One name repeatedly crops up in these discussions: Valley Medical Group.

With four locations in the Connecticut River Valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical’s flagship office in Florence can be found right on Main Street, next door to a pizza restaurant and near a Friendly’s.

Valley has 90 medical providers — including doctors, nurse practitioners, and physician assistants — and on-site labs, X-rays, and vision care. With tens of thousands of patients, it’s become one of the largest independent practices in western Massachusetts.

It forms a key part of the region’s health care infrastructure, yet Valley Medical has rarely been under more strain than it is now. In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions.

Despite patient demand — there are waiting lists to be seen — primary care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group’s CEO, primary care physician Paul Carlan. Rates are outlined in the group’s contracts with insurance providers.

“It has to do with the fact that our contracts don’t pay as well as we think they should,” Carlan said. “The cost of everything is going up.”

Valley Medical Group is far from alone in this predicament. Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.

In response, many are banding together to form Independent Physician Associations, or IPAs. The goal is to increase their market power, change the way they get paid, and retain control over how they treat patients.

Threats to Physician Autonomy

Primary care practices in the U.S. are in serious trouble, according to workforce surveys. The American Association of Medical Colleges estimates a deficit of up to 86,000 primary care doctors by 2036, as more primary care doctors retire and fewer enter the field.

The number of people who can’t find a primary care doctor has grown by 20% in the past decade, according to a recent JAMA Internal Medicine report.

Lower relative salaries and higher professional stress are disincentives when medical students consider a career in primary care. Newly minted doctors can earn more in specialties such as cardiology or surgery.

Financial stresses in U.S. health care, exacerbated by the covid pandemic, have led to the closure of many primary care practices, according to the AAMC.

The Massachusetts Health Policy Commission released a report in 2025 partly blaming the crisis on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to get worse when the Republican-backed cuts to Medicaid start to take effect later this year.

As they seek financial security, many primary care practices have merged with large hospital systems, with doctors becoming employees of those systems.

But the doctors at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the autonomy doctors need to make the best clinical decisions for their patients, Carlan said. It also siphons off income into the larger hospital system.

“Our priorities get muddled up,” he said. “And I think when you’re part of a health system, you’re constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full.”

By contrast, primary care providers need time and money to manage or prevent illness, Carlan said, and their insurance reimbursement rates should take that into account.

In December, Valley Medical Group announced it would be joining an Independent Physician Association. Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.

“It’s a moment of transition,” said Lisa Bielamowicz, chief clinical officer of TrustWorks Collective, an independent health care consultancy that works with health systems and physician groups.

IPAs are gaining momentum as older doctors retire, especially following the challenging years of the covid pandemic, Bielamowicz said. “As the baby boomers move out and younger physicians take leadership roles, these kinds of models become more attractive.”

The American Academy of Family Physicians, a trade group, is hearing from practice owners who joined hospital systems but now want to break off and return to being a smaller practice.

“So if independent IPAs can create the infrastructure support to make independent practice viable, then that’s a good thing,” said Karen Johnson, a vice president at AAFP.

IPAs can bring more clout to the table when negotiating rates with insurance companies. Some insurers say they like working with these partnerships because they help stabilize primary care practices, maintaining access and options for insured patients.

Otherwise, some doctors shift their business model to “direct primary care,” which bypasses insurance altogether.

“We’re looking at independent practices that aren’t buoyed by …. these large health systems and can support members in the community in the ways that they want to be supported,” said Lisa Glenn, a vice president with Blue Cross Blue Shield of Massachusetts.

A Different Payment Model

When those independent practices band together, Glenn said, Blue Cross can offer “value-based” contracts. Instead of getting a payment for each visit or procedure, the medical practice is given a budgeted amount for each patient’s care, which provides an incentive to keep them healthy so they need fewer treatments.

Medical providers “make different kinds of choices than they would if they’re paid for every procedure, every visit, every widget,” TrustWorks’ Bielamowicz said.

If there is money left at the end of the year, it’s split between the practice and the insurer.

The catch, Glenn said, is that a value-based contract works only if there’s a big enough pool of patients to spread out the risk, in case a few get really sick. Otherwise, she said, “the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance.”

Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010, an innovative way to bring costs down for the health system as a whole.

But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change, if enough primary care providers work together to build market power through IPAs.

“If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system,” said Chris Kryder, CEO of Arches Medical IPA in Cambridge, Massachusetts, the IPA specializing in value-based contracts that Valley Medical joined. “And we create more income for the PCPs [primary care providers], which is dreadfully needed.”

These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists, and medical assistants can take on some of the less complex medical tasks, saving the practice money.

IPAs Can Help, Depending on Who’s in Charge

But IPAs are not a panacea for primary care’s problems, according to some health care leaders.

There are hundreds of IPAs, but not all offer the independence and autonomy that many doctors crave. Some IPAs are actually owned by hospital systems, or even private equity companies, and they’re less focused on preventive care.

The American Academy of Family Physicians advises its members to seek out IPAs with “integrity,” ones that give doctors a strong role in decision-making.

“Who’s calling the shots, who’s making the decisions, and is it really focused on the best interests and long-term benefit of physicians in practice and their patients?” asked AAFP’s Johnson.

Arches Medical is owned entirely by physicians and focused specifically on primary care, Kryder said. But to be more effective, Arches needs to recruit more practices that want value-based contracts.

That can be a hard sell, said Glenn, of Blue Cross. Under that payment model, doctors might see a lag of more than a year from the time they provide care to the moment they realize savings.

“It doesn’t happen overnight, and it does take an investment,” she said.

That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, said CEO Carlan. But he has faith that, after some time, the practice will become more financially stable, be able to offer higher salaries, and, most important, keep the doctors in charge.

This article is from a partnership with New England Public Media and NPR.

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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Within a few days, Reynolds became so desperate that she and her husband had to physically restrain Jonah, dumping pain medication down his throat as he screamed in pain.

“It broke our hearts,” said Reynolds, who lived in Georgetown, Kentucky, at the time. “And I remember just thinking that it shouldn’t have to come to that.”

Reynolds couldn’t find a dentist with an opening who could treat Jonah, who is autistic and often resists dental exams due to hypersensitivity and anxiety. Over the course of five days, Reynolds took Jonah twice to a nearby emergency room as he struggled with persistent pain and a fever due to a likely infected tooth with an exposed nerve. The ER had no dentists; both times, the family was sent home with only pain medication and an ice pack.

Across the nation, more children are entering ERs for preventable tooth problems. Dentists, hygienists, and researchers attributed that trend to a shortage of pediatric dental care professionals in rural areas and worsening oral hygiene since the covid-19 pandemic. Tens of thousands of kids end up in the hospital for dental emergencies each year, according to Melissa Burroughs, senior director of policy and advocacy at the national health nonprofit CareQuest Institute for Oral Health.

ER visits for tooth problems unrelated to physical injuries rose almost 60% nationally for children under 15 years old from 2019 to 2022, according to a report released late last year by CareQuest. And local data reflects that national trend: At Children’s Hospital Colorado in the Denver area, nontraumatic dental cases, such as cavities or gum infections, in its ER increased 175% from 2010 to 2025, according to hospital spokesperson Sarah Bonar. In Kentucky, where Jonah lives, children’s visits to the ER for dental problems rose 72% from 2020 to 2024, according to the state.

Policy changes under the Trump administration are poised to worsen the trend. President Donald Trump’s 2025 federal budget reconciliation law, known as the One Big Beautiful Bill Act, called for billions in cuts from Medicaid, which may force states to limit or drop dental coverage from the public insurance program for those with low incomes or disabilities. New eligibility requirements for Medicaid in some states could affect kids’ access to dental care, even though children are guaranteed dental coverage under the program. Research shows that when parents lose Medicaid, even kids with coverage are more likely to have untreated cavities and less likely to go to a dentist.

The Trump administration has also promoted skepticism about fluoride. Decades of research show that fluoride in drinking water and topical fluoride treatments dramatically reduce tooth decay and prevent cavities. In recent months, the Food and Drug Administration warned health professionals against the use of fluoride supplements and the Environmental Protection Agency released an assessment of “potential health risks of fluoride in drinking water.” Health and Human Services Secretary Robert F. Kennedy Jr. has called fluoride a “neurotoxin” and “industrial waste.” A 2025 study in JAMA Pediatrics linked high levels of fluoride with lower IQ in children — but only at concentrations far exceeding the recommended level in public drinking water.

Donald Chi, a pediatric dentist at the University of Washington who studies fluoride hesitancy, worries that these anti-fluoride stances will further erode trust in fluoride treatment. Since the start of 2026, lawmakers in at least 15 states have introduced bills prohibiting or limiting fluoride in public drinking water. Utah and Florida in 2025 became the first states to enact fluoride bans.

“Will that have an effect on cavity rates?” Chi asked. “Absolutely.”

Severe Dental Cases Rise

Pediatric dentists Katherine Chin and Chaitanya Puranik said they are treating more patients like Jonah at Children’s Hospital Colorado. More severe cases have become more common, too. Puranik said he used to typically see patients with only one cavity, but now his patients are often coming in with tooth decay throughout their mouth.

During the pandemic, many dental offices closed temporarily, and studies show children also increased their sugar intake, a major risk factor for cavities. Severe cavities that lead to tooth extraction can affect children’s developing jaws, sometimes causing long-term problems with talking or sleeping.

Millions of people live in dental care shortage areas in the U.S., with scant dentists within driving distance. On top of that, only 1 in 3 dentists treat Medicaid patients, due to low reimbursement rates, which are on average less than 40% of their typical dental charges, according to the American Dental Association.

Children with intellectual or developmental disabilities may especially struggle to access quality dental care. Few general dentists have sufficient pediatric training to care for kids with disabilities such as Jonah, who are easily overwhelmed or need to be sedated for an exam, according to KFF, a health information nonprofit that includes KFF Health News. Over 26% of children have special health care needs, and those children are twice as likely to have unmet dental needs. Their parents are also more likely to report challenges finding a dentist.

When he was younger, Jonah would not let his parents brush his teeth, which led to cavities in his baby teeth, his mother said. After Jonah’s first visit to the ER, Reynolds found a general dentist with an opening. But unlike a trained pediatric dentist, she said, the dentist did not know how to examine Jonah in a way he could tolerate and wasn’t prepared to provide sedation. Jonah left without treatment and was soon back in the ER when his fever returned.

ERs Rarely Provide Solutions

Bradley Weitz, a pediatrician in Washington County, Maine, said he is fielding “the most horrifying cavities” at Down East Community Hospital.

ERs are often ill-equipped to treat dental concerns, Weitz said. Similar to the ER Jonah went to in Kentucky, Down East has no dentists on staff. Weitz often finds himself prescribing antibiotics as a temporary measure.

“But a month later, they’re back again because it’s flaring up again,” Weitz said.

As a potential solution, states such as Maine and Alaska are proposing to use money from the $50 billion Rural Health Transformation Program to develop the oral health workforce or to create specialized dental care centers, which can better serve children with special health care needs on short notice. But those initiatives won’t address the loss of coverage anticipated from Medicaid cuts. California last year awarded $47 million in state grants to develop or expand over 120 dental facilities to serve patients with special health care needs.

Jonah’s dental emergency cost Reynolds a week of work from her job as a dog groomer and Jonah three days of third grade, plus hundreds of dollars in out-of-pocket costs.

Eventually, Reynolds found an oral surgeon who extracted the tooth. But even that went poorly, she said. When Jonah became upset over a needle stick, the surgeon threatened to hold him down, Reynolds said. She said the surgeon left quickly after the procedure and never gave her a clear diagnosis of what caused Jonah’s pain. The procedure did resolve his toothache, but Reynolds said more professionals should know how to handle cases like Jonah’s, with sensitivity to the families. Four years later, forcing Jonah to take his pain meds still lives fresh in her memory.

“That will never leave my mind,” Reynolds said.

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• Click here to hear Rayasam on Criminal.
• Read Rayasam’s “As More States Target Disavowed ‘Excited Delirium’ Diagnosis, Police Groups Push Back.”

On CBS News’ CBS Mornings on March 5, Céline Gounder, KFF Health News’ editor-at-large for public health, discussed the Massachusetts governor’s retort to comments by Health and Human Services Secretary Robert F. Kennedy Jr. about popular coffee chains.

• Click here to watch Gounder on CBS Mornings.

KFF Health News California correspondent Christine Mai-Duc discussed Affordable Care Act premium increases on CapRadio’s Insight With Vicki Gonzalez on March 2.

• Click here to hear Mai-Duc on Insight With Vicki Gonzalez.
• Read Mai-Duc’s “‘Kind of Morbid’: Health Premiums Threaten Their Nest Egg. A Terminal Diagnosis May Spare It.”

KFF Health News rural health reporter Andrew Jones discussed how younger doctors are struggling to diagnose measles on KMOX’s Total Information AM on Feb. 27.

• Click here to hear Jones on Total Information AM.
• Read Jones’ “Hospitals Fighting Measles Confront a Challenge: Few Doctors Have Seen It Before.”

KFF Health News South Dakota correspondent Arielle Zionts discussed the $50 billion Rural Health Transformation Program on Marketplace’s Make Me Smart podcast on Feb. 19.

• Click here to hear Zionts on Make Me Smart.
• Read Zionts’ “States Race To Launch Rural Health Transformation Plans,” co-reported with Sarah Jane Tribble and Maia Rosenfeld.

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Cuando agentes federales de inmigración llegaron a su ciudad, deportaron primero al padre de Gabi y luego a su tía.

Gabi nació en Estados Unidos y es ciudadana estadounidense. Su mejor oportunidad de algún día pararse, o incluso caminar, es una cirugía compleja en las piernas y los pies que estaba programada para enero.

Pero su madre, quien está tan asustada que ni siquiera se anima a sacar la basura, y mucho menos a atravesar la ciudad hasta el hospital, canceló el procedimiento. (En este artículo, KFF Health News y NPR acordaron identificar solo parcialmente a los pacientes y a sus familias porque temen convertirse en blanco de la ofensiva migratoria del presidente Donald Trump).

“Quiero más que nada, mi deseo, es que mi bebé empiece a caminar”, dijo su madre, mientras Gabi se movía en sus brazos, con una sonda de alimentación que salía de su estómago conectada a un soporte de suero intravenoso. “Pero con la situación que está pasando, cancelé la cita de cirugía porque le van a hacer cirugía en sus piernas y todas las citas de terapia física; lo cancelé todo. Porque tengo miedo de salir”.

El Departamento de Seguridad Nacional (DHS, por sus siglas en inglés) declaró el fin de lo que llamó Operation Metro Surge (Operación Metro Surge), llevada a cabo por agentes del Servicio de Inmigración y Control de Aduanas (ICE, por sus siglas en inglés) y de la Oficina de Aduanas y Protección Fronteriza (CBP, por sus siglas en inglés). Aun así, trabajadores de salud dicen que los agentes de inmigración siguen apostados en los estacionamientos de hospitales. Y drones sobrevuelan zonas agrícolas en las afueras de Minneapolis, donde inmigrantes somalíes y latinos se han establecido en los últimos años.

La ofensiva en Minnesota mostró el alcance del sistema de vigilancia y detención que la administración Trump está utilizando para desarraigar a comunidades inmigrantes del país y su fuerte impacto en el sistema de salud.

Crisis de salud similares surgieron dondequiera que se concentraron oficiales de inmigración en el último año.

En Dallas, clínicas de salud pública administraron unas 6.000 vacunas a latinos en agosto pasado, la mitad que en un programa similar un año antes. En Chicago, a diario, doctores redirigieron a los pacientes de una clínica a otra dependiendo de la actividad de ICE.

En todo el país, las redadas redujeron las visitas de inmigrantes a servicios de salud.

En Minnesota, los sistemas de salud reportaron tasas de cancelación y ausencias de hasta el 60 % desde diciembre. Un vocero del DHS culpó a los manifestantes por la interrupción. “Si alguien está impidiendo que los estadounidenses asistan a citas o recojan recetas, es un agitador violento que está bloqueando carreteras, embistiendo vehículos y dañando propiedad”, dijo.

Mientras residentes de Minnesota protestaban en las calles contra el operativo, doctores y enfermeras organizaron en silencio redes médicas informales para atender a pacientes en sus casas y evitar ser detectados.

“Antes miraba a alguien a los ojos y decía, de buena fe: ‘Estarás bien en el hospital’”, dijo Emily Carroll, enfermera especializada en HealthFinders Collaborative, una clínica comunitaria en Faribault, a unas 50 millas al sur de Minneapolis. “Pero ahora no puedo garantizar eso”.

A medida que miles de agentes federales se retiran de Minneapolis, otras comunidades deben prepararse, dijo la senadora estatal demócrata de Minnesota, Alice Mann, quien es médica.

“Sé que suena extraño”, dijo, pero los proveedores de salud “necesitan empezar una red clandestina para llevar atención médica a las casas. Porque dejar que la gente muera en su hogar o que esté al borde de la muerte por miedo a ir al hospital, en 2026, es inaceptable”.

El operativo causa daños

Los médicos dicen que las visitas a domicilio pueden ser la única forma de llegar a quienes todavía se sienten bajo amenaza. En Los Ángeles, desde junio, St. John’s Community Health llevó atención médica a unas 2.000 familias inmigrantes demasiado asustadas para salir durante un operativo migratorio, después de que las ausencias a citas superaran el 30%, dijo Jim Mangia, presidente de la organización.

Muchas de las grandes instituciones de salud de Minnesota han recurrido a la telemedicina y han usado menos la atención en el hogar.

No así Munira Maalimisaq, cofundadora de Inspire Change Clinic en el vecindario Ventura Village de Minneapolis. Después de que cerca de un tercio de sus pacientes dejara de ir a sus citas, “pensé: ‘Tenemos que hacer algo’”, dijo la enfermera especializada. Entonces llamó a una amiga doctora. ¿Y si empezaran a ver pacientes en sus casas?

“Y ella dijo: ‘¿Sabes qué? Hagámoslo’”.

Ahora cuentan con unos 150 doctores, un equipo voluntario de “respuesta rápida” que ha realizado más de 135 visitas domiciliarias. Su primera llamada fue para ver a una mujer cuyo esposo había sido deportado. Estaba en casa con sus hijos, con 39 semanas de embarazo y en trabajo de parto. Maalimisaq llamó a una obstetra voluntaria y fueron a la casa.

“Tenía 8 centímetros de dilatación”, dijo Maalimisaq, “y no quería que llamáramos a una ambulancia. Decía: ‘¿Puedo tener al bebé aquí?’”.

La mujer no era una buena candidata para un parto en casa, dijo Maalimisaq. La convencieron de ir al hospital en el auto de Maalimisaq, un Tesla pequeño con asientos blancos. “Todo lo que podía salir mal, estaba ahí”.

Pero llegaron al hospital a tiempo y la mujer tuvo un parto seguro y saludable. “Si no hubiéramos estado allí, no puedo imaginar lo que habría pasado”.

En otras visitas, dijo, ha visto “personas tan estresadas que se arrancaban el cabello”. Contó que conoció a una madre que estaba racionando el medicamento anticonvulsivo de su hijo, aunque el niño había tenido “una convulsión tras otra”.

La administración Trump afirma que su operativo en Minnesota mejoró la seguridad pública. “Desde que comenzó la Operación Metro Surge, nuestros valientes agentes del DHS han arrestado a más de 4.000 extranjeros indocumentados con antecedentes penales, incluidos asesinos, violadores, pedófilos y personas extremadamente peligrosas”, dijo Tricia McLaughlin, vocera del DHS.

El DHS anunció la semana del 16 de febrero que McLaughlin dejará su cargo.

Funcionarios correccionales de Minnesota dijeron que muchas personas acusadas de delitos fueron entregadas directamente a ICE por prisiones y cárceles estatales o del condado. Y solo el 29 % de los arrestos de ICE a nivel nacional en enero fueron personas con condenas penales, según datos del DHS. Muchos menos habían sido condenados por delitos violentos.

Agentes afuera de hospitales y clínicas

En el primer día de su segundo mandato, el presidente Donald Trump anuló una política de 2011 que prohibía la aplicación de leyes migratorias en “lugares sensibles” como iglesias, escuelas y hospitales.

En Northfield, a unas 45 millas al sur de Minneapolis, agentes del ICE han estado sentados en sus autos durante horas, al menos dos veces por semana, fuera de clínicas de salud, incluida una que opera el hospital del pueblo, dijo Carroll. Los agentes han realizado arrestos en la zona casi todos los días, según Carroll y sus colegas.

“El ICE no realiza operativos en hospitales, punto”, dijo McLaughlin.

Una mañana reciente, tres vehículos del ICE estaban en el estacionamiento de una iglesia bautista frente a una escuela primaria en Northfield, mientras voluntarios transportaban a 35 hijos de inmigrantes hacia y desde la escuela para que sus padres no tuvieran que salir, dijo Carroll.

“El ICE no va a las escuelas para arrestar a niños; estamos protegiendo a los niños”, dijo McLaughlin.

Drones sobrevuelan la mayoría de las noches y a veces durante el día, sobre un parque de casas móviles donde viven principalmente inmigrantes que se mudaron a la zona para trabajar en agricultura y manufactura en los últimos 15 años. Las familias cubren las ventanas con papel, dijo Carroll.

“No puedes sentirte seguro en ningún lugar”, dijo. “Camino a la escuela, camino a la clínica, puedes encontrarte con el ICE. El miedo y la sensación de estar atrapados que viven estas familias son inaceptables”.

Ese miedo significa que pacientes con diabetes y enfermedades cardíacas están perdiendo controles de azúcar en sangre y de anticoagulación. No están haciendo ejercicio y las personas con enfermedades crónicas están empeorando, dijo Calla Brown, pediatra en Minneapolis.

En la clínica de Faribault, donde trabaja Carroll, el personal entrega medicamentos, comida y otras necesidades a los pacientes. Un empleado transporta cada día a 12 estudiantes de escuela media y secundaria en una camioneta de la clínica.

Algunos pacientes reciben atención en casa. Carroll diagnosticó recientemente a un bebé con influenza y les dijo a los padres que no era una amenaza inmediata, por ahora.

“‘Si ven que el bebé tiene dificultad para respirar, si no está comiendo, si no moja pañales, tienen que ir al hospital’”, contó Carroll que les dijo. “‘No puedo prometer que sea seguro. Pero tienen que ir’”.

“Somos amables entre nosotros”

En Minneapolis, la enfermera partera Fernanda Honebrink pasa la mayor parte del día llamando, coordinando y trasladándose entre un grupo creciente de personas con miedo que permanecen en sus casas. Prefiere no llamarlo una red médica clandestina.

“Es más bien así como funcionamos en Minnesota”, dijo Honebrink, ciudadana estadounidense que emigró de Ecuador hace 23 años. “Somos amables entre nosotros”.

Honebrink pasó una tarde reciente en la casa de una familia con un bebé. Sus padres, Alex e Isa, quieren que reciba vacunas y análisis de sangre en su cita de control cuando cumpla 1 año.

Pero no han salido de su apartamento en más de un mes. “No sabes qué es más importante: salir por su bienestar o salir pensando que quizás no regreses”, dijo Alex.

La pareja venezolana entró legalmente a Estados Unidos en 2024 bajo un programa llamado Humanitarian Parole, que Trump finalizó en mayo. Desde entonces, agentes federales han detenido y deportado trabajadores de una empresa donde Alex, ingeniero mecánico, trabajaba en construcción.

Han visto vehículos del gobierno afuera de su casa. Dijeron conocer a un hombre que tenía documentos de trabajo válidos, pero fue detenido cuando caminaba a la iglesia un domingo, trasladado a Texas y luego enviado en avión a Venezuela. Era una perspectiva aterradora para quienes huyeron de la dictadura y la crisis económica de ese país.

“Se siente como un ataque psicológico”, dijo Alex. “La posibilidad de ser separado de tu familia”.

Isa, abogada en Venezuela, ha sufrido depresión posparto, encerrada durante semanas en su apartamento. El programa estatal que proporcionaba seguro médico a todos los inmigrantes terminó el 1 de enero. Una terapeuta la llama ocasionalmente sin costo.

Ha intentado sostener a la familia vendiendo pasteles y collares hechos en casa y cuidando niños.

Su mayor temor es que la separen de su hijo, que nació en Estados Unidos y es ciudadano. No había considerado esa posibilidad hasta que un conocido le sugirió firmar un formulario para designar a alguien para la custodia temporal en caso de que fuera deportada.

“Fue algo que nunca imaginé”, dijo Isa, llorando al recordarlo. “¡Es mi bebé! ¡No es de otra persona! ¿Qué? ¿Mi bebé se quedaría aquí con alguien más?’’

Honebrink intervino de inmediato: “Yo me haré responsable de él. Firmaré el formulario”.

Más tarde dijo a una reportera: “Le dije a mi esposo que no haría eso. Ya he firmado como patrocinadora de cuatro niños”.

En cuanto salió del apartamento, Honebrink volvió al teléfono y coordinó con pediatras, programadores de clínicas y voluntarios locales. En pocas horas, había conseguido una nueva cita de control para el bebé y había encontrado un conductor verificado para transportar a la familia.

“Una persona blanca”, explicó Honebrink.

Dos días después, envió una foto de su pequeña victoria: el bebé de Alex e Isa con una curita en las piernas. “Recibió sus vacunas”, escribió por mensaje de texto. “Estoy muy feliz”.

Pero otras necesidades médicas no pueden resolverse con la misma rapidez. Una noche de febrero, Honebrink visitó a Gabi y a su madre con el baúl del auto lleno de toallitas húmedas, pañales y juguetes donados.

La cirugía de Gabi fue reprogramada para agosto. Su madre dijo que espera que para entonces sea seguro salir de casa.

“Antes llevaba a los niños al parque, pero ahora no salimos para nada”, dijo. “Agarran a la gente y la maltratan. Da miedo salir. ¡Ojalá que se termine pronto lo que está pasando!”.

Jackie Fortiér, de KFF Health News, colaboró con este artículo.

[Aclaración: Este artículo fue revisado a las 11 am ET del 6 de marzo de 2026, para aclarar que agentes del Servicio de Inmigración y Control de Aduanas de Estados Unidos se habían posicionado cerca de clínicas, incluida una propiedad de un hospital].

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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Sam Walker, 35, has severe autism and other disabilities. He is deaf and cannot speak. Sometimes when he’s frustrated, he hits himself or others.

Medicaid provides about $8,500 a month for health workers who visit his apartment in the basement of his parents’ home. The staffers help him with everyday tasks, including dressing, bathing, and eating. They also take Walker on outings, such as dining at restaurants, volunteering at Goodwill, and exercising at a recreation center or on park trails. They stick to a strict routine, which soothes him.

His parents say that without the in-home services, their son would need to move to a specialized residential facility in another state. Sending him away would break their hearts and cost taxpayers much more money. They strive to keep him home because they know change makes him anxious.

“The last thing I want is to put him into some kind of care facility, where he’ll just get kicked out,” said his mother, Leisa. The Iowa Department of Health and Human Services did not respond to KFF Health News’ questions about the Walkers’ case.

Federal Cuts Raise Pressure

Patient advocates say state administrators in Iowa appear to be reining in Medicaid spending by cutting what are known as home and community-based services for people with disabilities, and they’ve heard of multiple families facing battles like the Walkers’.

Disability rights advocates expect the pressure to intensify as states respond to reductions in federal Medicaid funding called for under the Trump administration’s signature tax and spending law, which passed last year.

June Klein-Bacon, CEO of the Brain Injury Association of Iowa, said the cuts and proposed rule changes appear to be part of a quiet attempt to save money in response to the state’s budget deficit and expected reductions in federal Medicaid funding.

Medicaid, jointly financed by the federal and state governments, covers people with low incomes or disabilities. Walker is one of nearly 2 million people served by “Medicaid waiver” programs, which pay for care that allows people with disabilities or who are at least 65 to live at home.

Unlike most parts of Medicaid, waiver programs are optional for states. Idaho’s governor noted that fact in January, when he suggested legislators consider cutting them. Disability rights groups fear other states will do the same. Leaders in Colorado, Missouri, and Nebraska have considered such cuts this year.

Leisa Walker has heard Trump administration officials claim the national Medicaid cuts are intended to reduce waste, fraud, and abuse. That’s not how it will play out, she said. “These are real people, real families, and this causes real suffering when you do this to people,” she said. “It’s a very scary time.”

Iowa Total Care, a private insurance company that manages Sam Walker’s Medicaid benefits, intends to cut his in-home care coverage by about $3,200 per month, his mother said. Company leaders told a judge they are following state officials’ direction, but they did not dispute Leisa Walker’s math.

Walker has been on the waiver program for three decades. It covers assistance from workers known as “direct service providers” — one of whom has been with him for 25 years. His parents receive no pay for the hours they spend caring for him when the aides aren’t working.

On a February morning, Leisa and Kent Walker drove an hour and a half to Des Moines for an appeal hearing. An administrative law judge sat behind a wooden desk in a conference room as the Walkers and their lawyer faced off against three representatives from Iowa Total Care, a subsidiary of the national insurer Centene Corp.

Leisa testified that her son is 6 feet tall and weighs 230 pounds. Although he knows some sign language, he has trouble communicating, she said. When he becomes frustrated or his routine is interrupted, he sometimes wails and hits himself or other people. “It’s devastating to watch,” she testified.

He’s not a bad person, she said. “He doesn’t understand how strong he is.”

She said her family would try to keep his main caregiver employed under the planned Medicaid reduction but would have to drop others who cover nights and weekends. She said no residential facility near their southern Iowa home could address her son’s complicated needs. She said a case manager told her that a Florida facility might be the closest one that could safely handle him.

Leisa Walker testified that the state’s Medicaid program would pay about $22,000 per month to put him in an institution, more than double what the program spends on his home care.

Sam Walker’s longtime psychiatrist, Christopher Okiishi, testified that Walker’s family and their support staff spent years developing a “fragile” but stable existence for him.

Lori Palm, a senior manager for Iowa Total Care, testified that Sam Walker gets about 16 hours of daily assistance financed by Medicaid. Palm said much of that time amounts to “supervision.” She said state officials recently advised her company that the program should pay mainly for “skill-building” time, not supervision.

The Walkers showed the judge a 2018 document in which a previous Iowa Medicaid director stipulated that supervision of people with disabilities is an allowable service for workers paid under the program.

Judge Rachel Morgan asked the Iowa Total Care representatives if the recent policy change was made in writing by the state Department of Health and Human Services. They said it was not and that they couldn’t specify who at the department had given them the new guidance.

The judge suggested during the hearing that for someone like Sam Walker, learning to regulate emotions could be an important form of skill-building. Three days later, the judge ruled in the Walkers’ favor, writing that the insurer’s attempt to cut care hours was improper. The insurer appealed the decision to the director of the Iowa Department of Health Human Services, who could overrule it. The dispute could eventually wind up in district court.

Iowa Total Care and the state Department of Health and Human Services did not respond to questions about the reports that many other Iowans with disabilities face reductions in care hours covered by Medicaid. Department spokesperson Danielle Sample said in an email that the agency supports home and community-based services, which, she noted, help “states save money by avoiding expensive long-term facility care.”

Spokespeople for the federal Department of Health and Human Services, which oversees Medicaid nationally, did not respond to a request for comment on the issue.

Medicaid waiver programs started in the 1980s, after President Ronald Reagan heard about an Iowa girl with a disability who was forced to live in a hospital for months because Medicaid wouldn’t pay for home care. The Republican president thought it was outrageous that the girl, Katie Beckett, had to live that way, even though home care would have been cheaper.

Members of Congress approved allowing states to use their Medicaid programs to pay for in-home care. But they made the change optional, to offer states flexibility and encourage innovation.

Designating such spending as optional “waiver programs” also made the change more politically palatable, said Kim Musheno, senior director of Medicaid policy for The Arc of the United States, which represents people with intellectual and developmental disabilities.

Prospects were much different for babies born with serious disabilities before the change, Musheno said. “Doctors instructed families to forget they existed, and to put them in an institution.”

Waivers Have Been Cut Before

All states have Medicaid waiver programs, but benefits and the number of people covered vary significantly. Applicants often wait months or years to get into the programs because of limited funding. More than 600,000 Americans were on waiting lists or “interest lists” for waiver services in 2025, according to KFF, a health information nonprofit that includes KFF Health News.

Disability rights advocates and care providers have fought for decades to maintain funding for the programs, but a national leader said the threat feels especially severe now.

“When Medicaid is cut, people with disabilities are at the center of the impact,” said Barbara Merrill, CEO of the American Network of Community Outcomes and Resources, which represents agencies that care for people with intellectual disabilities or autism.

That’s what happened after Congress reduced Medicaid funding in 2011, according to a recent paper published by Health Affairs.

States could again rein in waiver programs by limiting enrollment, reducing covered services, or cutting pay for caregivers, who already are in short supply.

However, states that try to cut the in-home care programs could face legal challenges, Musheno said. The U.S. Supreme Court declared in 1999 that people with disabilities have a right to live outside of institutions if possible. The decision, in the case of Olmstead v. L.C., has been cited in lawsuits against states that fail to provide care options apart from nursing homes and similar facilities.

Several Iowans who belong to a Facebook group for Medicaid participants have posted in recent weeks that their families were notified of impending cuts in coverage of home care services for people with disabilities.

Sam Walker’s main caregiver, Andy Koettel, has worked with him since Walker was in fourth grade. Koettel, who works full-time, knows how to keep Walker calm in most situations and soothe him during a blowup. Their relationship took years to build, and it is a key reason Walker can continue to live at home with his parents, Koettel said.

“If I was not there, it would be incredibly difficult for all of them,” he said.

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But plans to spend those nine-digit awards aren’t all warmly received.

At least one group of Republican state lawmakers appears to have scuttled an initiative preapproved by federal officials. And at least one hospital association persuaded its state health leaders to alter who greenlights spending. Other critics are taking a more cautious approach.

That’s because the Centers for Medicare & Medicaid Services, which manages the five-year Rural Health Transformation Program, says states could lose money if they make major changes to the plans approved in their applications. Changes could also delay states’ ability to get projects rolling in time to show the agency that they’re meeting progress deadlines.

“During the application period, states were advised to only propose initiatives and state policy actions that the state deemed feasible,” said CMS spokesperson Catherine Howden, who noted that the agency will work with states case by case.

The recent pushback reflects “tension” over state plans — which were approved by the federal government — from state lawmakers and health leaders who want more input amid tight deadlines, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics.

Cochran-McClain said many states must pass a bill to allow federal dollars to be spent and added that because the program rolled out so quickly “there’s important work that still needs to be done in some states between the legislatures and the governors.”

State lawmakers want to have a say, she said, in “how the funding is being allocated — how the implementation will go.”

Congressional Republicans created the program as a last-minute sweetener to include in their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset concerns about the outsize fallout anticipated in rural communities from the law, which is expected to slash Medicaid spending by nearly $1 trillion over a decade.

CMS officials announced first-year funding — ranging from $147 million for New Jersey to $281 million for Texas — on Dec. 29, after scoring applications. Federal officials will begin evaluating progress in late summer and announce 2027 allocations at the end of October.

A chorus of critics say the program won’t make up for harm caused by Medicaid cuts.

The program is “a complete sham,” Sen. Ron Wyden (D-Ore.) said at a rural policy conference in February.

Medicaid, a joint federal-state program for low-income and disabled Americans, serves nearly 1 in 4 rural residents, and many rural hospitals depend on it to stay afloat.

But the rural health program tilts toward seeding innovative projects and technologies, not shoring up rural hospital finances. States can use only up to 15% of their funding to pay providers for patient care.

That hasn’t stopped some federal officials and lawmakers from framing the program as a rural hospital rescue.

For example, the White House website says, “President Trump secured $50 billion in funding for rural hospitals.”

Now that applications have been approved, some state Republican lawmakers — who are more likely to represent rural voters than Democrats are — and hospital associations are upset that the political rhetoric doesn’t match what they see.

They’re also lobbing criticisms at specific aspects of their states’ plans, including the proposed projects, what’s not included, and the spending approval process.

In Wyoming, lawmakers didn’t just criticize an initiative from their state’s application. They moved to kill it.

State Rep. John Bear, a Republican, said he and other lawmakers declined to fund “BearCare,” a proposed state-sponsored health insurance plan that patients could use only after medical emergencies. But they did approve other aspects of the rural health program.

The Wyoming Department of Health won’t “proceed with BearCare without express legislative authority to do so,” said spokesperson Lindsay Mills.

While Wyoming lawmakers removed an initiative from their state’s rural health plan, a group in Ohio wants to add something.

Ohio Rep. Kellie Deeter and other Republican lawmakers asked their governor to use the maximum allowed funding for provider payments — 15% — to support 13 independent, rural hospitals.

“We understand that the rural transformation fund is not designed to be given directly to prop up hospitals,” Deeter said. “We just want to capitalize on the mechanism of the fund that can be utilized for that purpose.”

Those hospitals “operate with very, very narrow margins, and it’s just difficult and, frankly, unsustainable,” she added.

Ken Gordon, a press secretary responding for the governor’s office and the state health department, said, “It’s still very early in this process, and many details are being worked out.”

State lawmakers around the country are also trying to ensure the federal program’s dollars benefit rural areas.

In North Dakota, Rep. Bill Tveit, a Republican who lives in a town with about 2,000 residents, introduced a bill that would have required the state to reserve its funding for programs located more than 35 miles from urban areas and small cities.

During a hearing, lawmakers appeared sympathetic to Tveit’s concerns but quickly shot down his idea.

State Sen. Brad Bekkedahl said the North Dakota health department already committed to prioritizing funding for the most pressing rural health needs. He also said he’s concerned any significant changes could cause the state to lose funding because CMS already reviewed and approved the plan.

Meanwhile, Republican lawmakers in Michigan and North Carolina have criticized their states’ definitions of “partially rural” or “rural,” saying that counties that include urban population centers could take money from lower-density counties, according to Michigan Advance and North Carolina Health News.

Lawmakers aren’t the only ones speaking out.

The Colorado Hospital Association wrote a letter to state lawmakers denouncing how the state created its plan and two of its proposed initiatives.

“Not only were Colorado’s rural hospitals’ recommendations disregarded,” president and CEO Jeff Tieman wrote, but the plan includes ideas “they actively oppose and believe will harm the communities they serve.”

The department responded to one of the association’s concerns by adding rural health leaders to the funding approval committee.

Meanwhile, in Michigan and Nebraska, some health groups are upset that their states’ plans lack specific funding streams for rural hospitals.

Lauren LaPine-Ray, who oversees rural health policy at the Michigan Health & Hospital Association, predicted the state’s rural hospitals will compete with other organizations, such as academic centers and health clinics, for funding. She said about 65% of the group’s rural members have never applied for a state grant before.

“The rural hospitals, the ones that really need the funding the most, will not be well equipped to apply for and pull down these dollars,” LaPine-Ray said.

Jed Hansen, executive director of the Nebraska Rural Health Association, said the federal funding won’t go to “rural hospitals, rural clinics, and rural providers in a meaningful way.”

“Rural Health Transformation will not save a single hospital in our state,” he said. “I don’t think it will save a hospital nationally.”

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The city’s mobile crisis team had just gotten a call about a man walking around outside without shoes. The man’s family told the team he was having a mental health crisis and wouldn’t come inside.

As they drove down the highway toward the city’s outskirts, team member Evan Thiessen spoke with the relative who had reached out.

“You’re doing the right thing, and we’re going to make sure he gets help today, OK?” he said.

They pulled up the man’s police record on a laptop and saw that he did have a record of some previous encounters with police, including some that had turned violent.

Luke Forney, a licensed therapist, had that in mind as they pulled into a neighborhood of single-family homes. He stepped out of the Ford Bronco and headed toward the front door.

A Funding Problem

Many communities around the country send out teams like this one to help people in psychiatric crisis, rather than dispatching regular police.

A recent survey found there were at least 1,800 mobile teams nationwide in 2023. But financial support for them is often inadequate and inconsistent, leaving many communities struggling to keep the teams operating.

Two programs — one in Great Falls, in central Montana, and one in Billings, in south-central Montana — recently shut down. Six units remain in Montana.

The strategy began in the late 1980s in Eugene, Oregon, but gained momentum nationally over the past 10 years.

Recent national headlines about police killing people who are experiencing a psychiatric crisis have sparked conversations about how to safely and effectively respond. Most police officers are not trained to deal with people experiencing delusions or hallucinations, nor to de-escalate situations involving threatening behaviors to themselves or others.

An analysis of police-involved fatal shootings across 27 states found that about a third of the victims showed signs of being in crisis. Another study found that people with a serious mental illness were at least 11 times as likely to experience use of force by police as those without.

By contrast, crisis response teams have been trained to de-escalate such situations and provide appropriate therapeutic care.

When the team arrived at the house in Bozeman, the man had already gone back inside. The team then talked with the man’s family for about half an hour and helped them devise a plan to keep him at home — and safe. Before they left, team members determined the man wasn’t a threat to himself or others.

Also, they planned to follow up within a few days to connect him with ongoing mental health care. After an encounter with the team, some clients might need follow-up therapy, assistance with psychiatric medications, or help finding treatment for substance abuse.

The Bozeman team is available 12 hours a day, seven days a week, and costs roughly $1 million a year to run.

Police departments are generally funded by local taxpayers. Mobile crisis teams don’t have a single, reliable source of funding.

Some, despite successful operations and local support, are shrinking operations or have closed entirely. One that shuttered was Oregon’s pioneering program.

Most crisis calls end with people staying where they are, avoiding a trip to the emergency room or going to jail, according to Connections Montana, which runs the mobile crisis program in Bozeman.

Beyond police and firefighters, members of the public can call the team directly.

“I’ve been out on calls where individuals have barricaded themselves in residences or in their vehicles with a firearm. So, helping to assist not only law enforcement, the negotiators, but consulting on the behavioral health side of that,” said Ryan Mattson, who leads the Bozeman crisis team.

The program has reduced the time that Bozeman police officers must spend on mental health calls by nearly 80%, according to Mattson, and prevented unnecessary ER visits.

Residents and political leaders see that value, he said, but finding a way to pay for the service has been difficult.

“I’m confident we’ll be here through next fiscal year. That’s about as confident as I am at this point,” Mattson said.

Mobile crisis programs in Montana, which began operating about five years ago, have cost more than the state originally projected.

Health insurance is sometimes a revenue source for mobile crisis teams. That’s because a crisis call is a type of mental health service, provided by trained professionals such as therapists or crisis intervention specialists. Still, many private insurance companies don’t reimburse for mobile crisis services.

What Medicaid Pays For — And Doesn’t

Medicaid, the government-funded insurance program for low-income and disabled Americans, is another funding source. Two-thirds of states allow Medicaid reimbursement for such calls, but rates vary.

In Montana, Medicaid reimburses the team only for the time they spend responding to a call in the field. Additional time spent on a case — documenting the encounters, or waiting for the next call — isn’t reimbursed.

“You need to pay for the capacity to be at the ready, just like we do with fire or police, regardless of whether somebody is going to be called out,” said Angela Kimball of Inseparable, a nonprofit that advocates for mental health policy reform.

It’s not feasible for mobile crisis teams to rely solely on reimbursement from insurance companies, she said.

To deal with the shortfalls, many mobile teams rely on a patchwork of grants and other funding, according to Heather Saunders, who studies Medicaid policy at KFF, a health information nonprofit that includes KFF Health News.

Some state governments have stepped in to help.

Eight states, including New Jersey, California, and Washington, mandate that private insurers cover the cost of mobile crisis calls for people on their plans, according to Kimball. At least 10 states have implemented fees on cellphone bills to help pay for service.

Montana hasn’t followed suit.

The state provides about $2 million annually in supplemental funds to help the mobile teams pay for service calls that aren’t reimbursed through Medicaid, according to an emailed statement from Jon Ebelt, a state health department spokesperson.

But program managers counter that the paperwork to access that funding is complicated and often isn’t worth the staff time.

Will Montana Step In?

Despite this state support, mobile teams are still struggling to stay afloat, Ebelt acknowledged. He said Montana officials are considering boosting what Medicaid reimburses for each service call.

In Missoula, the mobile crisis team turned to local taxpayers for additional help. Their annual expenditure is $1.4 million, but Medicaid reimbursements were covering only about 20% of the cost, according to program manager John LaRocque. Even with local tax dollars, the program faces a $250,000 shortfall, so LaRocque is looking for grants.

Mobile crisis is still a relatively new concept, and growing pains are to be expected, said Sierra Riesberg, director of the Behavioral Health Alliance of Montana.

Still, abrupt closures create instability and lead some patients to the ER, placing financial pressure on another distressed part of the local health system.

“A much-needed service is available and then not available, available and then not available. These things need to be taken into consideration when developing programs in communities,” she said.

If more mobile crisis teams shut down, that might interfere with Montana’s recent efforts to overhaul an outdated and underfunded mental health system. The state’s only psychiatric hospital hasn’t kept up with the number of patients committed to the facility.

Later this year, Montana hopes to join a federal pilot program to open a new type of clinic: Certified Community Behavioral Health Clinics, or CCBHCs. Those clinics will receive boosted levels of federal funding, but they are required to offer round-the-clock mobile crisis services as well as other crisis care.

That could be a tall order for rural communities, said Casey Schreiner, an executive at Alluvion Health in Great Falls.

Alluvion used to operate the mobile crisis team in Great Falls before it shuttered the service. One major reason it closed was that the expected Medicaid payments covered less than anticipated. Before Alluvion would consider getting involved again, the state would need to “completely revamp” the way the service is funded, Schreiner said.

“Is it a priority for our state or not?” he asked.

This article is from a partnership with Montana Public Radio and NPR.

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

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The boys sat in one waiting room and then another. Two hours and 20 minutes passed before the two were isolated, according to Centers for Medicare & Medicaid Services records obtained by KFF Health News. Then two more hours ticked by.

As the sun rose, an emergency room doctor called the state epidemiologist and described the symptoms. The public health official told him to keep the kids in the hospital and quarantine them. Shortly after that call, the patients were diagnosed.

It was measles.

Hospital staff gave the father instructions on how to quarantine the family and sent them home.

The virus exposed at least 26 other people in the hospital that January day, federal investigators determined. Health inspectors for CMS investigated the measles infections and other failures in care and concluded that the twins’ symptoms should have triggered an isolation procedure for which Mission Hospital staffers had trained seven months earlier. CMS designated Mission in “Immediate Jeopardy” for the exposures and other unrelated issues, one of the most severe sanctions a hospital can face, threatening to pull federal funding unless it remedied the problems.

A spokesperson for Mission said its staff was trained to manage airborne sickness and is following federal rules.

As U.S. hospitals face an increasing risk of encountering measles, and pressure to immediately spot it, health care workers face an unusual barrier: Many don’t know what it looks like.

“There’s a word, ‘morbilliform’ — it means measles-like, and there are lots of viruses that can cause a rash that looks like a measles rash in children,” said Theresa Flynn, a pediatrician in Raleigh and the president of the North Carolina Pediatric Society. In 30 years in health care, she’s never seen a measles case, she said.

North Carolina has reported more than 20 cases since mid-December, and more than 3,000 people nationwide have been infected since the beginning of 2025.

Children in areas with low immunization rates have been especially susceptible to outbreaks, triggering public health campaigns to promote the measles vaccine. CMS Administrator Mehmet Oz encouraged vaccination in a CNN interview on Feb. 8.

With two doses of the measles, mumps, and rubella vaccine, a person has a 3% chance of getting the virus after exposure. If exposed, an unvaccinated person has a 90% chance of being infected, according to the CDC. It can take a week or two before someone infected with measles shows symptoms.

But for the past year, the Trump administration has sown doubt about vaccine effectiveness. Health and Human Services Secretary Robert F. Kennedy Jr. was a longtime anti-vaccine activist before taking office, and under his leadership the Centers for Disease Control and Prevention has reduced the number of shots recommended to children.

After measles erupted in West Texas last year, Kennedy publicly recommended unconventional and unproven treatments for the virus, including steroids, antibiotics, and cod liver oil.

Infectious disease experts and doctors said federal policies have left health care workers to lean on their own experience or guidance from their state public health systems to fight a disease that many are preparing to see for the first time and that initially may behave like the common cold.

“As measles becomes more common, all of us are leveling up in our ability to recognize and immediately respond to suspected measles,” Flynn said.

Three C’s

Officially, the U.S. has maintained “measles elimination status” since 2000, meaning the U.S. has avoided significant spread of the virus. After outbreaks in Texas, Arizona, Utah, and now South Carolina, the nation is on track to lose that designation before the year is out. Its own adopted regulations tie elimination status to a lack of a continuous viral spread persisting for 12 months.

One county in South Carolina, an hour’s drive from Asheville, has had more than 900 cases in the current outbreak — more than Texas reported in all of 2025.

Symptoms of measles, a virus that attacks the lungs and airways, can include fever, cough, a blotchy rash, and red, watery eyes. Researchers consider measles among the most contagious diseases, and the virus may remain active for up to two hours after an infected person leaves a room.

It can be lethal, with 1 to 3 deaths per 1,000 cases in children.

In 2025, two children in Texas and one adult in New Mexico died of measles.

Along with tracking data, the CDC provides detailed summaries on its website for diagnosing measles. State public health agencies and some counties have developed dashboards tracing the disease as it surfaces in such places as hospitals, schools, grocery stores, and airports. Large hospital systems developed staff training protocols last year and shared them with area clinics.

Look for the three C’s, that guidance said: cough, coryza (cold symptoms), and conjunctivitis (pink eye). According to CMS inspection records, HCA Healthcare, which owns Mission Hospital, trained Mission staff on the three C’s early last year. On top of failing to isolate the twin patients right away, Mission staff didn’t have a designated area for patients with respiratory symptoms, federal inspectors found.

The CDC advises health workers to immediately place patients with measles or suspicious symptoms in a special isolation room, where airflow is controlled inward. The Mission patients were separated from other patients only by plastic partitions, according to the CMS records.

Mission spokesperson Nancy Lindell said the hospital was equipped and staffed to manage airborne illnesses like measles.

“Our hospital has been working with state and federal health officials on proactive preparedness, and we are following guidance provided by the CDC,” Lindell said.

(Dogwood Health Trust, a private foundation established as part of HCA’s purchase of Mission Health, helps fund KFF Health News coverage.)

Most U.S. clinics and hospitals have never experienced measles cases, said Patsy Stinchfield, a former president of the National Foundation for Infectious Diseases and a nurse practitioner. She called CMS’ Immediate Jeopardy penalty for Mission “extreme,” given the virus can be so difficult to identify.

“In the middle of winter right now, measles looks like every other viral respiratory infection that kids come in with,” Stinchfield said.

The CDC has been less communicative in the past year with clinics about their response to outbreaks, said health workers and infectious disease experts. This disconnect began soon after Trump took office, according to a KFF Health News investigation finding that health officials in West Texas were unable to talk with CDC scientists as measles surged last February and March.

“We certainly do not feel the support or guidance from the CDC right now,” said Brigette Fogleman, a pediatrician at Asheville Children’s Medical Center, where staff members have come up with their own method of staving off the virus: screening patients over the phone and in their cars before a visit.

In response to questions about how the CDC is supporting health care organizations during the measles resurgence, spokesperson Andrew Nixon said that “state and local health departments have the lead in investigating measles cases and outbreaks” and that the CDC provides support “as requested.” He pointed to numerous guides and simulation tools the agency has developed as the virus has spread.

Jennifer Nuzzo, an epidemiologist and director of the Pandemic Center at Brown University, acknowledged that diagnosing measles is a major challenge, emphasizing that coordination among public health agencies is critical in overcoming that challenge.

Stinchfield attributed the spread of measles to CDC leaders’ lack of communication to clinics and to the public — no ads on buses, no social media campaigns, no sense of urgency. “When you are at the highest level of measles cases in 30 years, we should be seeing lots more from our federal government,” Stinchfield said. “And I think it’s harming kids and causing an inordinate amount of work and expense that really doesn’t belong in health care right now.”

State Prepares for More Measles Cases

In North Carolina’s Buncombe County, home to Asheville and Mission Hospital, health officials had counted seven measles cases by mid-February and anticipated many more, according to state epidemiologist Zack Moore. It’s unclear how many of those are connected to the Mission exposure.

“We are preparing for a future in which we follow a trajectory like South Carolina,” Moore said, “where we see sort of a gradual accumulation of cases, and then all of a sudden it reaches kind of a tipping point, and we see a more explosive growth in the outbreak and spread across the state.”

Fogleman, who is also a pediatrician, and Buncombe health department director Jennifer Mullendore spoke during a recent Facebook livestream hosted by the county, urging families to get their children vaccinated, debunking vaccine misinformation, and updating parents on local case numbers.

Days before, a local private school had quarantined about 100 students after an exposure. Only 41% of students there were immunized, according to state data.

At Fogleman’s clinic, parents are asked to wait in their vehicles with their children, and staffers come out to screen them there. Some parents resist vaccination and note recently weakened federal recommendations around measles vaccines for children under 4, she said.

Kennedy handpicked the committee members who made those recommendations, with several members having spread medical misinformation in the past.

One parent recently told a nurse, “It’s only measles. It doesn’t kill anybody,” Fogleman said.

That’s not true, her team must explain.

As the clinic holds families in the parking lot, trying to figure out whether symptoms point to the dangerous virus, it’s difficult to get the message across, Fogleman said, especially when the nation’s top disease agency hasn’t conducted a widespread information campaign about the risks from measles — or the vaccine’s ability to almost entirely prevent it.

“We can’t change the past,” Fogleman said. “All we can do is try to educate and move forward.”

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The legislation introduced in Colorado, Florida, Hawaii, Indiana, Maine, Michigan, Ohio, and Washington builds on efforts made in other states in past years. This latest push for patient protections comes as the Trump administration has backed away from federal debt protections, health care has become more costly, and more people are expected to go without medical coverage or choose cheaper but riskier high-deductible insurance plans that could lead them into debt.

“In the wealthiest country on Earth, people are going bankrupt, suffering wage garnishment, just because they get sick,” said Colorado state Rep. Javier Mabrey, a Democrat who introduced legislation on Feb. 19 that would, among other measures, ban wage garnishment for medical debt.

That legislation is under consideration after a KFF Health News investigation found that courts approved wage garnishment requests in an estimated 14,000 medical debt cases a year in Colorado. The investigation also showed that it isn’t just urban hospitals or big health care chains allowing their patients’ wages to be garnished. It’s also small rural hospitals, physician groups, and public ambulance services, among other medical care providers. And the reporting showed that wage garnishment can erroneously target patients. For example, one family lost wages — and subsequently power to their home, because they couldn’t pay their electric bill — after an ambulance company incorrectly billed the family instead of Medicaid.

Wage garnishment is one tool creditors can use in most states to recoup money from people with unpaid bills. In many states, they can garnish someone’s bank account or put a lien on their home, too. To garnish a person’s wages, a creditor must typically get permission from a court to make the person’s employer hand over a piece of the debtor’s earnings.

“The creditor is taking the money directly out of somebody’s paycheck, and so it doesn’t leave people with any choice to say, ‘I need to prioritize food for my children,’” said Lauren Jones, legal and policy director for the National Center for Access to Justice. The center, based at Fordham Law School, scores states and the District of Columbia on how fair their laws are to consumers who get sued over debt.

It is legal to garnish patients’ wages for medical debt in all but a few states, according to the Commonwealth Fund, a nonprofit foundation based in New York focused on health care.

Now, lawmakers in additional states seek to ban the practice entirely. Others want to limit it by exempting debtors whose household income falls under a certain threshold or by upping the amount of earnings immune from garnishment.

Such policies on wage garnishment fit into a larger push around the country to address the effect of medical debt on people’s lives and finances. Those efforts include barring medical debt from credit reports, prohibiting liens on people’s homes, capping interest rates, and limiting the ability to file lawsuits against people with low incomes over unpaid medical bills.

Debt collectors have fought against such measures, arguing they don’t solve the problem of health care affordability and hurt the ability of medical providers to continue to provide care.

“The wage garnishment process is already highly regulated at the federal and state level and includes many consumer protection measures,” said Scott Purcell, chief executive of ACA International, an association of credit and collection professionals.

Even before the Colorado legislation was introduced, BC Services sent a letter warning its clients that the legislation “poses an existential threat,” especially to rural health providers. And Bridget Frazier, a spokesperson for the Colorado Hospital Association, said Feb. 20 that the bill “could drive up costs and financial risk for health care providers, making it harder to keep hospitals sustainable and ensuring Coloradans have access to care when they need it most.”

The pending Colorado measure would ban wage garnishment for all patients. It also would limit bank garnishments, in which a patient’s financial institution must hand over a chunk of the money in the person’s account. Additionally, among other things, it would prevent payment plans from exceeding 4% of weekly net income, require creditors to check whether uninsured patients are eligible for public health insurance before collecting, bar creditors from collecting on bills that are more than three years old, and leave medical care providers liable to the patient for at least $3,000 if collectors don’t comply.

“No one is saying, ‘Don’t get paid for your services.’ We’re saying getting health care should not lead to financial ruin for people,” said Dana Kennedy, co-executive director at the Denver-based Center for Health Progress, a health advocacy group that has been working with lawmakers on the Colorado measure.

Kennedy said that KFF Health News’ investigation drove home how many kinds of Colorado health care facilities are willing to let this collection practice happen to their patients, and that the people whose wages are being garnished are often working at Family Dollar, Walmart, Amazon, or gas stations and restaurants.

“Medical debt is typically different from other forms of indebtedness,” said Colorado state Sen. Mike Weissman, a Democrat co-sponsoring the legislation. “You could choose to keep driving your old car or buy a new one and take on debt for that. You could upgrade your home. You could buy consumer appliances. There’s not usually that voluntary element in a health care context.”

Carolyn Carter, a senior attorney with the National Consumer Law Center, said broad laws that don’t require patients to jump through hoops to access protections are the most likely to be effective. Because of that, she and other consumer advocates prefer state policies that get rid of wage garnishment for all debtors and all types of debt.

“It can be hard to identify medical debt as medical debt,” Carter said. “For example, if you have a medical debt and you put it on your credit card, it’s not going to be easy for a court system to identify that debt as medical debt.”

She said another reason is that complexity is the enemy of effectiveness. Carter pointed to a report about Hamilton County, Tennessee, showing that even though people in the state can keep $10,000 in their bank accounts safe from garnishment, few consumers take advantage of the protection. They must know the protection exists, know where to find the relevant form, get the form notarized, file it, and mail copies to creditors. The same report found that garnishments can also be burdensome for employers, who must process garnishments and can find themselves in court if they make an error.

Jones, at the National Center for Access to Justice, said outlawing wage garnishment fully, rather than limiting it, has other benefits. “It’s also to protect people’s jobs, because in most states, if somebody has two or more orders of garnishment, they can lose their job for it,” she said.

Still, some lawmakers are pushing for the intermediate route. In Washington state, Democratic state Sen. Marko Liias is spearheading legislation to rope off a larger portion of low-wage earnings from garnishment. So, for example, a person making $1,000 a week would be able to keep their whole paycheck, as opposed to the $800 that the law would currently protect.

Mindy Chumbley, owner of a Washington-based collections company and an ACA International board member, testified against the bill on Feb. 2. “Washington has made sweeping changes to medical debt policy year after year without pausing to study the cumulative impact,” she told lawmakers. “Our clients are reporting clinic closures, urgent care centers shutting down, staffing shortages, and rural facilities struggling to stay open.”

The Washington State Hospital Association said it is neutral on the legislation. The American Hospital Association said it does not take positions on state policies.

Liias told KFF Health News that lawmakers need to ensure health care providers can recoup their costs while also protecting patients. “We don’t want families either to be driven into bankruptcy or to be driven into under-the-table work to avoid these garnishment thresholds,” he said.

Liias said his measure follows the lead of Arizona, which passed similar consumer protections in 2022. “Obviously, the health care system is still functioning in Arizona, and folks are able to make it work.”

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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Those preliminary numbers from the open enrollment period that ended in January are less than a third of what state officials had projected. Nevada is the third state so far to launch a public option plan, along with Colorado and Washington state. The idea is to offer lower-cost plans to consumers to expand health care access.

But researchers said plans like these are unlikely to fill the gaps left by sweeping federal changes, including the expiration of enhanced subsidies for plans bought on Affordable Care Act marketplaces.

The public option gained attention in the late 2000s when Congress considered but ultimately rejected creating a health plan funded and run by the government that would compete with private carriers in the market. The programs in Washington state, Colorado, and Nevada don’t go that far — they aren’t government-run but are private-public partnerships that compete with private insurance.

In recent years, states have considered creating public option plans to make health coverage more affordable and to reduce the number of uninsured people. Washington was the first state to launch a program, in 2021, and Colorado followed in 2023.

Washington and Colorado’s programs have run into challenges, including a lack of participation from clinicians, hospitals, and other care providers, as well as insurers’ inability to meet rate reduction benchmarks or lower premiums compared with other plans offered on the market.

Nevada law requires that the carriers of the public option plans — Battle Born State Plans, named after a state motto — lower premium costs compared with a benchmark “silver” plan in the marketplace by 15% over the next four years.

But that amount might not make much difference to consumers with rising premium payments from the loss of the ACA’s enhanced tax credits, said Keith Mueller, director of the Rural Policy Research Institute.

“That’s not a lot of money,” Mueller said.

Three of the eight insurers on the state’s exchange, Nevada Health Link, offered the state plans during the open enrollment period.

Insurance companies plan to meet the lower premium cost requirement in Nevada by cutting broker fees and commissions, which prompted opposition from insurance brokers in the state. In response, Nevada marketplace officials told state lawmakers in January that they will give a flat-fee reimbursement to brokers.

The public option has faced opposition among state leaders. In 2024, a state judge dismissed a lawsuit, brought by a Nevada state senator and a group that advocates for lower taxes, that challenged the public option law as unconstitutional. They have appealed to the state Supreme Court.

Federal Policy Impacts

Recent federal changes create more obstacles.

Nevada is consistently among the states with the largest populations of people who do not have health insurance coverage. Last year, nearly 95,000 people in the state received the enhanced ACA tax credits, averaging $465 in savings per month, according to KFF, a health information nonprofit that includes KFF Health News.

But the enhanced tax credits expired at the end of the year, and it appears unlikely that lawmakers will bring them back. Nationwide ACA enrollment has decreased by more than 1 million people so far this year, down from record-high enrollment of 24 million last year.

About 4 million people are expected to lose health coverage from the expiration of the tax credits, according to the Congressional Budget Office. An additional 3 million are projected to lose coverage because of other policy changes affecting the marketplace.

Justin Giovannelli, an associate research professor at the Center on Health Insurance Reforms at Georgetown University, said the changes to the ACA in the Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will make it more difficult for people to keep their coverage. These changes include more frequent enrollment paperwork to verify income and other personal information, a shortened enrollment window, and an end to automatic reenrollment.

In Nevada, the changes would amount to an estimated 100,000 people losing coverage, according to KFF.

“All of that makes getting coverage on Nevada Health Link harder and more expensive than it would be otherwise,” Giovannelli said.

State officials projected ahead of open enrollment that about 35,000 people would purchase the public option plans. Of the 104,000 people who had purchased a plan on the state marketplace as of mid-January, 10,762 had enrolled in one of the public option plans, according to Nevada Health Link.

Katie Charleson, communications officer for the state health exchange, said the original enrollment estimate was based on market conditions before the recent increases in customers’ premium costs. She said that the public option plans gave people facing higher costs more choices.

“We expect enrollment in Battle Born State Plans to grow over time as awareness increases and as Nevadans continue seeking quality coverage options that help reduce costs,” Charleson said.

According to KFF, nationally the enhanced subsidies saved enrollees an average of $705 annually in 2024, and enrollees would save an estimated $1,016 in premium payments on average in 2026 if the subsidies were still in place. Without the subsidies, people enrolled in the ACA marketplace could be seeing their premium costs more than double.

Insights From Washington and Colorado

Washington and Colorado are not planning to alter their programs due to the expiration of the tax credits, according to government officials in those states.

Other states that had recently considered creating public options have backtracked. Minnesota officials put off approving a public option in 2024, citing funding concerns. Proposals to create public options in Maine and New Mexico also sputtered.

Washington initially saw meager enrollment in its Cascade Select public option plans; only 1% of state marketplace enrollees chose a public option plan in 2021. But that changed after lawmakers required hospitals to contract with at least one public option plan by 2023. Last year the state reported that 94,000 customers enrolled, accounting for 30% of all customers on the state marketplace. The public option plans were the lowest-premium silver plans in 31 of Washington’s 39 counties in 2024.

A 2025 study found that since Colorado implemented its public option, called the Colorado Option, coverage through the ACA marketplace has become more affordable for enrollees who received subsidies but more expensive for enrollees who did not.

Colorado requires all insurers offering coverage through its marketplace to include a public option that follows state guidelines. The state set premium reduction targets of 5% a year for three years beginning in 2023. Starting this year, premium costs are not allowed to outpace medical inflation.

Though the insurers offering the public option did not meet the premium reduction targets, enrollment in the Colorado Option has increased every year it has been available. Last year, the state saw record enrollment in its marketplace, with 47% of customers purchasing a public option plan.

Giovannelli said states are continuing to try to make health insurance more affordable and accessible, even if federal changes reduce the impact of those efforts.

“States are reacting and trying to continue to do right by their residents,” Giovannelli said, “but you can’t plug all those gaps.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story.

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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This story can be republished for free (details).