes. What happens when those who need help are too frightened to ask? 

In WAMU’s July 9 “Health Hub” segment, KFF Health News correspondent Vanessa G. Sánchez explained why health advocates worry these changes could lead to worse patient outcomes. 

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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Céline Gounder, KFF Health News’ editor-at-large for public health, discussed measles cases on CBS News’ “CBS News 24/7” on July 9. Gounder also discussed the presence of Immigration and Customs Enforcement in medical facilities on CBS News’ “CBS Mornings Plus” on July 8.

• Click here to watch Gounder on “CBS News 24/7.”
• Click here to watch Gounder on “CBS Mornings Plus.”

KFF Health News contributor Sarah Kwon discussed a delay in implementing California’s law mandating that some insurance plans cover in vitro fertilization on KVPR’s “Central Valley Daily” podcast on July 9.

• Click here to hear Kwon on “Central Valley Daily.”
• Read Kwon’s “California’s Much-Touted IVF Law May Be Delayed Until 2026, Leaving Many in the Lurch.”

KFF Health News senior correspondent Angela Hart discussed how health care cuts in President Donald Trump’s megabill will affect Californians on KQED’s “Political Breakdown” podcast on July 8.

• Click here to hear Hart on “Political Breakdown.”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Renuka Rayasam, and Bernard J. Wolfson.

KFF Health News chief rural correspondent Sarah Jane Tribble discussed possible effects of the megabill on rural hospitals on CNN’s “CNN This Morning” on July 4.

• Click here to watch Tribble on “CNN This Morning.”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Renuka Rayasam, and Bernard J. Wolfson.

KFF Health News senior correspondent Renuka Rayasam discussed the megabill and its impacts on health care in Texas on KXAN’s “KXAN Midday” on July 3.

• Click here to hear Rayasam on “KXAN Midday.”
• Read “Republican Megabill Will Mean Higher Health Costs for Many Americans,” by Phil Galewitz, Julie Appleby, Rayasam, and Bernard J. Wolfson.

KFF Health News Southern correspondent Sam Whitehead discussed enrollment in Affordable Care Act marketplace plans on WUGA’s “The Georgia Health Report” on June 27.

• Click here to hear Whitehead on “The Georgia Health Report.”
• Read “In a First, Trump and GOP-Led Congress Prepare To Swell Ranks of US Uninsured,” by Renuka Rayasam and Whitehead.

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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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Elliott Hinkle experienced depression and suicidal thoughts even before entering the foster care system in Casper, Wyoming, at age 15.

At the time, Hinkle, who is transgender, struggled with their sexual identity and gender issues, and their difficulties continued in foster care. They felt like they had no one to confide in — not their foster parents, not church leaders, not their caseworker.

“To my knowledge, I don’t remember ever taking a suicide screening,” Hinkle said. “No one ever said: ‘Are you having thoughts of taking your life? Do you feel hopeless?’”

With their psychological and behavioral health needs left unaddressed, Hinkle’s depression and suicidal thoughts worsened.

“Do I stay in the closet and feel terrible and want to end my life?” Hinkle said. “Or do I come out and lose all my supports, which also feels dangerous?”

Children in foster care are significantly more likely to have mental health issues, researchers say. They attempt or complete suicide at rates three to four times that of youths in the general population, according to several studies.

LGBTQ+ people in foster care, like Hinkle, are at an even higher risk of having suicidal thoughts.

Yet despite the concentration of young people at risk of serious mental illness and suicide, proactive efforts to screen foster children and get them the treatment they need have been widely absent from the system. And now, efforts underway to provide widespread screening, diagnosis, and treatment are threatened by sweeping funding cuts the Trump administration is using to reshape health care programs nationwide.

In June, federal officials announced they would shut down a suicide hotline serving LGBTQ+ youths as part of those cuts.

Children in foster care use a disproportionate amount of Medicaid-funded mental health services. Meanwhile, President Donald Trump’s massive budget package, passed this month by Congress, contains substantial shifts in Medicaid funding and policies that are projected to drastically reduce services in many states.

“I think anybody who cares about kids’ well-being and mental health is concerned about the possibility of reduced Medicaid funding,” said Cynthia Ewell Foster, a child psychologist and clinical associate professor in the University of Michigan psychiatry department. “The most vulnerable children, including those in foster care, are already having trouble getting the services they need.”

A lack of federal standards and other system-level issues create barriers to psychological and behavioral care in the child welfare system, said Colleen Katz, a professor at Hunter College’s Silberman School of Social Work in New York.

“When you’re talking about anyone getting screened for suicide ideation upon entrance into the system, it’s inconsistent at best,” she said.

Katz said all children entering foster care should have a brief, standardized suicide screening embedded into their initial medical assessment. And more screenings need to be conducted throughout a foster care stay, she said, because youths getting ready to transition out of the system are also vulnerable. 

Hinkle, now 31, said the summer before they aged out of the system was “one of the darkest periods, because I was coming to terms with the church not wanting me to be gay and I was about to lose stable housing and whatever foster care support there was.”

Katz studied transition-age youths in foster care in California, which has the highest numbers of placements in foster care nationwide. According to her analysis, 42% of study participants had thoughts of taking their life and 24% had attempted suicide, and she expects findings would be similar in other states.

Katz also examined suicide screening tools and found many that already exist could work and be easily administered by trained child welfare workers or alternative frontline service providers, or embedded in existing mental health services.

Still, the quality of services varies by state and locality and can hinder attempts to curb suicides.

Julie Collins, vice president of practice excellence at the Child Welfare League of America, which advocates for improvements to the child welfare system, said the gap in suicide prevention in foster care mirrors the overall nationwide void of behavioral health services for children and adolescents. “The preparation of people coming into the field isn’t what it needs to be,” Collins said of the lack of training for caseworkers.

Ewell Foster is trying to change that.

She worked with the state of Michigan to redefine and update the competencies required to earn an undergraduate certificate in child welfare in the state. Eighteen colleges and universities that offer certificate programs in child welfare in Michigan now teach about suicide prevention.

“It’s something the workforce has asked for,” Ewell Foster said. “They need real clear guidance on what to do when they are worried about someone.”

So far, Ewell Foster’s effort to change the wider system has not run into any roadblocks. Her work with Michigan’s child welfare agency is still being funded under a grant administered by the Substance Abuse and Mental Health Services Administration.

Agency spokesperson Danielle Bennett said such grants will continue for up to three years.

However, the future of the federal agency has been in question for months. The Trump administration has laid off hundreds of its employees and has proposed folding its functions into another agency.

Some states have made changes to address the foster care gaps on their own, but often it has taken legal action to spark changes in suicide prevention efforts.

In Kansas, officials made several changes after the state settled the McIntyre v. Howard class action lawsuit in 2021 on behalf of foster children who the suit alleged were subjected to inadequate access to mental health resources and moved from home to home frequently.

The state increased salaries for social workers in the child welfare system and reduced their caseloads, among other things.

Other states, including Texas, have implemented similar changes after facing lawsuits.

Still, experts caution that the changes taking place in foster care systems are not enough to steer outcomes.

Lily Brown, an assistant professor of psychology and director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania Perelman School of Medicine, said moving the needle in suicide prevention will require implementing a universal risk assessment for children in state care.

Brown recently sought a grant to fund and implement free, universal suicide risk screening in foster care throughout Pennsylvania. She had several counties agree to the project, but not enough to support her application — the study wouldn’t have had enough participants to work statistically, she said.

Without such studies, foster care systems nationwide can’t meet the needs of children, she said.

April Miller, 27, entered the system in Minnesota at age 3. As a Native American, she is part of a group that is overrepresented in foster care.

“The child welfare system as a whole neglected me,” said Miller, who said she endured several traumatic events in her early life, including witnessing a murder.

“I did a lot of self-harm and had thoughts of suicide but didn’t have access to means, which is why I am still alive,” she said.

Today, Miller is a social worker and suicide prevention coordinator in Bemidji, Minnesota.

Similarly, Hinkle’s experience in the system made them driven to change the trajectory of other young people.

Hinkle provides training, consultation, and policy development services at Unicorn Solutions in Oregon in support of youths and young adults affected by systems such as child welfare, with a particular focus on the LGBTQ+ community.

They said they are committed to making sure that sexual identity and gender topics are not avoided in the system.

“I think every young person should feel loved and cared for,” Hinkle said.

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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After years of legal battles, state attorneys general won billions of dollars in opioid settlements from drug companies accused of fueling the addiction crisis. They declared victory at press conferences, and some touted the deals during their gubernatorial campaigns.

But now that the windfall is being spent, are attorneys general doing enough to ensure it’s used for the intended purposes?

No, say many families affected by the overdose crisis, recovery and harm reduction advocates, policy experts, and researchers following the cash.

“This is blood money,” said Toni Torsch, a Maryland resident whose son Dan died of an overdose at age 24. It can’t make up for the lives lost, but “we do want to make sure that it’s going to count.”

Torsch and others affected by the crisis are increasingly worried that no one seems to be guarding the opioid settlement cash while elected officials eye it hungrily. With the Trump administration slashing federal funding for addiction and Congress approving massive reductions to Medicaid — the largest payer for addiction care nationwide — people fear state legislators will use the settlements as a grab bag to fill budget shortfalls.

In the face of these concerns, two research and advocacy organizations are proposing a solution: a crowdsourced database to identify potential examples of misuse and prompt attorneys general to investigate.

The Opioid Policy Institute and Popular Democracy launched a website that allows members of the public to submit alleged cases of waste, fraud, abuse, and mismanagement of opioid settlement funds. Submissions are reviewed by Jonathan Stoltman, director of the Opioid Policy Institute, and then posted with details such as how much money was spent, what was purchased, who made the decision, and links to relevant news articles or budget documents.

The database, shared first with KFF Health News, includes about 150 examples to start, including $2,362 awarded by a Missouri county to its roads and bridge department and $375,600 spent on a body scanner for a Michigan county jail. The initial examples were sourced from people in recovery, advocates, and others Stoltman and his team asked to test the project. Stoltman acknowledged he’ll face criticism as the primary arbiter of what qualifies as misuse for the database, but said he’ll use research studies to defend his decisions.

The website also shows people how to file complaints with their state attorney general and ask the office to develop a formal process for receiving and investigating such complaints.

“I hope this is a wake-up call for state AGs that their work on this project is not done,” said Frank Kearl, who co-led the effort with Stoltman and is working as an attorney at Popular Democracy until July 14. “We still have time” to make changes to ensure we “spend this money in a way that actually responds to the harm that was caused.”

The website’s launch comes just over a week after New Jersey lawmakers passed a budget that gave health systems $45 million in settlement funds despite the state attorney general’s opposition. Legislators said it would shield hospitals from the blow of federal Medicaid cuts, but harm-reduction advocates said it gives short shrift to people with substance use disorders, whom the money was meant to serve.

Lawmakers in North Carolina and Washington, D.C., are also considering using settlement funds to plug gaps, and Connecticut and Nevada have discussed it too.

“That’s not what it’s there for,” said Torsch, who runs a nonprofit dedicated to addiction recovery in her son’s honor. “We want to make sure that money is being spent in the most responsible and effective way to help people that are still struggling.”

Last year, when Torsch heard that a western Maryland county spent some of its settlement money on guns, she reached out to her state attorney general to complain. The office said it wasn’t its responsibility, Torsch said, and told her to contact the health department.

She was confused.

The attorney general’s office is supposed to represent “the top cops,” Torsch told KFF Health News.

The Maryland attorney general’s office declined to answer KFF Health News’ questions about how it handles opioid settlement complaints.

About a dozen companies are expected to pay state and local governments more than $50 billion in opioid settlements over nearly two decades. Purdue Pharma’s case, the most well known, is still wending its way through court. But other companies, including Johnson & Johnson, CVS Health, and Walgreens, have begun paying.

Although the specifics of each settlement deal vary, most require states to use at least 85% of the money on efforts related to the opioid crisis. But enforcement is left to the companies that paid out the money. And legal experts are skeptical that the companies are monitoring state spending.

Attorneys general should be enforcing that standard too, said Stoltman, of the Opioid Policy Institute. “If you’re going to bang your chest about how much money you got for your state for opioids,” he said, “what are you doing to make sure that it’s actually being spent well?”

Stoltman’s and Kearl’s teams surveyed attorneys general offices in 56 states and territories to see if each office had a complaint form specific to this pot of money, explained the details needed to report misuse, and allowed submitters to track their complaints. They also searched websites of state auditors, comptrollers, and similar entities for complaint forms or procedures.

Their findings? Only three states mentioned specific processes for reporting misuse of opioid settlement money.

South Carolina and New Jersey had links on settlement-related websites that directed people to general complaint forms. Oklahoma was the only state to have an opioid settlement-specific form.

Jill Nichols, opioid response and grant coordinator in the Oklahoma Office of Attorney General, said it was created in April in response to the researchers’ inquiry. As of late June, she’d received one complaint, which was found to be without merit.

Stoltman and Kearl said they hope the crowdsourced database will encourage more attorneys general to take an active oversight role by illustrating how much potential misuse is occurring.

The Michigan attorney general’s office said it plans to publish a settlement-specific complaint form this year.

But some attorneys general told KFF Health News it wasn’t their job to track how the money is spent.

Brett Hambright, a spokesperson for Pennsylvania Attorney General David Sunday, said the state created an opioid settlement council to take on that responsibility.

In North Carolina, Attorney General Jeff Jackson’s office said, settlement funds are controlled by the state legislature and local governments. “Our office does not administer the funds nor do we have the power to withhold them,” spokesperson Ben Conroy said.

Even when attorneys general watch the money closely, their power may be limited. For example, Arizona Attorney General Kris Mayes went to court last year to stop the state legislature from giving $115 million in settlement funds to the Department of Corrections. But a judge ruled against her.

Maryland Attorney General Anthony Brown’s office directed KFF Health News’ questions to other state agencies.

Michael Coury, a spokesperson for Maryland’s Office of Overdose Response, said members of the public can email the office with complaints. If the office agrees misuse has occurred, it will bring the complaint to the attorney general, who — per the state’s agreement with local governments — “may” take action.

As of this year, the attorney general’s office will receive $1.5 million of Maryland’s opioid settlement funds annually to cover personnel and administration costs related to opioid-related lawsuits. This may involve suing more companies for future settlement deals.

Torsch, the Maryland mom, said she wishes the focus wasn’t just on winning more money but also ensuring that existing settlement dollars are spent well.

“We owe it to all the families that have been destroyed and suffered great losses,” she said.

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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LOS ANGELES — Inside a bright new building in the heart of Skid Row, homeless people hung out in a canopy-covered courtyard — some waiting to take a shower, do laundry, or get medication for addiction treatment. Others relaxed on shaded grass and charged their phones as an intake line for housing grew more crowded.

The Skid Row Care Campus officially opened this spring with ample offerings for people living on the streets of this historically downtrodden neighborhood. Pop-up fruit stands and tent encampments lined the sidewalks, as well as dealers peddling meth and fentanyl in open-air drug markets. Some people, sick or strung out, were passed out on sidewalks as pedestrians strolled by on a recent afternoon.

For those working toward sobriety, clinicians are on site to offer mental health and addiction treatment. Skid Row’s first methadone clinic is set to open here this year. For those not ready to quit drugs or alcohol, the campus provides clean syringes to more safely shoot up, glass pipes for smoking drugs, naloxone to prevent overdoses, and drug test strips to detect fentanyl contamination, among other supplies.

As many Americans have grown increasingly intolerant of street homelessness, cities and states have returned to tough-on-crime approaches that penalize people for living outside and for substance use disorders. But the Skid Row facility shows Los Angeles County leaders’ embrace of the principle of harm reduction, a range of more lenient strategies that can include helping people more safely use drugs, as they contend with a homeless population estimated around 75,000 — among the largest of any county in the nation. Evidence shows the approach can help individuals enter treatment, gain sobriety, and end their homelessness, while addiction experts and county health officials note it has the added benefit of improving public health.

“We get a really bad rap for this, but this is the safest way to use drugs,” said Darren Willett, director of the Center for Harm Reduction on the new Skid Row Care Campus. “It’s an overdose prevention strategy, and it prevents the spread of infectious disease.”

Despite a decline in overdose deaths, drug and alcohol use continues to be the leading cause of death among homeless people in the county. Living on the streets or in sordid encampments, homeless people saddle the health care system with high costs from uncompensated care, emergency room trips, inpatient hospitalizations, and, for many of them, their deaths. Harm reduction, its advocates say, allows homeless people the opportunity to obtain jobs, taxpayer-subsidized housing, health care, and other social services without being forced to give up drugs. Yet it’s hotly debated.

Politicians around the country, including Gov. Gavin Newsom in California, are reluctant to adopt harm reduction techniques, such as needle exchanges or supervised places to use drugs, in part because they can be seen by the public as condoning illicit behavior. Although Democrats are more supportive than Republicans, a national poll this year found lukewarm support across the political spectrum for such interventions.

Los Angeles is defying President Donald Trump’s agenda as he advocates for forced mental health and addiction treatment for homeless people — and locking up those who refuse. The city has also been the scene of large protests against Trump’s immigration crackdown, which the president has fought by deploying National Guard troops and Marines.

Trump’s most detailed remarks on homelessness and substance use disorder came during his campaign, when he attacked people who use drugs as criminals and said that homeless people “have no right to turn every park and sidewalk into a place for them to squat and do drugs.” Health and Human Services Secretary Robert F. Kennedy Jr. reinforced Trump’s focus on treatment.

“Secretary Kennedy stands with President Trump in prioritizing recovery-focused solutions to address addiction and homelessness,” said agency spokesperson Vianca Rodriguez Feliciano. “HHS remains focused on helping individuals recover, communities heal, and help make our cities clean, safe, and healthy once again.”

A comprehensive report led by Margot Kushel, a professor of medicine at the University of California-San Francisco, this year found that nearly half of California’s homeless population had a complex behavioral health need, defined as regular drug use, heavy drinking, hallucinations, or a recent psychiatric hospitalization.

The chaos of living outside, she said — marked by violence, sexual assault, sleeplessness, and lack of housing and health care — can make it nearly impossible to get sober.

Skid Row Care Campus

The new care campus is funded by about $26 million a year in local, state, and federal homelessness and health care money, and initial construction was completed by a Skid Row landlord, Matt Lee, who made site improvements on his own, according to Anna Gorman, chief operating officer for community programs at the Los Angeles County Department of Health Services. Operators say the campus should be able to withstand potential federal spending cuts because it is funded through a variety of sources.

Glass front doors lead to an atrium inside the yellow-and-orange complex. It was designed with input from homeless people, who advised the county not just on the layout but also on the services offered on-site. There are 22 recovery beds and 48 additional beds for mostly older homeless people, arts and wellness programs, a food pantry, and pet care. Even bunnies and snakes are allowed.

John Wright, 65, who goes by the nickname Slim, mingled with homeless visitors one afternoon in May, asking them what they needed to be safe and comfortable.

“Everyone thinks we’re criminals, like we’re out robbing everyone, but we aren’t,” said Wright, who is employed as a harm reduction specialist on the campus and is trying, at his own pace, to stop using fentanyl. “I’m homeless and I’m a drug addict, but I’m on methadone now so I’m working on it,” he said.

Nearby on Skid Row, Anthony Willis rested in his wheelchair while taking a toke from a crack pipe. He’d just learned about the new care campus, he said, explaining that he was homeless for roughly 20 years before getting into a taxpayer-subsidized apartment on Skid Row. He spends most of his days and nights on the streets, using drugs and alcohol.

The drugs, he said, help him stay awake so he can provide companionship and sometimes physical protection for homeless friends who don’t have housing. “It’s tough sometimes living down here; it’s pretty much why I keep relapsing,” said Willis, who at age 62 has asthma and arthritic knees. “But it’s also my community.”

Willis said the care campus could be a place to help him kick drugs, but he wasn’t sure he was ready.

Research shows harm reduction helps prevent death and can build long-term recovery for people who use substances, said Brian Hurley, an addiction psychiatrist and the medical director for the Bureau of Substance Abuse Prevention and Control at the Los Angeles County Department of Public Health. The techniques allow health care providers and social service workers to meet people when they’re ready to stop using drugs or enter treatment.

“Recovery is a learning activity, and the reality is relapse is part of recovery,” he said. “People go back and forth and sometimes get triggered or haven’t figured out how to cope with a stressor.”

Swaying Public Opinion

Under harm reduction principles, officials acknowledge that people will use drugs. Funded by taxpayers, the government provides services to use safely, rather than forcing people to quit or requiring abstinence in exchange for government-subsidized housing and treatment programs.

Los Angeles County is spending hundreds of millions to combat homelessness, while also launching a multiyear “By LA for LA” campaign to build public support, fight stigma, and encourage people to use services and seek treatment. Officials have hired a nonprofit, Vital Strategies, to conduct the campaign including social media advertising and billboards to promote the expansion of both treatment and harm reduction services for people who use drugs.

The organization led a national harm reduction campaign and is working on overdose prevention and public health campaigns in seven states using roughly $70 million donated by Michael Bloomberg, the former mayor of New York.

“We don’t believe people should die just because they use drugs, so we’re going to provide support any way that we can,” said Shoshanna Scholar, director of harm reduction at the Los Angeles County Department of Health Services. “Eventually, some people may come in for treatment but what we really want is to prevent overdose and save lives.”

Los Angeles also finds itself at odds with California’s Democratic governor. Newsom has spearheaded stricter laws targeting homelessness and addiction and has backed treatment requirements for people with mental illness or who use drugs. Last year, California voters approved Proposition 36, which allows felony charges for some drug crimes, requires courts to warn people they could be charged with murder for selling or providing illegal drugs that kill someone, and makes it easier to order treatment for people who use drugs.

Even San Francisco approved a measure last year that requires welfare recipients to participate in treatment to continue receiving cash aid. Mayor Daniel Lurie recently ordered city officials to stop handing out free drug supplies, including pipes and foil, and instead to require participation in drug treatment to receive services. Lurie signed a recovery-first ordinance, which prioritizes “long-term remission” from substance use, and the city is also expanding policing while funding new sober-living sites and treatment centers for people recovering from addiction.

‘Harm Encouragement’

State Sen. Roger Niello, a Republican who represents conservative suburbs outside Sacramento, says the state needs to improve the lives of homeless people through stricter drug policies. He argues that providing drug supplies or offering housing without a mandate to enter treatment enables homeless people to remain on the streets.

Proposition 36, he said, needs to be implemented forcefully, and homeless people should be required to enter treatment in exchange for housing.

“I think of it as tough love,” Niello said. “What Los Angeles is doing, I would call it harm encouragement. They’re encouraging harm by continuing to feed a habit that is, quite frankly, killing people.”

Keith Humphreys, who worked in the George W. Bush and Barack Obama administrations and pioneered harm reduction practices across the nation, said that communities should find a balance between leniency and law enforcement.

“Parents need to be able to walk their kids to the park without being traumatized. You should be able to own a business without being robbed,” he said. “Harm reduction and treatment both have a place, and we also need prevention and a focus on public safety.”

Just outside the Skid Row Care Campus, Cindy Ashley organized her belongings in a cart after recently leaving a local hospital ER for a deep skin infection on her hand and arm caused by shooting heroin. She also regularly smokes crack, she said.

She was frantically searching for a home so she could heal from two surgeries for the infection. She learned about the new care campus and rushed over to get her name on the waiting list for housing.

“I’m not going to make it out here,” she said, in tears.

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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As summer ushers in peak mosquito season, health and vector control officials are bracing for the possibility of another year of historic rates of dengue. And with climate change, the lack of an effective vaccine, and federal research cuts, they worry the disease will become endemic to a larger swath of North America.

About 3,700 new dengue infections were reported last year in the contiguous United States, up from about 2,050 in 2023, according to the Centers for Disease Control and Prevention. All of last year’s cases were acquired abroad, except for 105 cases contracted in California, Florida, or Texas. The CDC issued a health alert in March warning of the ongoing risk of dengue infection.

“I think dengue is here with us to stay,” said infectious disease specialist Michael Ben-Aderet, associate medical director of hospital epidemiology at Cedars-Sinai in Los Angeles, about dengue becoming a new normal in the U.S. “These mosquitoes aren't going anywhere.”

Dengue is endemic — a label health officials assign when diseases appear consistently in a region — in many warmer parts of the world, including Latin America, India, and Southeast Asia. Dengue cases increased markedly last year in many of those places, especially in Central and South America.

The disease, which can spread when people are bitten by infected Aedes mosquitoes, was not common in the contiguous United States for much of the last century. Today, most locally acquired (meaning unrelated to travel) dengue cases in the U.S. happen in Puerto Rico, which saw a sharp increase in 2024, triggering a local public health emergency.

Most people who contract dengue don’t get sick. But in some people symptoms are severe: bleeding from the nose or mouth, intense stomach pain, vomiting, and swelling. Occasionally, dengue causes death.

California offers a case study in how dengue is spreading in the U.S. The Aedes aegypti and Aedes albopictus mosquitoes that transmit dengue weren’t known to be in the state 25 years ago. They are now found in 25 counties and more than 400 cities and unincorporated communities, mostly in Southern California and the Central Valley.

The spread of the mosquitoes is concerning because their presence increases the likelihood of disease transmission, said Steve Abshier, president of the Mosquito and Vector Control Association of California.

From 2016 through 2022, there were an average of 136 new dengue cases a year in California, each case most likely brought to the state by someone who had traveled and been infected elsewhere. In 2023, there were about 250 new cases, including two acquired locally.

In 2024, California saw 725 new dengue cases, including 18 acquired locally, state data shows.

Climate change could contribute to growth in the Aedes mosquitoes’ population, Ben-Aderet said. These mosquitoes survive best in warm urban areas, often biting during the daytime. Locally acquired infections often occur when someone catches dengue during travel, then comes home and is bitten by an Aedes mosquito that bites and infects another person.

“They've just been spreading like wildfire throughout California,” Ben-Aderet said.

Dengue presents a challenge to the many primary care doctors who have never seen it. Ben-Aderet said doctors who suspect dengue should obtain a detailed travel history from their patients, but confirming the diagnosis is not always quick.

“There's no easy test for it,” he said. “The only test that we have for dengue is antibody tests.” He added that “most labs probably aren't doing it commercially, so it's usually like a send-out test from most labs. So you really have to suspect someone has dengue.”

Best practices for avoiding dengue include eliminating any standing pools of water on a property — even small pools — and using mosquito repellent, Abshier said. Limiting activity at dusk and dawn, when mosquitoes bite most often, can also help.

Efforts to combat dengue in California became even more complicated this year after wildfires ripped through Los Angeles. The fires occurred in a hot spot for mosquito-borne illnesses. San Gabriel Valley Mosquito and Vector Control District officials have worked for months to treat more than 1,400 unmaintained swimming pools left in the wake of fire, removing potential breeding grounds for mosquitoes.

San Gabriel vector control officials have used local and state resources to treat the pools, said district spokesperson Anais Medina Diaz. They have applied for reimbursement from the Federal Emergency Management Agency, which has not historically paid for vector control efforts following wildfires.

In California, vector control agencies are often primarily funded by local taxes and fees on property owners.

Some officials are pursuing the novel method of releasing sterilized Aedes mosquitoes to reduce the problem. That may prove effective, but deploying the method in a large number of areas would be costly and would require a massive effort at the state level, Abshier said. Meanwhile, the federal government is pulling back on interventions: Several outlets have reported that the National Institutes of Health will stop funding new climate change-related research, which could include work on dengue.

This year, reported rates of dengue in much of the Americas have declined significantly from 2024. But the trend in the United States likely won’t be clear until later in the year, after the summer mosquito season ends.

Health and vector control researchers aren't sure how bad it will get in California. Some say there may be limited outbreaks, while others predict dengue could get much worse. Sujan Shresta, a professor and infectious disease researcher at the La Jolla Institute for Immunology, said other places, like Nepal, experienced relatively few cases of dengue in the recent past but now regularly see large outbreaks.

There is a vaccine for children, but it faces discontinuation from a lack of global demand. Two other dengue vaccines are unavailable in the United States. Shresta’s lab is hard at work on an effective, safe vaccine for dengue. She hopes to release results from animal testing in a year or so; if the results are positive, human trials could be possible in about two years.

“If there's no good vaccine, no good antivirals, this will be a dengue-endemic country,” she said.

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

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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Con el verano marcando el comienzo de la temporada alta de mosquitos, autoridades sanitarias y de control de vectores se preparan para la posibilidad de otro año con tasas históricas de dengue. Y con el cambio climático, la falta de una vacuna eficaz y los recortes federales en la investigación, les preocupa que la enfermedad se vuelva endémica en una franja más amplia de Norteamérica.

El año pasado se reportaron alrededor de 3.700 nuevas infecciones por dengue en Estados Unidos, frente a las 2.050 de 2023, según los Centros para el Control y Prevención de Enfermedades (CDC). Todos los casos de 2024 se adquirieron en el extranjero, excepto 105 contraídos en California, Florida o Texas. Los CDC emitieron una alerta sanitaria en marzo advirtiendo sobre el riesgo continuo de infección por dengue.

"Creo que el dengue ha llegado para quedarse", declaró Michael Ben-Aderet, especialista en enfermedades infecciosas y director médico asociado de epidemiología hospitalaria del Cedars-Sinai de Los Ángeles, sobre la posibilidad de que el dengue se convierta en la nueva normalidad en el país. "Estos mosquitos no se irán a ninguna parte".

El dengue es endémico —una etiqueta que las autoridades de salud pública asignan cuando las enfermedades aparecen de forma constante en una región— en muchas zonas más cálidas del mundo, como Latinoamérica, India y el sudeste asiático. Los casos de dengue aumentaron notablemente el año pasado en muchos de esos lugares, especialmente en Centro y Sur América.

La enfermedad, que puede propagarse por la picadura de mosquitos Aedes que portan el virus, no fue común en Estados Unidos continental durante gran parte del siglo pasado. Actualmente, la mayoría de los casos de dengue adquiridos localmente (es decir, no relacionados con viajes) en el país se registran en Puerto Rico, donde se registró un fuerte aumento en 2024, lo que desencadenó una emergencia de salud pública local.

La mayoría de las personas que desarrollan dengue no se enferman. Sin embargo, en algunas, los síntomas son graves: sangrado por la nariz o la boca, dolor de estómago intenso, vómitos e hinchazón. En ocasiones, el dengue causa la muerte.

California ofrece un caso centinela sobre la propagación del dengue en el país. Hace 25 años, no se conocía la presencia de los mosquitos Aedes aegypti y Aedes albopictus, que transmiten el dengue, en el estado. Actualmente, se encuentran en 25 condados y más de 400 ciudades y comunidades no incorporadas, principalmente en el sur de California y en el Valle Central.

La propagación de los mosquitos es preocupante porque su presencia aumenta la probabilidad de transmisión de enfermedades, afirmó Steve Abshier, presidente de la Mosquito and Vector Control Association of California.

Entre 2016 y 2022, se registró un promedio de 136 nuevos casos de dengue al año en California, cada uno de los cuales probablemente traído al estado por alguien que viajó y se infectó en otro lugar. En 2023, se registraron alrededor de 250 casos nuevos, incluyendo dos adquiridos localmente.

En 2024, California registró 725 nuevos casos de dengue, incluyendo 18 adquiridos localmente, según datos estatales.

El cambio climático podría contribuir al aumento de la población de mosquitos Aedes, afirmó Ben-Aderet. Estos mosquitos sobreviven mejor en zonas urbanas cálidas, y suelen picar durante el día. Las infecciones de transmisión local suelen ocurrir cuando alguien contrae dengue durante un viaje, regresa a casa y lo pica un mosquito Aedes que, a su vez, pica e infecta a otra persona.

"Se han propagado rápidamente por toda California", explicó Ben-Aderet.

El dengue representa un desafío para muchos médicos de atención primaria que nunca lo han visto. Ben-Aderet dijo que los médicos que sospechan dengue deben obtener un historial de viaje detallado de sus pacientes, pero confirmar el diagnóstico no siempre es rápido.

"No existe una prueba sencilla para detectarlo", afirmó. "La única prueba que tenemos para el dengue son las pruebas de anticuerpos". Agregó que "la mayoría de los laboratorios probablemente no lo estén comercializando, por lo que suele ser una prueba que se debe analizar en otra instalación. Por lo tanto, es fundamental sospechar que alguien tiene dengue".

Las mejores prácticas para evitar el dengue incluyen eliminar cualquier agua estancada en una propiedad, aunque sea poca, y usar repelente de mosquitos, dijo Abshier. Limitar la actividad al atardecer y al amanecer, cuando los mosquitos pican con mayor frecuencia, también puede ayudar.

Los esfuerzos para combatir el dengue en California se complicaron aún más este año después de que los incendios forestales arrasaran Los Ángeles.

Los incendios ocurrieron en una zona de alta incidencia de enfermedades transmitidas por mosquitos. Funcionarios del San Gabriel Valley Mosquito and Vector Control District han trabajado durante meses para tratar más de 1.400 piscinas sin mantenimiento que quedaron tras el incendio, eliminando así posibles criaderos de mosquitos.

Estos oficiales han utilizado recursos locales y estatales para tratar las piscinas, dijo Anais Medina Díaz, vocera del distrito. Han solicitado un reembolso a la Agencia Federal para el Manejo de Emergencias (FEMA), que históricamente no ha financiado las iniciativas de control de vectores luego de incendios forestales.

En California, las agencias de control de vectores suelen financiarse principalmente con impuestos y tasas locales que pagan los propietarios.

Algunos funcionarios están implementando el novedoso método de liberar mosquitos Aedes esterilizados para reducir el problema. Eso puede resultar eficaz, pero implementar el método en un gran número de áreas sería costoso y requeriría un esfuerzo masivo a nivel estatal, dijo Abshier.

Mientras tanto, el gobierno federal está reduciendo sus intervenciones: varios medios han informado que los Institutos Nacionales de Salud dejarán de financiar nuevas investigaciones relacionadas con el cambio climático, que podrían incluir trabajos sobre el dengue.

Este año, las tasas de dengue reportadas en gran parte del continente americano han disminuido significativamente desde 2024. Sin embargo, es probable que la tendencia en Estados Unidos no se esclarezca hasta finales de año, después que termine la temporada de mosquitos de verano.

Los investigadores de salud y control de vectores no están seguros de la gravedad de la situación en California.

Algunos afirman que podría haber brotes limitados, mientras que otros predicen que el dengue podría empeorar mucho. Sujan Shresta, profesor e investigador de enfermedades infecciosas en el Instituto de Inmunología de La Jolla, señaló que otros lugares, como Nepal, experimentaron relativamente pocos casos de dengue en el pasado reciente, pero ahora se registran brotes grandes con regularidad.

Existe una vacuna para niños, pero está siendo discontinuada debido a la falta de demanda mundial. Otras dos vacunas no están disponibles en Estados Unidos. El laboratorio de Shresta trabaja arduamente en una vacuna eficaz y segura contra el dengue. Espera publicar los resultados de las pruebas en animales en aproximadamente un año; si son positivos, los ensayos en humanos podrían ser posibles en unos dos años.

"Si no hay una buena vacuna ni buenos antivirales, este será un país endémico para dengue", afirmó.

Phillip Reese es especialista en reportaje de datos y profesor asociado de Periodismo en la Universidad Estatal de California-Sacramento.

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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For Brianna Henderson, birth control isn’t just about preventing pregnancy.

The Texas mother of two was diagnosed with a rare and potentially fatal heart condition after having her second child. In addition to avoiding another pregnancy that could be life-threatening, Henderson has to make sure the contraception she uses doesn’t jeopardize her health.

For more than a decade, a small team of people at the Centers for Disease Control and Prevention worked to do just that, issuing national guidelines for clinicians on how to prescribe contraception safely for millions of women with underlying medical conditions — including heart disease, lupus, sickle cell disease, and obesity. But the Department of Health and Human Services, which oversees the CDC, fired those workers as part of the Trump administration’s rapid downsizing of the federal workforce.

It also decimated the CDC’s larger Division of Reproductive Health, where the team was housed — a move that clinicians, advocacy groups, and fired workers say will endanger the health of women and their babies.

Clinicians said in interviews that counseling patients about birth control and prescribing it is relatively straightforward. But for women with conditions that put them at higher risk of serious health complications, special care is needed.

“We really were the only source of safety monitoring in this country,” said one fired CDC staffer who worked on the guidelines, known as the U.S. Medical Eligibility Criteria for Contraceptive Use, or MEC. “There’s no one who can actually do this work.” KFF Health News agreed not to name this worker and others who were not authorized to speak to the press and feared retaliation.

The stakes are high for people like Henderson. About six weeks after having her second baby, she said, her heart “was racing.”

“I feel like I’m underwater,” Henderson said. “I felt like I couldn’t breathe.” She eventually went to the hospital, where she was told she was “in full-blown heart failure,” she said.

Henderson was diagnosed with peripartum cardiomyopathy, an uncommon type of heart failure that can happen toward the end of pregnancy or shortly after giving birth. Risk factors for the condition include being at least 30 years old, being of African descent, high blood pressure, and obesity.

The CDC contraception guidelines say that combined hormonal contraception, which contains both estrogen and progestin to prevent pregnancy, can pose an “unacceptable health risk” for most women with peripartum cardiomyopathy, also known as PPCM. For some women with the diagnosis, a birth control injection commonly known by the brand name Depo-Provera also carries risks that outweigh its benefits, the guidelines show. Progestin-only pills or a birth control implant, inserted into an arm, are the safest.

Henderson said her cardiologist had to greenlight which contraception she could use. She uses a progestin-only birth control implant that’s more than 99% effective at preventing pregnancy.

“I didn’t know that certain things can cause blood clots,” Henderson said, “or make your heart failure worse.” Heart failure is a leading cause of maternal mortality and morbidity in the U.S., with PPCM accounting for up to 70% of heart failure cases during pregnancy.

Sweeping HHS layoffs in late March and early April gutted the CDC’s reproductive health division, upending several programs designed to protect women and infants, three fired workers said.

About two-thirds of the division’s roughly 165 employees and contractors were cut, through firings, retirements, or reassignments to other parts of the agency, one worker said.

Among those fired were CDC staffers who carried out the Pregnancy Risk Assessment Monitoring System, a survey established nearly 40 years ago to improve maternal and infant health outcomes by asking detailed questions of women who recently gave birth. The survey was used “to help inform and help reduce the contributing factors that cause maternal mortality and morbidity,” a fired worker said, by allowing government workers to examine the medical care people received before and during pregnancy, if any, and other risk factors that may lead to poor maternal and child health.

The firings also removed CDC workers who collected and analyzed data on in vitro fertilization and other fertility treatments.

“They left nothing behind,” one worker said.

U.S. contraception guidelines were first published in 2010, after the CDC adapted guidance developed by the World Health Organization. The latest version was published last August. It includes information about the safety of different types of contraception for more than 60 medical conditions. Clinicians said it is the premier source of evidence about the safety of birth control.

“It gave us so much information which was not available to clinicians at their fingertips,” said Michael Policar, a physician and professor of obstetrics, gynecology, and reproductive sciences at the University of California-San Francisco School of Medicine.

“If you’ve got a person with, let’s say, long-standing Type 2 diabetes, someone who has a connective-tissue disease like lupus, someone who’s got hypertension or maybe has been treated for a precursor to breast cancer — something like that? In those circumstances,” Policar said, “before the MEC it was really hard to know how to manage those people.”

The CDC updates the guidelines comprehensively roughly every five years. On a weekly basis, however, government workers would monitor evidence about patients’ use of contraception and the safety of various methods, something they were doing when HHS abruptly fired them this spring, two fired workers said. That work isn’t happening now, one of them said.

Sometimes the agency would issue interim changes outside the larger updates if new evidence warranted it. Now, if something new or urgent comes up, “there’s not going to be any way to update the guidelines,” one fired worker said.

In 2020, for example, the CDC revised its contraception recommendations for women at high risk of HIV infection, after new evidence showed that various methods were safer than previously thought.

HHS spokesperson Emily Hilliard declined to say why CDC personnel working on the contraception guidelines and other reproductive health issues were fired, or answer other questions raised by KFF Health News’ reporting.

Most women of reproductive age in the U.S. use contraception. CDC data from 2019, the most recent available, shows that more than 47 million women ages 15 to 49 relied on birth control. About 1 in 10 used long-acting methods such as intrauterine devices and implants; 1 in 7 used oral contraception.

The latest guidelines included updated safety recommendations for women who have sickle cell disease, lupus, or PPCM, and those who are breastfeeding, among others. Clinicians are now being told that combined hormonal contraception poses an unacceptable health risk for women with sickle cell disease, because it might increase the risk of blood clots.

“It can really come down to life or death,” said Teonna Woolford, CEO of the Sickle Cell Reproductive Health Education Directive, a nonprofit that advocates for improved reproductive health care for people with the disease.

“We really saw the CDC guidelines as a win, as a victory — they’re actually going to pay attention,” she said.

The 2024 guidelines also for the first time included birth control recommendations for women with chronic kidney disease. Research has shown that such women are at higher risk of serious pregnancy complications, including preeclampsia and preterm delivery. Their medical condition also increases their risk of blood clots, which is why it’s important for them not to use combined hormonal contraception, fired CDC workers and clinicians said.

The CDC information “is the final say in safety,” said Patty Cason, a family nurse practitioner and president of Envision Sexual and Reproductive Health. Having only static information about the safety of various types of birth control is “very scary,” she said, because new evidence could come out and entirely new methods of contraception are being developed.

Henderson said it took her heart two years to recover. She created the nonprofit organization Let’s Talk PPCM to educate women about the type of heart failure she was diagnosed with, including what forms of birth control are safe.

“We don’t want blood clots, worsening heart failures,” Henderson said. “They already feel like they can’t trust their doctors, and we don’t need extra.”

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch 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.

USE OUR CONTENT

This story can be republished for free (details).