“I heard one officer say about us ‘they smell like sh–,’” one detained person recounted in a federal court filing. “And another officer responded, ‘They are sh–.’”

Attorneys for immigrant children collected these stories, and more, from youth and families detained in what they called “prison-like” settings across the U.S. from March through June, even as the Trump administration has requested a federal district court judge terminate existing protections that mandate basic rights and services — including safe and sanitary conditions — for children held by the government.

The administration argues that the protections mandated under what is known as the Flores Settlement Agreement encourage immigration and interfere with its ability to establish immigration policy. U.S. District Court Judge Dolly Gee, who is in California, is expected to issue a ruling on the request after an Aug. 8 hearing.

With the agreement in place, children are being held in “unsafe and unsanitary” U.S. Customs and Border Protection facilities such as tents, airports, and offices for up to several weeks despite the agency’s written policy saying people generally should not be held in its custody longer than , according to the from immigrants’ attorneys. In the U.S. Department of Justice’s May request to terminate the Flores consent decree, the attorneys demanded more monitoring for children in immigration detention.

“The biggest fear is that without Flores, we will lose a crucial line of transparency and accountability,” said , executive director of the California-based Center for Human Rights and Constitutional Law. “Then you have a perfect storm for the abuse of individuals, the violation of their rights, and the kind of treatment that this country doesn’t stand for.”

The has set minimum standards and oversight for detained immigrant children since 1997, when it brought an end to a decade-long lawsuit filed on behalf of unaccompanied immigrant minors who had been subjected to poor treatment in unsafe and unsanitary conditions without access to medical care. It is named for Jenny Lisette Flores, a 15-year-old from El Salvador who was taken into U.S. custody in the mid-1980s, subjected to strip searches, and housed alongside unrelated men.

The agreement established national standards for the protection of immigrant children detained by federal authorities, with requirements for safe and sanitary detention facilities, access to clean water, appropriate food, clothing, bedding, recreational and educational opportunities, sanitation, plus appropriate medical and mental health care. Children in immigrant detention range from infants to teens.

In 2015, Gee ruled that the agreement includes children accompanied by adults.

The Justice Department and the Department of Homeland Security, which includes both the Customs and Border Protection agency and Immigration and Customs Enforcement, declined to respond on the record to questions about the administration’s intent to end the Flores agreement or about the conditions in which kids are detained. In a , government attorneys argued, among other points, that the agreement improperly directs immigration decisions to the courts, not the White House. U.S. Attorney General Pam Bondi also that the Flores agreement has “incentivized illegal immigration,” and that Congress and federal agencies have resolved the problems Flores was designed to fix.

ICE detention facilities have the “highest standards,” Abigail Jackson, a White House spokesperson, said in an email to Â鶹ŮÓÅ Health News. “They are safe, clean, and hold illegal aliens who are awaiting final removal proceedings.”

Immigration lawyers and researchers have on the idea that the Flores agreement encourages migration, arguing that the conditions in people’s homelands are driving them to move.

Trump is not the first president to seek to modify, or end, the agreement.

In 2016, President Barack Obama’s administration unsuccessfully sought to exempt accompanied minors from the Flores agreement, arguing that an influx of immigrants from Central America had overwhelmed the system.

In 2019, following a , the first Trump administration announced it would replace Flores with new regulations to expand family detention and eliminate detention time limits. The courts rejected that plan, too.

In 2024, President Joe Biden’s administration successfully requested to remove the Department of Health and Human Services from the agreement after the Office of Refugee Resettlement incorporated some Flores standards into agency regulations.

Allegations of unsafe conditions under the agreement also predate this latest immigration crackdown under Trump. One court filing from 2019 said that attorneys visiting two Texas detention centers found at least 250 infants, children, and teens, some of whom had been held at the facility for nearly a month. “Children were filthy and wearing clothes covered in bodily fluids, including urine,” the filing said.

Seven children are while in federal custody from 2018 to 2019, according to media reports.

And in 2023, 8-year-old Anadith Danay Reyes Alvarez became while in Customs and Border Protection custody in Texas for nine days. Her parents had turned over medical records detailing the girl’s medical history, including diagnoses of sickle cell disease and congenital heart disease, upon their detention. Yet her mother’s repeated pleas for emergency medical care were ignored.

Her family filed a in May.

Advocates attributed the deaths partly to prolonged detention in increasingly crowded facilities and delayed medical care. Officials have said they and in the wake of the deaths.

But with the Trump administration’s unprecedented push to detain and deport migrants — including families — the threat to the health of children caught up in those sweeps is alarming child advocates.

“Very rarely do you have spikes in populations of detained folk that you don’t see a drastic decrease in the quality of their medical care,” said Daniel Hatoum, a senior supervising attorney at the , one of the groups that filed the wrongful death claim for Anadith’s family.

Recent reports from court-appointed monitors cite continued ; temperature extremes; recreational opportunities; and clothing; and an inability to dim lights to sleep.

Terminating the Flores agreement would remove all outside oversight of immigration detention facilities by court-ordered monitors and attorneys. The public would have to depend on the government for transparency about the conditions in which children are held.

“Our system requires that there be some oversight for government, not just the Department of Homeland Security, but in general,” Hatoum said. “We know that. So, I do not believe that DHS could police itself.”

In the months after Trump took office and the Elon Musk-led Department of Government Efficiency began cuts, DHS’ Office for Civil Rights and Civil Liberties, the Office of the Citizenship and Immigration Services Ombudsman, and the Office of the Immigration Detention Ombudsman, which were intended to add a layer of oversight. After a lawsuit, the Trump administration , but it is unclear how those offices have been affected by shifts in policy and cuts in staffing.

Leecia Welch, an attorney with the legal advocacy group , said the Flores agreement itself, or efforts to hold the government responsible for abiding by its requirements, are not rooted in partisan politics. She said she raised concerns about conditions during Biden’s administration, too.

“These are not political issues for me,” Welch said. “How does our country want to treat children? That’s it. It’s very simple. I’m not going to take it easy on any administration where children are being harmed in their care.”

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Concerned onlookers called an ambulance. But Whitten instead had friends pick him up and take him to a nearby hospital, the Helen Diller Medical Center, operated by the University of California-San Francisco.

“I knew that ambulances were expensive, and I didn’t think I was going to die,” he said.

Whitten said doctors treated him for a mild concussion, a broken toe, and bruises.

As he sat in a hospital bed, attached to an IV and wearing a neck brace, Whitten said, doctors told him that because he had suffered a traumatic injury, they had to send him by ambulance to the city’s only trauma center, Zuckerberg San Francisco General Hospital.

After a short ambulance ride, Whitten said, emergency room doctors checked him out, told him he had already received appropriate treatment, and released him.

Then the bill came.

The Medical Procedure

Traumatic injuries are those that threaten life or limb, and some facilities specialize in providing care for them. For someone hit by a car, that stabilizing vital signs, screening for internal injuries, and treating broken bones and concussions. Zuckerberg Hospital is a Level 1 trauma center, meaning it can provide any care needed for severely injured patients.

In emergency medicine, it is standard to transfer patients to centers best equipped to provide care. Ambulances are typically used for transfers because they are able to handle trauma patients, with tools to aid in resuscitation, immobilization, and life support.

At the first hospital, Whitten said, doctors performed a thorough workup, including a CT scan and X-rays, and advised him to follow up with his primary care physician and an orthopedic doctor. He was evaluated at the second hospital and released without additional treatment, he said.

The Final Bill

$12,872.99 for a 6-mile ambulance ride between hospitals: a $11,670.11 base rate, $737.16 for mileage, $314.45 for EKG monitoring, and $151.27 for “infection control.”

The Billing Problem: Surprise Bills Are Common With Ground Ambulances

Ground ambulance services are operated by a hodgepodge of private and public entities — with no uniform structure, or regulatory oversight, for billing — and most function outside insurance networks. Patients don’t typically have a choice of ambulance provider.

There are state and federal laws shielding patients from out-of-network ambulance bills, but none of those protections applied in Whitten’s case.

Whitten was insured under his father’s employer-sponsored health plan from Anthem Blue Cross. So when he received a nearly $13,000 bill months after his short transfer ride, he sent a photo of it to his dad.

Brian Whitten said the bills from the two hospitals — and the family’s out-of-pocket responsibility — were in line with what he had anticipated. But he was stunned by his son’s ambulance bill from AMR, one of the nation’s largest ambulance providers. Anthem Blue Cross denied the claim, saying the ambulance was out-of-network and required pre-authorization.

“It didn’t make a whole lot of sense to me, because the doctor is the one who put him in the ambulance,” Brian Whitten said. “It’s not like somehow he just decided, ‘Hey, can I take an ambulance ride?’”

Kristen Bole, a UCSF spokesperson, said in a statement that the health system’s standard of care is to stabilize patients and, when appropriate, transfer them to other medical facilities that are most appropriate to care for patients’ needs, adding that ambulance transfers between hospitals are standard practice.

While the medical system at large relies on negotiated prices for services, ambulance services operate largely outside of the competitive marketplace, said Patricia Kelmar, senior director of health care campaigns for PIRG, a nonpartisan consumer protection and good-government advocacy organization.

Ambulance transfers between hospitals to ensure the highest quality of care available are fairly common, Kelmar said. And with many hospitals being purchased and consolidated, it would follow that the number of ambulance transfers between facilities could increase as specialized medical units at any given hospital are downsized or eliminated, she said.

According to of private insurance claims data conducted in 2023, about 80% of ground ambulance rides resulted in out-of-network billing.

Generally, out-of-network providers may charge patients for the remainder of their bill after insurance pays. In some cases, patients can be on the hook even when they did not knowingly choose the out-of-network provider. These bills are known as “surprise” bills.

“It’s a financial burden, a significant financial burden,” said Kelmar, who is a member of the federal lawmakers on surprise bills and emergency ambulance transportation.

Eighteen states have implemented laws regulating surprise ambulance billing. A California law cracking down on surprise ambulance billing took effect on Jan. 1, 2024 — months after Jagdish Whitten’s ambulance ride.

But Kelmar said those state laws don’t really help people with employer-sponsored insurance, because those plans are beyond state control — which is why federal legislation is so important, she said.

As of 2022, federal law protects patients from receiving some surprise bills, especially for emergency services. But while lawmakers included protections against air ambulance bills in the law, known as the , they .

The Resolution

Whitten’s father filed an insurance appeal on his son’s behalf, which Anthem granted. The insurer paid AMR $9,966.60.

Michael Bowman, a spokesperson for Anthem, said AMR had not submitted all the information it required to process the claim, leading to the initial denial. After consulting with AMR, Anthem paid its coverage amount, Bowman said.

But the insurer’s payment still left Whitten with a $2,906.39 bill for his out-of-network ambulance ride. Brian Whitten said he called an AMR customer service number several times to contest the remaining charges but was unable to bypass its automated system and speak with a human.

“I couldn’t find a way to talk to somebody about this bill other than how to pay it, and I didn’t want to pay it,” he said.

Unsuccessful and frustrated, Brian Whitten paid the remaining bill in January 2024, he said, concerned it would be turned over to a collection agency and hurt his son’s credit — and his well-being.

There was one more twist: He was shocked when he later reviewed his credit card statements and discovered that AMR had quietly but fully refunded his payment in October.

“It’s amazing that he got his money back,” Kelmar said. “That’s what’s shocking.”

In a statement, Suzie Robinson, vice president of revenue cycle management with AMR, said the company’s third-party billing agency regularly performs audits to ensure accuracy. An audit of Jagdish Whitten’s bill “revealed that the care provided did not meet the criteria for critical care,” Robinson said, which prompted the full refund.

Robinson said audits indicated fewer than 1% of its 4 million medical encounters annually are billed incorrectly.

The Takeaway

Robinson said patients who feel that AMR has billed them incorrectly should contact the company via email.

For patients in need of an ambulance in an emergency, there are few protections — and usually few options: Sometimes you don’t have a better choice than to get in.

require that health plans cover certain surprise bills, with patients paying only what they would if they had received in-network care. Expanding those protections to ground ambulance bills would require Congress to act.

Ambulance providers deserve to be appropriately compensated for their vital role in our medical system, Kelmar said. But the system as it stands almost incentivizes providers to charge a higher rate, which can lead to surprise billing and financial hardship for patients and their families, she said.

Kelmar said she worries not just about the debt those bills create for consumers but also that people may decline vital ambulance transportation in an emergency, for fear of getting hit with an exorbitant bill.

“We just need to bring some sense back to the system,” she said.

Bill of the Month is a crowdsourced investigation by  and  that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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It had been days since Hurricane Beryl blew ashore from the Gulf of Mexico on July 8, causing widespread destruction and knocking out power to more than 2 million people, including the Houston senior independent living facility where Kitzmiller lives. Outdoor temperatures had reached at least 90 degrees most days, and the heat inside the building was stifling.

Kitzmiller moved there not long ago with Kai, her 12-year-old dog, shortly after riding out 90-plus-mph winds from a under a comforter on the floor of the 33-foot RV she called home. She didn’t need medical care, as a nursing home would offer, and thought she and Kai could be safer at an independent senior facility than in the RV. She assumed her new home would have an emergency power system in place at least equivalent to that of the post offices she’d worked in for 35 years.

“I checked out the food. I checked out the activities,” said Kitzmiller, 61, now retired. “I didn’t know I needed to inquire about a generator.”

Even after multiple incidents of extreme weather — including a 2021 Texas winter storm that caused widespread blackouts and prompted a — not much has changed for those living in long-term care facilities when natural disasters strike in Texas or elsewhere.

“There has been some movement, but I think it’s been way too slow,” said , a professor of health care policy at Harvard Medical School. “We keep getting tested and we keep failing the test. But I do think we are going to have to face this issue.”

A power outage can be difficult for anyone, but older adults are especially vulnerable to temperature extremes, with medications or medical conditions affecting their bodies’ and . Additionally, some medications need .

Federal guidelines require nursing homes to maintain safe indoor temperatures but do not regulate how. For example, facilities face no requirement that generators or other alternative energy sources support heating and air conditioning systems. States are largely responsible for compliance, Grabowski said, and if states are failing in that regard, change doesn’t happen.

Furthermore, while nursing homes face such federal oversight, lower-care-level facilities that provide some medical care — known as assisted living — are regulated at the state level, so the rules for emergency preparedness vary widely.

Some states have toughened those guidelines. Maryland in assisted living facilities following Hurricane Isabel, which left more than 1.2 million residents in the state without power in 2003. Florida in 2018, after Hurricane Irma led to deaths at one facility.

But Texas has not. And no requirements for generators exist in Texas for the roughly 2,000 assisted living facilities or the even less regulated independent living sites, like Kitzmiller’s.

Generally, apartment complexes marketed to senior citizens, known in the industry as independent living facilities, don’t have any special regulations in Texas and many other states.

Nationally, assisted living facilities and independent living facilities have been the fastest-growing sectors in senior living. Residents at such facilities often have medical needs, Grabowski said, but for a variety of reasons have chosen to live in an environment that allows more independence than a nursing home, which would provide medical care. That doesn’t mean the residents in these lower-care-level facilities are any less susceptible to extreme temperatures when the power goes out.

“If you’re overwhelmed by the heat in your apartment, that’s unsafe,” he said.

Republican state Rep. tried several times since 2020 to pass legislation requiring assisted living facilities in Texas to have backup generators. But the bills failed. He is not seeking reelection this year.

“It’s horrible what the state of Texas is doing,” said Thompson, blaming corporate greed and politicians more interested in stirring up their base and raising their national profile than improving the lives of Texans. “How we treat our elderly says something about us — and they’re not being treated right.”

Nim Kidd, chief of the Texas Division of Emergency Management, said at that senior facility operators are accountable if they do not keep residents safe. “That location is responsible for the health, safety, and welfare of the patients and residents that are there,” he . “It is that facility’s responsibility.”

Under , power restoration is supposed to be prioritized for nursing, assisted living, and hospice facilities.

The resistance to adding oversight or more governmental protections has not surprised , a senior manager at the Harris County Long-Term Care Ombudsman Program at UTHealth Houston’s Cizik School of Nursing. He said that while he believes the safety and health of residents are paramount, he recognizes that installing generators is expensive. He also said some people within the industry continue to believe extreme events are rare.

“But all of us in Houston this year already learned that they’re happening more frequently,” Shelley said. “This is already the third time since May that big portions of Houston have been without power for long periods of time.”

After the 2021 blackouts, Texas’ Health and Human Services Commission conducted a that found 47% of the assisted living and 99% of the nursing care facilities that responded reported having generators.

The U.S. Senate investigation following the 2021 Texas storm recommended a national requirement that assisted living facilities have emergency power supplies to both maintain safe temperatures and keep medical equipment running.

A from Texas’ long-term care ombudsman, Patty Ducayet, also recommended requiring generators at assisted living centers. The report suggested that all long-term care facilities maintain safe temperatures in a location that can be accessed by every resident. The report recommended requiring assisted living facilities to annually submit emergency response plans to state regulators to be reviewed by state officials. The recommendations have not been adopted.

On July 15 — more than a week after Beryl hit — Kitzmiller said she just wanted the power back on. She praised the staff at her facility but said she worried for residents who were isolated on her building’s second and third floors, which were hotter amid the outage. Some were unable to keep required medicine refrigerated, she said. And without functioning elevators, many couldn’t get to the first floor, where it was cooler.

Mostly, Kitzmiller said, she was frustrated with companies and politicians who hadn’t yet fixed the problem.

“It’s their mothers, their grandmothers, and their family in these homes, these facilities,” she said. “All I can think is ‘Shame on you.’”

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Although lead was banned from new water service lines in 1986, it’s estimated that still carry drinking water to homes and businesses throughout the country. Under the EPA’s proposal, water utilities would be required to replace within 10 years.

The proposal from the Biden administration builds on different rules put out in the waning days of the Trump term that allowed up to 30 years for service line replacement, triggered only when lead levels test higher than 15 parts per billion. The new proposal, which would largely supplant , calls for stricter monitoring, enhanced public education, and the 10-year pipe replacement mandate regardless of lead levels.

An October deadline looms for the new rules to be adopted; otherwise, enforcement of the less-stringent Trump administration rules will begin. And complicating matters more: November’s election results could shake up whose rules the nation must follow.

While many cities and states have begun to replace their lead pipes, some utilities and officials say the 10-year and too expensive. They say it would be difficult for water utilities to follow the rules while dealing with contaminants, known as “forever chemicals,” and , among other issues.

“Nobody will tell you that having lead in contact with water is a great idea,” said Steve Via, director of federal relations for the , the country’s largest nonprofit water utility industry group. “The question becomes: How urgent a matter is it, and at what pace does it need to be done?”

Already, have argued that the proposed rules infringe on states’ rights and chase “speculative” benefits. On the other side, said that the EPA should find more ways to ensure pipes are quickly replaced in low-income areas.

To be sure, to consume. Lead is a irreversible long-term organ damage, lower IQs, higher risk for miscarriage, asthma, cardiovascular disease, impotence, and elevated blood pressure.

Public health advocates say societal costs — in health care, social services, and lost productivity — far outweigh the cost of replacement. They say corrosion controls that have limited lead exposure can and do fail, pointing to human and systemic errors that prompted the , where thousands of people were exposed to high lead levels in their drinking water.

“That’s the whole thing about lead pipes: They unexpectedly release lead into drinking water,” said , who manages an initiative focused on reducing lead exposure from water with the , a national advocacy group. “I don’t think kicking the can down the road is the solution.”

According to a by , an instructor at Harvard’s T.H. Chan School of Public Health, the benefit of replacing lead pipes outweighs the costs by a 35:1 ratio.

Using the EPA’s estimated $335 million annual costs from the Trump rules, which include water sampling, corrosion control treatments, inventorying and replacement of lead service lines, and educational outreach, Levin’s analysis shows that $9 billion in annual health care costs could be avoided. An additional $2 billion in spending — through upgraded infrastructure and reduced corrosion damage to appliances — could be saved. The broad spectrum of health-related costs has historically been ignored in analyzing the actual costs of leaving lead service lines in place, said Levin, a former EPA scientist.

Estimates of the cost to replace the nation’s lead pipes range from to more than , far higher than the set aside in the . The Biden administration has framed those funds as a down payment, or principal forgiveness loans of the estimated number of lead pipes per state. Other can also be tapped.

Replacement costs vary widely by location, with average costs ranging from per service line to .

, legislative director for sustainability at the National League of Cities, said funding challenges could render the EPA’s 10-year timeline unrealistic. While her organization is encouraging local leaders to secure as much funding as possible, what’s available won’t be enough to cover replacement costs for some localities — especially low-income areas, which often have older infrastructure and more lead pipes.

Some direct costs could fall to property owners, such as replacing the lines connecting their water meters to their homes. And people could face indirect costs if utilities increase customer rates to offset the expense.

Still, some communities, such as Olathe, Kansas, are finding ways to move forward with a patchwork of funding. Out of 37,000 service lines there, 266 galvanized pipes were found serving downtown properties, where many of the city’s most vulnerable residents live. The coating for .

Workers will replace the lines at no cost to property owners in the city of 147,000 people outside Kansas City, said Megan Spence, who is . It is expected to cost around $2.3 million, paid for with from the Kansas Department of Health and Environment and about $1.2 million in federal infrastructure funding. About $500,000 for lawn restoration is included.

“We’re really looking at this as an opportunity and another way to protect public health,” said Spence. “There shouldn’t be any lead lines in any drinking water distribution systems.”

Elsewhere, some Republicans, such as Indiana state Sen. , are leading the charge to replace the pipes despite historical pushback in conservative states against federal mandates. He said lawmakers should consider the harm — and long-term costs — caused by delaying the cleanup of lead from drinking water.

In March, Indiana’s Republican Gov. signed a , which Koch authored, designed to lower costs for replacing customer-owned lead service lines. Under the law, landlords are required to enroll in a state-approved program to have their lead pipes removed at no cost by their water utility or pay for replacement themselves.

Koch said estimates for replacing customer-owned service lines are around $8,000, though the cost could be significantly higher for some properties. But by starting the work now, Koch said, utilities can avoid price inflation and ultimately remove pipes more cost efficiently.

Meanwhile, time is running out to publish the Biden administration’s proposed rules in the . Water utilities will be required to comply with the Trump rules as of Oct. 16 unless the EPA publishes the newer rules before then, said , a senior strategic director of the National Resources Defense Council, an advocacy group. It remains unknown what the June 28 Supreme Court , known as the “Chevron deference” decision, will mean for either set of rules.

A deadline is also looming for the 60-day “look-back” period under the , during which a regulation can be repealed. If control of Congress or the White House flips with the November election, the Biden administration’s rules could be repealed under an emboldened Congress even before the January swearing in of new officeholders.

“Depending on how the election goes, it could become a hot issue,” said , national director of the advocacy organization .

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“I was just trying to make a living,” said Brady, 56, a dealer and supervisor at Borgata in that New Jersey resort city. “You don’t think, you know, that you’re going to get sick at your job.”

Some casinos continue to allow indoor smoking even as the share of Americans who smoke fell from about and smoking is banned in at least some public spaces , the District of Columbia, and U.S. territories. Still, 13 of the that allow casino gambling permit smoking in at least part of their facilities.

Brady is among the casino employees, anti-smoking advocates, and public health experts who argue it is long past time to snuff out casino exemptions from smoking bans, given the dangers of secondhand smoke. But they’ve faced stiff pushback from some gambling industry leaders, including in Missouri, Louisiana, Kentucky, and New Jersey, who argue that smoking bans drive gamblers away — especially in places where patrons can go instead to a casino in a nearby jurisdiction that allows them to light up.

The covid-19 pandemic renewed this fight and sharpened the arguments on both sides — on the dangers of particulate matter for the anti-smoking side and the vulnerability of revenues for the casino industry, even as the American Gaming Association reported in 2022 for in-person casino gambling beyond the growth of sports betting and online gambling.

Casinos were for several months in spring 2020 as part of the nationwide effort to mitigate the spread of the coronavirus. Rules governing reopening, including masking and physical distancing requirements and bans on smoking, varied by state and, in some cases, by casino operator and community.

After suffering , some casino executives, and representing workers, leaned into commissioned by the Casino Association of New Jersey to combat efforts to ban or restrict smoking at their properties. Using data from 2019, the report suggests that as many as 2,500 Atlantic City casino workers could lose their jobs and tax revenue could fall by as much as $44 million in the first year if smoking is banned in New Jersey but not in neighboring Pennsylvania. Both states considered prohibitions on casino smoking in 2023; New Jersey lawmakers and Pennsylvania’s .

, a social media influencer specializing in casinos and gambling, said he has heard the arguments about lost business before — and is unconvinced. “People are not driving or flying to a casino to have a cigarette,” he said.

Still, officials in some places are persuaded by arguments about depressed tax revenue. Last spring, Shreveport, Louisiana, officials on smoking in casinos. Those pushing said local gambling taxes fell when gamblers left for nearby casinos where they could smoke. The new ordinance of the casino floor.

And announced in June it was planned for empty mall space in Owensboro, Kentucky, to a location outside the city limits. Though the company declined to comment for this article, the city’s mayor told the newspaper that a primary reason for the move was the city’s long-standing voter-approved smoking restrictions, which do not exempt casinos.

, director of the St. Louis County Department of Public Health in Missouri, was part of an effort last year to end a casino loophole in her county’s 2011 indoor smoking ban. But after pushback from the gambling company , a allowing smoking on 50% of a casino’s floor.

“It’s a balance and one that we feel the marketplace should determine, particularly in such a competitive environment with other gaming facilities nearby and in neighboring states,” said Jeff Morris, Penn Entertainment’s vice president of public affairs and government relations.

Penn Entertainment employs “state of the art ventilation systems, extremely high ceilings,” and “adequate separation of smoking and non-smoking areas,” he wrote in an email to Â鶹ŮÓÅ Health News.

The problem, Cunningham said, is that secondhand smoke cannot be contained to a single location in a big room.

“There’s no safe amount, and trying to restrict it to a certain area isn’t going to work,” she said.

Filtration systems can remove much of the visible smoke, as well as the odor, from indoor spaces even when lots of people are smoking, creating the impression of clean air. But existing technology does not eliminate the dangerous particulates in cigarette smoke, according to a from the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE.

A for the National Institutes of Health evaluated particulate matter at eight Las Vegas casinos that allowed smoking and one that did not. In casinos where smoking is allowed, particulate levels were significantly higher — even in areas designated as nonsmoking — than at the nonsmoking casino.

And in ventilated casinos where indoor smoking is allowed, , workers can have nicotine levels as much as 600% higher than employees exposed to smoking in other workplaces.

can cause coronary heart disease, stroke, lung cancer, and other diseases. Some studies have shown a link to breast cancer, although more research is needed, .

The pandemic raised awareness of the dangers of airborne particulates, giving smoking bans fresh momentum, said , co-founder of the independent industry consulting group C3 Gaming, which produced a largely refuting the economic risk of casinos going smoke-free.

Indeed, more than 1,000 U.S. casinos and other gambling properties , including more than 140 tribal casinos, according to Americans Nonsmokers’ Rights Foundation.

New Mexico’s tribal leaders collectively agreed to maintain smoking bans when pandemic restrictions were lifted, said , chief executive of Acoma Business Enterprises and in North Acomita Village. Employee health has improved, he said, qualifying the casino for rebates on its insurance premium. Cleaning and replacement costs for carpets and equipment fell, he said, and the tribes “haven’t missed a beat” on revenues.

Some guests have grumbled about having to go outside to smoke, Floge said, but that’s about it. “We don’t have anybody who jumps up and down, or throws a fit and says, ‘I’m leaving and never coming back!’” he said.

Casino executives who oppose smoking restrictions overlook people who want to enjoy the “great food and the great entertainment, but won’t step foot in a casino because they get hit by a blast of smoke as soon as they step in,” said Pete Naccarelli, a Borgata dealer and one of three co-founders of the advocacy organization

He said they founded the group, which has chapters in New Jersey, Kansas, Pennsylvania, Rhode Island, and Virginia, after his casino put out ashtrays at 12:01 a.m. the day the pandemic-related smoking ban officially ended. Borgata did not answer requests for comment.

The industry-commissioned report on New Jersey suggests that while more nonsmokers might frequent casinos once smoking is banned, they probably would not make up for the revenue lost if smokers choose other venues or when smokers take breaks from gambling to light up.

But Brady, now cancer-free after chemotherapy and a full mastectomy, believes that if policymakers spent some time breathing the same air she and her co-workers do they’d act more quickly to ban smoking in casinos, rather than prioritize tax revenues. “Our lives are more important,” she said.

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But, just five weeks after confirming her pregnancy, and the day after a gender-reveal party where she announced she was having a girl, she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain.

“I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.”

An ultrasound showed she had . Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby, Tabitha Winnie Denkins.

Black women are than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a that contribute to disproportionately high Black maternal mortality rates.

“This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said , who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.”

In fact, Harris County ranks third, behind only Chicago’s Cook County and Detroit’s Wayne County, in what are known as excess Black infant deaths, according to the federal . Those three counties, which also are among the nation’s most populated counties, 7% of all Black births in the country and 9% of excess Black infant deaths, said Ashley Hirai, a senior scientist at HRSA. The counties have the largest number of Black births but also that would not occur if Black babies had the same chance of reaching their 1st birthdays as white infants.

exist for Black infants to die at higher rates than white infants. Such deaths are often called “deaths of disparity” because they are likely attributable to systemic racial disparities. Regardless of economic status or educational attainment, the stress from experiencing persistent systemic racism leads to adverse health consequences for Black women and their babies, published in the journal Women’s Health Issues.

These miscarriages and deaths can occur even in communities that otherwise appear to have vast health resources. In Harris County, for example, home to two public hospitals and the — the largest medical complex in the world, with more than 54 medical-related institutions and 21 hospitals — mortality rates were 11.1 per 1,000 births for Black infants from 2014 through 2019, according to the March of Dimes, compared with 4.7 for white infants.

The abundance of providers in Harris County pregnant Black patients that they can find care that is timely, appropriate, or — care that acknowledges a person’s heritage, beliefs, and values during treatment.

Regardless of income or insurance status, studies show, medical providers Black women’s questions and concerns, , and fail to offer appropriate care. By contrast, a study of 1.8 million hospital births spanning 23 years in Florida found that the gap in mortality rates between Black and white newborns for Black babies when Black physicians cared for them.

In 2013, Houstonian Kay Matthews was running a successful catering business when she lost the daughter she’d named Troya eight months and three weeks into pregnancy.

Matthews hadn’t felt well — she’d been sluggish and tired — for several days, but her doctor told her not to worry. Not long afterward, she woke up realizing something was terribly wrong. She passed out after calling 911. When she woke up, she was in the emergency room.

None of the medical staffers would talk to her, she said. She had no idea what was happening, no one was answering her questions, and she started having a panic attack.

“It kind of felt like I was watching myself lose everything,” she recalled. She said the nurse seemed annoyed with her questions and demeanor and gave her a sedative. “When I woke up, I did not have a baby.”

Matthews recalled one staffer insinuating that she and her partner couldn’t afford to pay the bill, even though she was a financially stable business owner, and he had a well-paying job as a truck driver.

She said hospital staffers showed minimal compassion after she lost Troya. They seemed to dismiss her grief, she said. It was the first time she could remember feeling as if she was treated callously because she is Black.

“There was no respect at all, like zero respect or compassion,” said Matthews, who has since founded the , a Houston nonprofit focused on improving maternal mental health, primarily for Black patients.

To help combat these high mortality rates in Harris County, Robinson created a maternal child and health office and launched a home-visit pilot program to connect prenatal and postpartum patients with resources such as housing assistance, medical care, and social services. Limited access to healthy food and recreational activities are barriers to healthy pregnancy outcomes. Studies have also shown a .

For Hill, not having insurance was also likely a factor. While pregnant, Hill said, she had had just a single visit at a community health center before her miscarriage. She was working multiple jobs as a college student and did not have employer-provided medical coverage. She was not yet approved for Medicaid, the state-federal program for people with low incomes or disabilities.

Texas has the nation’s highest uninsured rate, with nearly 5 million Texans — or — lacking coverage, said Anne Dunkelberg, a senior fellow with , a nonprofit research and advocacy institute focused on equity in public policy. While non-Hispanic Black Texans have a slightly better rate — 17% — than that overall state level, it’s still higher than the 12% rate for non-Hispanic white Texans, according to census data. Health experts fear that many more people are losing insurance coverage as for Medicaid.

Without full coverage, those who are pregnant may avoid seeking care, meaning they skip being seen in the critical first trimester, said , medical director at Houston’s .

Texas had the receiving early prenatal care in the nation in 2020, according to the state’s 2021 Healthy Texas Mothers and Babies Databook, and non-Hispanic Black moms and babies were less likely to receive first-trimester care than other racial and ethnic groups. Babies were three times as likely to have a low birth weight and five times as likely to die as those whose mothers had care.

If Hill’s miscarriage reflects how the system failed her, the birth of her twins two years later demonstrates how appropriate support has the potential to change outcomes.

With Medicaid coverage from the beginning of her second pregnancy, Hill saw a high-risk pregnancy specialist. Diagnosed early with what’s called an , Hill was consistently seen, monitored, and treated. She also was put on bed rest for her entire pregnancy.

She had an emergency cesarean section at 34 weeks, and both babies spent two weeks in neonatal intensive care. Today, her premature twins are 3 years old.

“I believe God — and the high-risk doctor — saved my twins,” she said.

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They are part of a new migration of Americans who are uprooting their lives in response to a across the country restricting health care for transgender people.

Missouri, Florida, and Texas are among at least components of gender-affirming health care for trans youth. Those three states are also among the — the public health insurance for people with low incomes — from paying for key aspects of such care for patients of all ages.

More than a quarter of trans adults surveyed by late last year said they had moved to a different neighborhood, city, or state to find more acceptance. Now, new restrictions on health care and the possibility of more in the future provide additional motivation.

Many are heading to places that are passing laws to support care for trans people, making those states appealing sanctuaries. California, for example, passed a law last fall to from prosecution. And now, California providers are getting more calls from people seeking to relocate there to prevent disruptions to their care, said Scott Nass, a family physician and expert on transgender care based in the state.

But the influx of patients presents a challenge, Nass said, “because the system that exists, it can’t handle all the refugees that potentially are out there.”

In Florida, the legislative targeting of trans people and their health care has persuaded Arlo Dennis, 35, that it is time to uproot their family of five from the Orlando area, where they’ve lived for more than a decade. They plan to move to Maryland.

Dennis, who uses they/them pronouns, no longer has access to hormone replacement therapy after Florida’s Medicaid program stopped covering transition-related care in late August under the claim that the treatments are experimental and lack evidence of being effective. Dennis said they ran out of their medication in January.

“It’s definitely led to my mental health having struggles and my physical health having struggles,” Dennis said.

Moving to Maryland will take resources Dennis said their family does not have. They launched a in April and have raised more than $5,600, most of it from strangers, Dennis said. Now the family, which includes three adults and two children, plans to leave Florida in July. The decision wasn’t easy, Dennis said, but they felt like they had no choice.

“I’m OK if my neighbor doesn’t agree with how I’m living my life,” Dennis said. “But this was literally outlawing my existence and making my access to health care impossible.”

Mitch and Tiffany Tillison decided they needed to leave Texas after the state’s Republicans made anti-trans policies for youth central to their legislative agenda. Their 12-year-old came out as trans about two years ago. They asked for only her middle name, Rebecca, to be published because they fear for her safety due to threats of violence against trans people.

This year, the Texas Legislature limiting gender-affirming health care for youth under 18. It specifically bans physical care, but local LGBTQ+ advocates say recent crackdowns also have had a chilling effect on the availability of mental health therapy for trans people.

While the Tillisons declined to specify what treatment, if any, their daughter is getting, they said they reserve the right, as her parents, to provide the care their daughter needs — and that Texas has taken away that right. That, plus increasing threats of violence in their community, particularly in the wake of the by a professed neo-Nazi at Allen Premium Outlets, about 20 miles from their home in the Dallas suburbs, caused the family to decide to move to Washington state.

“I’ve kept her safe,” said Tiffany Tillison, adding that she often thinks back to the moment her daughter came out to her during a long, late drive home from a daylong soccer tournament. “It’s my job to continue to keep her safe. My love is unending, unconditional.”

For her part, Rebecca is pragmatic about the move planned for July: “It’s sad, but it is what we have to do,” she said.

A close call on losing key medical care in Missouri also pushed some trans people to rethink living there. In April, Missouri Attorney General Andrew Bailey seeking to limit access to transition-related surgery and cross-sex hormones for all ages, and restrict puberty-blocking drugs, which pause puberty but don’t alter gender characteristics. The next day, Dempsey, 24, who uses they/them pronouns, launched a for themself and their two partners to leave Springfield, Missouri.

“We are three trans individuals who all depend on the Hormone Replacement Therapy and gender affirming care that is soon to be prohibitively limited,” Dempsey wrote in the fundraising appeal, adding they wanted to “escape Missouri when our lease is up at the end of May.”

Dempsey said they also got a prescription for a three-month supply of hormone therapy from their doctor in Springfield to tide them over until the move.

Bailey withdrew his rule after the state legislature in May to such treatments for minors, but not adults like Dempsey and their partners. Still, Dempsey said their futures in Missouri didn’t look promising.

Neighboring Illinois was an obvious place to move; the legislature there that requires state-regulated insurance plans to cover gender-affirming health care at no extra cost. Where exactly was a bigger question. Chicago and its suburbs seemed too expensive. The partners wanted a progressive community similar in size and cost of living to the city they were leaving. They were looking for a Springfield in Illinois.

“But not Springfield, Illinois,” Dempsey quipped.

Gwendolyn Schwarz, 23, had also hoped to stay in Springfield, Missouri, her hometown, where she had recently graduated from Missouri State University with a degree in film and media studies. She had planned to continue her education in a graduate program at the university and, within the next year, get transition-related surgery, which can take a few months of recovery.

But her plans changed as Bailey’s rule stirred fear and confusion.

“I don’t want to be stuck and temporarily disabled in a state that doesn’t see my humanity,” Schwarz said.

She and a group of friends are planning to move west to Nevada, where state lawmakers have approved a measure that gender-affirming treatment for trans patients.

Schwarz said she hopes moving from Missouri to Nevada’s capital, Carson City, will allow her to continue living her life without fear and eventually get the surgery she wants.

Dempsey and their partners settled on Moline, Illinois, as the place to move. All three had to quit their jobs to relocate, but they have raised $3,000 on GoFundMe, more than enough to put a deposit down on an apartment.

On May 31, the partners packed the belongings they hadn’t sold and made the 400-mile drive to their new home.

Since then, Dempsey has already been able to see a medical provider at a clinic in Moline that caters to the LGBTQ+ community — and has gotten a new prescription for hormone therapy.

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Shelton had been taking medication for months for what her doctor said was toenail fungus, but one nail still looked gross.

After Shelton completed her purchase, the woman pulled her aside and said that, while she wasn’t a doctor, she thought Shelton was dealing with something more serious than fungus.

“She’s like: ‘I know I’m just a random stranger, but please, go get it checked out by someone else,’” said Shelton, who lives in a Maryland suburb of Washington, D.C.

Shelton, now 42, took the advice.

The initial lab work didn’t give a clear diagnosis, but her new doctor said he was confident she had acral lentiginous melanoma, a form of skin cancer. Additional testing proved him right. While rare, it is the most common subtype of melanoma in Black people, like Shelton. It is the disease that at age 36, and is most often found on skin less frequently exposed to the sun, such as the hands, the soles of the feet, and under nails. Researchers do not understand what causes acral lentiginous melanoma, and they don’t know how to prevent it. It is often overlooked in skin checks or misdiagnosed.

Skin cancer, in general, is often missed or misdiagnosed in Black patients.

Historically, Black people and those with dark skin have been left out of efforts to combat skin cancer. Long neglected by sunscreen manufacturers and a medical community lagging in diversity and cultural competency — the acknowledgment of a patient’s heritage, beliefs, and values — many have not been informed about sun safety or how to check their skin for signs of damage or cancer.

To be sure, skin cancer rates are lower for people with dark skin tones. Melanoma is more than 20 times as , with an overall lifetime risk of 1 in 38 for white people compared with 1 in 1,000 for Black people. Melanin does provide some protection against sun damage, so those with more of it — those with darker skin — are better protected than those with fairer skin.

But overall, Black patients are more likely to be diagnosed with various forms of skin cancer at more advanced stages, said , with the , a nonprofit that works to educate doctors and the public on skin health.

The five-year melanoma survival rate among non-Hispanic Black people is 66%, compared with 90% for non-Hispanic white people, according to . And 1 in 3 Black men or women diagnosed with melanoma in the U.S. die of the disease, compared with at least 1 in 7 for non-Hispanic white people, .

Given the known disparities in outcomes, Dr. , president of the Skin of Color Society, said two areas of research are needed: studying educational initiatives to see if awareness might lead to earlier diagnosis and improved survival; and determining risk factors in patients with dark skin, especially factors leading to the occurrence of melanoma in places less exposed to the sun.

Improving cultural competency and diversity within dermatology is just one step toward improving diagnosis and outcomes. According to the , fewer than 3% of dermatologists nationwide are Black. Orthopedics is the only medical specialty with a smaller share.

Dermatology has traditionally been one of the most competitive specialties in medicine, said Dr. , a clinical instructor of dermatology at . In addition to stiff academic requirements, admission to dermatology programs also depends on connecting with mentors and extensive networking, which can be expensive. And that, Henry said, has traditionally created barriers for Black medical students who want to pursue dermatology.

“There are so many hurdles that make it difficult for a lot of students of color to do the things that they need to do in such an uber-exclusive and small space,” she said.

Recent initiatives to help students overcome those barriers are beginning to work, said Dr. , vice chair for diversity, equity, and inclusion in the dermatology department at the University of Pennsylvania and founder of the Skin of Color Society. Initiatives from the include holistic reviews of residency applications, mentorships, and programs to increase interest among and prepare high school students for college and medical school.

Medical app company is working to reduce disparities in medicine through by creating a catalog of images reflecting various diseases in different skin colors. Skin cancers may appear different on fairer skin than on darker skin, and because doctors may have been trained only with fair-skin depictions, the chance for misdiagnosis in people with dark skin increases.

Change has also come to the sunscreen industry.

, senior vice president and partner with Chicago market research company , said failures within the medical community to provide adequate skin care for people with dark skin mirror the lack of availability of sunscreens to meet patients’ needs, especially for Black people.

“What that has done is that it has pushed Black entrepreneurs, from one day to the next, to come up with their own solutions and their own products,” Martínez-Bonilla said. “Not only from the lack of availability, but because these are the people who know their needs best.”

is one of those entrepreneurs. She wasn’t thrilled when, in her 30s and 40s, she noticed she was getting moles on her face and neck similar to those she’d seen on older family members while she was growing up. She assumed it was just part of aging. But her dermatologist said it was sun damage.

“I was, literally, shocked. I was like: ‘But I’m Black,’” she said, adding that she had no experience with sunscreen growing up. “It was so foreign to me. I believed we just didn’t need it.”

After struggling to find a sunscreen that didn’t leave a residue or feel like it was burning her skin, she worked with a chemist who helped her create a tinted mineral-based sunscreen. At first, she intended it just for her personal use, but she ultimately launched . The Los Angeles-based company educates about skin care and sells products designed for consumers with dark skin.

also struggled to find a sunscreen that didn’t “leave a blue, purple, or other-colored hue on my skin.” Until, she said, “I realized it didn’t exist.”

So, in 2016, she developed products that left no residue, ultimately launching .

Education is fundamental to her company’s advertising, Lundy said. “Our mission is to equip people of all ages and skin tones with the right sunscreen products to take their skin health seriously and protect themselves from sun damage.”

Shelton, whose chance encounter in a store’s checkout line led to her cancer diagnosis, said she has become an evangelist for skin self-checks and sunscreen, and is now known at her local pool as “the sunblock lady.” The kind of skin cancer she had may not have stemmed from sun exposure, but it increased her awareness about skin damage and other types of skin cancers.

She has been cancer-free since the doctor successfully removed the tumor on her toe and she underwent chemotherapy and radiation. But the experience was traumatic.

“It’s life-altering,” she said.

Still, she said, she’s resumed an active and full life. She said she will forever be grateful to the stranger who pulled her aside that day, as well as the doctor who disbelieved the first set of labs that came back, opting instead to trust his instincts to immediately begin treatment.

Tips for Avoiding Skin Cancer for All Skin Tones

• Avoid direct sun, especially between 10 a.m. and 4 p.m. Keep babies out of the sun entirely.

• Use a broad-spectrum sunscreen with an SPF of 30 or higher every day. Reapply every two hours or after swimming or activity/sweating.

• Don’t leave sunscreen in the car, because temperature fluctuations can cause it to break down and become less effective.

• Wear clothing that covers arms and legs.

• Wear a broad-brimmed hat to protect the face, ears, and neck.

• Wear UV-blocking sunglasses.

• Avoid indoor tanning beds.

• Examine skin from head to toe every month. Look for dark spots or patches, or growths that are growing, bleeding, or changing; sores that are slow to heal, or heal and return; patches of skin that feel rough and dry; and dark lines underneath or around fingernails or toenails. Be diligent in checking nail beds, palms, soles of the feet, the head, lower legs, the groin, and other places that get little sun. Contact a doctor if you have any concerns.

• See a board-certified dermatologist at least once a year for a full-body examination.

Sources: Skin Cancer Foundation, American Academy of Dermatology, Dr. Janiene Luke, Dr. Michelle Henry, Katonya Breaux

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After taking reversible puberty blockers that pause a teenager’s body changes, Cameron considered whether he wanted to begin hormone therapy to physically transition more permanently. He did not take the decision lightly. Cameron said his doctor made him spend almost a year mulling over the question, working with his therapist, and thinking through the life-altering implications before the doctor believed he was ready to start taking the medications in 2020.

“I thought about if I stayed a girl, life would be so much easier,” said Cameron, who uses the pronouns he and him. “But this is what I want, and I’m not going to let anything stop me from being who I want to be, whether it’s hard or not.”

Then in November 2021, the GENder Education and Care, Interdisciplinary Support clinic in Dallas, known as Genecis, stopped taking new patients for gender dysphoria hormone treatment because of . Although doctors can continue to see patients like Cameron whom they were already treating, the clinic was dismantled. Cameron and his family now have concerns about what this means for them.

The Texas attorney general, Ken Paxton, also into pharmaceutical companies whose products are used by transgender patients, and Republican Gov. Greg Abbott and the state GOP are increasingly on a that target transgender young people, their parents, and their doctors.

Since then, in Houston announced it would stop offering hormone therapy. that Legacy Community Health, also in Houston, quietly paused hormone therapy for teens as well. And doctors throughout the state are telling patients they will no longer prescribe the medications under pressure from insurance companies.

Transgender young people and their families across Texas are now scrambling to find providers and maintain access to their medications, with some exploring options outside the state. An estimated 17,000 transgender people ages 13-17 live in Texas, according to , an LGBTQ+ education and advocacy organization.

For Chloe Ross, 15, who uses the pronouns she and her, the crackdown on her care has been distressing. “I’m just as human as everyone else,” she said.

Chloe’s doctor is still seeing her and prescribing her hormones. But her mother, Kathryn Ross, has started researching options for out-of-state care. The family has been saving money in case they need to move, Ross said, but they hope it doesn’t come to that.

“Having just moved, and Chloe making good friends, the last thing we want to do is uproot her,” said Ross. “Moving would be the last option.”

During the pandemic, the family relocated to a larger city within Texas, leaving behind bullies, and the teen found acceptance from new schoolmates who know her only as Chloe, someone who loves theater and wants to study genetics. But Abbott’s orders to investigate parents who allow their children to receive gender-affirming care, and legislative threats to criminalize such care, weigh heavily on Chloe.

“I’m just trying to get through high school and stuff,” Chloe said through tears. “Having Gov. Abbott make me worry about that kind of stuff is terrible because I don’t get a normal life anymore, you know? Right now, I’m having to go to my teachers to ask them to please not turn me in for being trans. I shouldn’t have to worry about something like that.”

For as long as she can remember, Chloe said, she has favored wearing jewelry, playing volleyball, and participating in theater. She did not know how to express what she was feeling and thought she was gay. Chloe and her mom said strangers regularly assumed Chloe was a girl even as she presented as a boy and had not yet come out as transgender.

Echoing other parents, Chloe’s mother said that even though she was already deeply involved in LGBTQ+ support and advocacy, Chloe’s coming out as transgender was a “gut punch.” Never once did she disbelieve Chloe, but she feared for her daughter’s future. She feared for what is happening now.

Young people receiving include those who are socially transitioning — for example, wearing clothing that reflects their gender identity — and those taking puberty blockers or hormones.

Not all young people who identify as transgender, however, move beyond social transitioning or experience the condition known as gender dysphoria, which means that they experience psychological stress when their body doesn’t match their identity. And people who take puberty blockers don’t necessarily decide to take gender hormones. Surgery is not recommended for people younger than 18.

Although gender-affirming care for trans young people remains politically controversial in many parts of the U.S., by JAMA Network Open showed a reduction in suicidal ideation in trans youths who received such care. Health care organizations that include the , the , and the endorse gender-affirming health care.

Despite the changes to Genecis, Cameron is scheduled for a May appointment with , the doctor overseeing his care. His mom, Myriam Reynolds, however, worries it won’t take place. Lopez has filed against , which jointly operated Genecis with Children’s Medical Center Dallas, alleging that the facility discriminated against some patients by preventing them from receiving gender-affirming care based on their gender identity.

In the meantime, Reynolds picks up Cameron’s hormone refills as soon as they are available to maintain a constant supply. She also said the family is considering all options to ensure Cameron can continue receiving care despite the state crackdown.

“They don’t care at all about trying to help my kid,” Reynolds said. “It’s all political theater.”

It’s especially hard because access to Genecis was a consideration when the family decided to relocate from Colorado to Texas in 2017. Cameron had already come out as transgender, and, after researching the clinic, his mother believed he would receive compassionate, thoughtful care as he transitioned. Now the family is concerned about what kind of care Cameron will be able to get in Texas.

Cameron, who hopes to study music production or become a firefighter, tries to be optimistic that politicians will stop cracking down on medical care for people like him.

“I can’t control the way I am,” said Cameron. “This is not my mom’s doing or my doctor’s doing. This is just me trying to be myself.”

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But for childhood vaccine requirements were passed by the state Senate in March and now face the House when the legislature reconvenes April 25.

They are among the more than introduced in statehouses nationwide since Jan. 1, according to data from the . Of those bills, specifically relate to childhood vaccine requirements in 25 states.

In Missouri, for example, legislators are considering exempting private school students from vaccine requirements. In Louisiana, a would prohibit vaccinations on school property and at school-sponsored events.

Fewer than 10% of the bills will likely gain any traction, but the volume of attempts to roll back vaccine requirements is alarming, said , director of advocacy and public policy at the , a vaccine education organization.

“Those are all chipping away at one of the end goals for anti-vaccine activists, which is completely doing away with school requirements,” said Lakshmanan. “That’s what people need to be paying very close attention to.”

All states require specific childhood vaccinations for illnesses such as polio, measles, and mumps, but exemptions vary. They all allow exemptions for people with medical concerns, 44 states allow religious exemptions, and 15 allow philosophical exemptions, from the National Conference of State Legislatures.

Vaccinations are central to public health efforts at disease control and are foundational to the country’s social and economic system, said , CEO of the , a public health advocacy organization.

“Politicians are poking holes in our public safety net,” Castrucci said of the onslaught of anti-vaccine legislation. “Vaccines, in and of themselves, are not medicine. It’s all of us collectively protecting each other.”

To be sure, anti-vaccine activists have existed as long as vaccines. And legislation to limit requirements to vaccinate against diseases such as polio, measles, and meningitis are not new. But, according to public health experts, the movement has gained momentum amid the coronavirus pandemic, boosting the reach of high-profile anti-vaccine activists.

“If you had told me that a pandemic — and what I would consider a miraculous vaccine for that disease — would trigger an anti-vax surge, I would never have believed it,” said , executive director of , which works to improve children’s and family health in the Kansas City area of Missouri and Kansas. “But that’s exactly what happened.”

One would mandate that vaccine exemption requests be accepted without scrutiny if based on religion or personal beliefs. Currently, the state leaves it to day care centers and school districts to accept requests for religious exemptions.

State Sen. stands behind nullifying Kansas’ childhood vaccine requirements. The Republican, who said he is “not an anti-vaxxer in any shape or form,” lamented mandates he said were a vestige of a “kinder, gentler time” and suggested that individual rights supersede mandates designed to protect public health.

Steffen, an anesthesiologist who said he is by the Kansas Board of Healing Arts for prescribing ivermectin to covid patients, said suggestions that a resurgence of vaccine-preventable diseases could occur if vaccination rates fall amount to fearmongering by people paid off by the pharmaceutical industry.

But , a Kansas vaccine advocate who launched a to organize pro-vaccine Kansans, called such assertions insulting and said he doesn’t take any money from drug companies. He contracted meningitis B in 2004 before vaccines against it were available. He was in a coma for three weeks and had parts of all four limbs amputated.

“For me, this has been part of what helped me move on from that trauma,” Marso said. “I have a story that people need to know about.”

The legislative efforts to nullify the requirements fly in the face of widespread public support for vaccines and vaccine mandates, nationally and in Kansas, said Russell. More than 9 in 10 Kansas voters believe wellness vaccines are safe and support vaccine requirements, according to conducted this year for Nurture KC. Kansas voters overwhelmingly support religious exemptions, but a majority say they support tightening existing exemptions, according to the survey.

Before the pandemic, outbreaks of measles in , , Washington, and , as well as outbreaks of , had reinforced the idea that preventing disease spread required consistently high vaccination rates. And mandates, in part, helped create the mechanism for public health authorities to make vaccines widely available and accessible, said , spokesperson for , an advocacy organization.

“Lost in what has become a political conversation around requirements is the danger of these vaccine-preventable diseases,” said DeWald. “All it takes is one case.”

Previously, anti-vaccine activists relied on long-since-debunked narratives that vaccines cause autism, said , the research manager of the , which studies cyber policies and how people use the internet. But in the years leading up to the pandemic, the movement began to shift its focus to align more with the populist ideology of “individual freedoms” put forward by Second Amendment advocates and the tea party.

Donald Trump expressed vaccine skepticism long before becoming president. But it was when the then-president was said naming Robert F. Kennedy Jr., a well-known anti-vaccine activist, to “investigate” vaccine safety that the movement found its footing, said , assistant professor in the health policy and management department at Texas A&M University. The embrace of anti-vaccine messaging by prominent politicians — whether because they are “true believers” or just see it as political necessity — has “lent legitimacy that the movement lacked before,” Callaghan added.

The similarity of bills from state to state raises red flags to vaccine advocates because it suggests that a coordinated effort to dismantle vaccine requirements and public health infrastructure is underway.

“Because the anti-vax movement is becoming aligned with the far right, I think those information-sharing channels are becoming more sophisticated,” said , executive director of the , a pro-vaccine organization. “Their ability to attract far-right politicians who see vaccines as a cause has grown. That gets them attention, if not votes.”

Not all Republicans find common cause with anti-vaccine activists, said Kansas state Rep. , a Republican and family physician. He said he voted against some covid-related restrictions, like a statewide mask mandate, because he believed doing so might help defuse pandemic tensions. But he advocates for all vaccines, including covid shots.

Enough others in the Kansas legislature agreed in the case of one bill: Language targeting vaccines, under the auspices of parental rights, was ultimately removed before it was passed. Some observers are cautiously optimistic the House won’t pass the other bills as written.

While Eplee hopes the “passions” inflamed by covid die down with distance from the early days of the pandemic, he’s concerned that voters have forgotten the damage done by vaccine-controllable diseases, making them susceptible to disinformation from determined anti-vaccine activists and the politicians among their ranks.

“I hate to see human nature play out like that,” said Eplee. “But if people are vocal enough and loud enough, they can swing enough votes to change the world in a not-so-good way for public health and vaccinations.”

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“I heard one officer say about us ‘they smell like sh–,’” one detained person recounted in a federal court filing. “And another officer responded, ‘They are sh–.’”

Attorneys for immigrant children collected these stories, and more, from youth and families detained in what they called “prison-like” settings across the U.S. from March through June, even as the Trump administration has requested a federal district court judge terminate existing protections that mandate basic rights and services — including safe and sanitary conditions — for children held by the government.

The administration argues that the protections mandated under what is known as the Flores Settlement Agreement encourage immigration and interfere with its ability to establish immigration policy. U.S. District Court Judge Dolly Gee, who is in California, is expected to issue a ruling on the request after an Aug. 8 hearing.

With the agreement in place, children are being held in “unsafe and unsanitary” U.S. Customs and Border Protection facilities such as tents, airports, and offices for up to several weeks despite the agency’s written policy saying people generally should not be held in its custody longer than , according to the from immigrants’ attorneys. In the U.S. Department of Justice’s May request to terminate the Flores consent decree, the attorneys demanded more monitoring for children in immigration detention.

“The biggest fear is that without Flores, we will lose a crucial line of transparency and accountability,” said , executive director of the California-based Center for Human Rights and Constitutional Law. “Then you have a perfect storm for the abuse of individuals, the violation of their rights, and the kind of treatment that this country doesn’t stand for.”

The has set minimum standards and oversight for detained immigrant children since 1997, when it brought an end to a decade-long lawsuit filed on behalf of unaccompanied immigrant minors who had been subjected to poor treatment in unsafe and unsanitary conditions without access to medical care. It is named for Jenny Lisette Flores, a 15-year-old from El Salvador who was taken into U.S. custody in the mid-1980s, subjected to strip searches, and housed alongside unrelated men.

The agreement established national standards for the protection of immigrant children detained by federal authorities, with requirements for safe and sanitary detention facilities, access to clean water, appropriate food, clothing, bedding, recreational and educational opportunities, sanitation, plus appropriate medical and mental health care. Children in immigrant detention range from infants to teens.

In 2015, Gee ruled that the agreement includes children accompanied by adults.

The Justice Department and the Department of Homeland Security, which includes both the Customs and Border Protection agency and Immigration and Customs Enforcement, declined to respond on the record to questions about the administration’s intent to end the Flores agreement or about the conditions in which kids are detained. In a , government attorneys argued, among other points, that the agreement improperly directs immigration decisions to the courts, not the White House. U.S. Attorney General Pam Bondi also that the Flores agreement has “incentivized illegal immigration,” and that Congress and federal agencies have resolved the problems Flores was designed to fix.

ICE detention facilities have the “highest standards,” Abigail Jackson, a White House spokesperson, said in an email to Â鶹ŮÓÅ Health News. “They are safe, clean, and hold illegal aliens who are awaiting final removal proceedings.”

Immigration lawyers and researchers have on the idea that the Flores agreement encourages migration, arguing that the conditions in people’s homelands are driving them to move.

Trump is not the first president to seek to modify, or end, the agreement.

In 2016, President Barack Obama’s administration unsuccessfully sought to exempt accompanied minors from the Flores agreement, arguing that an influx of immigrants from Central America had overwhelmed the system.

In 2019, following a , the first Trump administration announced it would replace Flores with new regulations to expand family detention and eliminate detention time limits. The courts rejected that plan, too.

In 2024, President Joe Biden’s administration successfully requested to remove the Department of Health and Human Services from the agreement after the Office of Refugee Resettlement incorporated some Flores standards into agency regulations.

Allegations of unsafe conditions under the agreement also predate this latest immigration crackdown under Trump. One court filing from 2019 said that attorneys visiting two Texas detention centers found at least 250 infants, children, and teens, some of whom had been held at the facility for nearly a month. “Children were filthy and wearing clothes covered in bodily fluids, including urine,” the filing said.

Seven children are while in federal custody from 2018 to 2019, according to media reports.

And in 2023, 8-year-old Anadith Danay Reyes Alvarez became while in Customs and Border Protection custody in Texas for nine days. Her parents had turned over medical records detailing the girl’s medical history, including diagnoses of sickle cell disease and congenital heart disease, upon their detention. Yet her mother’s repeated pleas for emergency medical care were ignored.

Her family filed a in May.

Advocates attributed the deaths partly to prolonged detention in increasingly crowded facilities and delayed medical care. Officials have said they and in the wake of the deaths.

But with the Trump administration’s unprecedented push to detain and deport migrants — including families — the threat to the health of children caught up in those sweeps is alarming child advocates.

“Very rarely do you have spikes in populations of detained folk that you don’t see a drastic decrease in the quality of their medical care,” said Daniel Hatoum, a senior supervising attorney at the , one of the groups that filed the wrongful death claim for Anadith’s family.

Recent reports from court-appointed monitors cite continued ; temperature extremes; recreational opportunities; and clothing; and an inability to dim lights to sleep.

Terminating the Flores agreement would remove all outside oversight of immigration detention facilities by court-ordered monitors and attorneys. The public would have to depend on the government for transparency about the conditions in which children are held.

“Our system requires that there be some oversight for government, not just the Department of Homeland Security, but in general,” Hatoum said. “We know that. So, I do not believe that DHS could police itself.”

In the months after Trump took office and the Elon Musk-led Department of Government Efficiency began cuts, DHS’ Office for Civil Rights and Civil Liberties, the Office of the Citizenship and Immigration Services Ombudsman, and the Office of the Immigration Detention Ombudsman, which were intended to add a layer of oversight. After a lawsuit, the Trump administration , but it is unclear how those offices have been affected by shifts in policy and cuts in staffing.

Leecia Welch, an attorney with the legal advocacy group , said the Flores agreement itself, or efforts to hold the government responsible for abiding by its requirements, are not rooted in partisan politics. She said she raised concerns about conditions during Biden’s administration, too.

“These are not political issues for me,” Welch said. “How does our country want to treat children? That’s it. It’s very simple. I’m not going to take it easy on any administration where children are being harmed in their care.”

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Concerned onlookers called an ambulance. But Whitten instead had friends pick him up and take him to a nearby hospital, the Helen Diller Medical Center, operated by the University of California-San Francisco.

“I knew that ambulances were expensive, and I didn’t think I was going to die,” he said.

Whitten said doctors treated him for a mild concussion, a broken toe, and bruises.

As he sat in a hospital bed, attached to an IV and wearing a neck brace, Whitten said, doctors told him that because he had suffered a traumatic injury, they had to send him by ambulance to the city’s only trauma center, Zuckerberg San Francisco General Hospital.

After a short ambulance ride, Whitten said, emergency room doctors checked him out, told him he had already received appropriate treatment, and released him.

Then the bill came.

The Medical Procedure

Traumatic injuries are those that threaten life or limb, and some facilities specialize in providing care for them. For someone hit by a car, that stabilizing vital signs, screening for internal injuries, and treating broken bones and concussions. Zuckerberg Hospital is a Level 1 trauma center, meaning it can provide any care needed for severely injured patients.

In emergency medicine, it is standard to transfer patients to centers best equipped to provide care. Ambulances are typically used for transfers because they are able to handle trauma patients, with tools to aid in resuscitation, immobilization, and life support.

At the first hospital, Whitten said, doctors performed a thorough workup, including a CT scan and X-rays, and advised him to follow up with his primary care physician and an orthopedic doctor. He was evaluated at the second hospital and released without additional treatment, he said.

The Final Bill

$12,872.99 for a 6-mile ambulance ride between hospitals: a $11,670.11 base rate, $737.16 for mileage, $314.45 for EKG monitoring, and $151.27 for “infection control.”

The Billing Problem: Surprise Bills Are Common With Ground Ambulances

Ground ambulance services are operated by a hodgepodge of private and public entities — with no uniform structure, or regulatory oversight, for billing — and most function outside insurance networks. Patients don’t typically have a choice of ambulance provider.

There are state and federal laws shielding patients from out-of-network ambulance bills, but none of those protections applied in Whitten’s case.

Whitten was insured under his father’s employer-sponsored health plan from Anthem Blue Cross. So when he received a nearly $13,000 bill months after his short transfer ride, he sent a photo of it to his dad.

Brian Whitten said the bills from the two hospitals — and the family’s out-of-pocket responsibility — were in line with what he had anticipated. But he was stunned by his son’s ambulance bill from AMR, one of the nation’s largest ambulance providers. Anthem Blue Cross denied the claim, saying the ambulance was out-of-network and required pre-authorization.

“It didn’t make a whole lot of sense to me, because the doctor is the one who put him in the ambulance,” Brian Whitten said. “It’s not like somehow he just decided, ‘Hey, can I take an ambulance ride?’”

Kristen Bole, a UCSF spokesperson, said in a statement that the health system’s standard of care is to stabilize patients and, when appropriate, transfer them to other medical facilities that are most appropriate to care for patients’ needs, adding that ambulance transfers between hospitals are standard practice.

While the medical system at large relies on negotiated prices for services, ambulance services operate largely outside of the competitive marketplace, said Patricia Kelmar, senior director of health care campaigns for PIRG, a nonpartisan consumer protection and good-government advocacy organization.

Ambulance transfers between hospitals to ensure the highest quality of care available are fairly common, Kelmar said. And with many hospitals being purchased and consolidated, it would follow that the number of ambulance transfers between facilities could increase as specialized medical units at any given hospital are downsized or eliminated, she said.

According to of private insurance claims data conducted in 2023, about 80% of ground ambulance rides resulted in out-of-network billing.

Generally, out-of-network providers may charge patients for the remainder of their bill after insurance pays. In some cases, patients can be on the hook even when they did not knowingly choose the out-of-network provider. These bills are known as “surprise” bills.

“It’s a financial burden, a significant financial burden,” said Kelmar, who is a member of the federal lawmakers on surprise bills and emergency ambulance transportation.

Eighteen states have implemented laws regulating surprise ambulance billing. A California law cracking down on surprise ambulance billing took effect on Jan. 1, 2024 — months after Jagdish Whitten’s ambulance ride.

But Kelmar said those state laws don’t really help people with employer-sponsored insurance, because those plans are beyond state control — which is why federal legislation is so important, she said.

As of 2022, federal law protects patients from receiving some surprise bills, especially for emergency services. But while lawmakers included protections against air ambulance bills in the law, known as the , they .

The Resolution

Whitten’s father filed an insurance appeal on his son’s behalf, which Anthem granted. The insurer paid AMR $9,966.60.

Michael Bowman, a spokesperson for Anthem, said AMR had not submitted all the information it required to process the claim, leading to the initial denial. After consulting with AMR, Anthem paid its coverage amount, Bowman said.

But the insurer’s payment still left Whitten with a $2,906.39 bill for his out-of-network ambulance ride. Brian Whitten said he called an AMR customer service number several times to contest the remaining charges but was unable to bypass its automated system and speak with a human.

“I couldn’t find a way to talk to somebody about this bill other than how to pay it, and I didn’t want to pay it,” he said.

Unsuccessful and frustrated, Brian Whitten paid the remaining bill in January 2024, he said, concerned it would be turned over to a collection agency and hurt his son’s credit — and his well-being.

There was one more twist: He was shocked when he later reviewed his credit card statements and discovered that AMR had quietly but fully refunded his payment in October.

“It’s amazing that he got his money back,” Kelmar said. “That’s what’s shocking.”

In a statement, Suzie Robinson, vice president of revenue cycle management with AMR, said the company’s third-party billing agency regularly performs audits to ensure accuracy. An audit of Jagdish Whitten’s bill “revealed that the care provided did not meet the criteria for critical care,” Robinson said, which prompted the full refund.

Robinson said audits indicated fewer than 1% of its 4 million medical encounters annually are billed incorrectly.

The Takeaway

Robinson said patients who feel that AMR has billed them incorrectly should contact the company via email.

For patients in need of an ambulance in an emergency, there are few protections — and usually few options: Sometimes you don’t have a better choice than to get in.

require that health plans cover certain surprise bills, with patients paying only what they would if they had received in-network care. Expanding those protections to ground ambulance bills would require Congress to act.

Ambulance providers deserve to be appropriately compensated for their vital role in our medical system, Kelmar said. But the system as it stands almost incentivizes providers to charge a higher rate, which can lead to surprise billing and financial hardship for patients and their families, she said.

Kelmar said she worries not just about the debt those bills create for consumers but also that people may decline vital ambulance transportation in an emergency, for fear of getting hit with an exorbitant bill.

“We just need to bring some sense back to the system,” she said.

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It had been days since Hurricane Beryl blew ashore from the Gulf of Mexico on July 8, causing widespread destruction and knocking out power to more than 2 million people, including the Houston senior independent living facility where Kitzmiller lives. Outdoor temperatures had reached at least 90 degrees most days, and the heat inside the building was stifling.

Kitzmiller moved there not long ago with Kai, her 12-year-old dog, shortly after riding out 90-plus-mph winds from a under a comforter on the floor of the 33-foot RV she called home. She didn’t need medical care, as a nursing home would offer, and thought she and Kai could be safer at an independent senior facility than in the RV. She assumed her new home would have an emergency power system in place at least equivalent to that of the post offices she’d worked in for 35 years.

“I checked out the food. I checked out the activities,” said Kitzmiller, 61, now retired. “I didn’t know I needed to inquire about a generator.”

Even after multiple incidents of extreme weather — including a 2021 Texas winter storm that caused widespread blackouts and prompted a — not much has changed for those living in long-term care facilities when natural disasters strike in Texas or elsewhere.

“There has been some movement, but I think it’s been way too slow,” said , a professor of health care policy at Harvard Medical School. “We keep getting tested and we keep failing the test. But I do think we are going to have to face this issue.”

A power outage can be difficult for anyone, but older adults are especially vulnerable to temperature extremes, with medications or medical conditions affecting their bodies’ and . Additionally, some medications need .

Federal guidelines require nursing homes to maintain safe indoor temperatures but do not regulate how. For example, facilities face no requirement that generators or other alternative energy sources support heating and air conditioning systems. States are largely responsible for compliance, Grabowski said, and if states are failing in that regard, change doesn’t happen.

Furthermore, while nursing homes face such federal oversight, lower-care-level facilities that provide some medical care — known as assisted living — are regulated at the state level, so the rules for emergency preparedness vary widely.

Some states have toughened those guidelines. Maryland in assisted living facilities following Hurricane Isabel, which left more than 1.2 million residents in the state without power in 2003. Florida in 2018, after Hurricane Irma led to deaths at one facility.

But Texas has not. And no requirements for generators exist in Texas for the roughly 2,000 assisted living facilities or the even less regulated independent living sites, like Kitzmiller’s.

Generally, apartment complexes marketed to senior citizens, known in the industry as independent living facilities, don’t have any special regulations in Texas and many other states.

Nationally, assisted living facilities and independent living facilities have been the fastest-growing sectors in senior living. Residents at such facilities often have medical needs, Grabowski said, but for a variety of reasons have chosen to live in an environment that allows more independence than a nursing home, which would provide medical care. That doesn’t mean the residents in these lower-care-level facilities are any less susceptible to extreme temperatures when the power goes out.

“If you’re overwhelmed by the heat in your apartment, that’s unsafe,” he said.

Republican state Rep. tried several times since 2020 to pass legislation requiring assisted living facilities in Texas to have backup generators. But the bills failed. He is not seeking reelection this year.

“It’s horrible what the state of Texas is doing,” said Thompson, blaming corporate greed and politicians more interested in stirring up their base and raising their national profile than improving the lives of Texans. “How we treat our elderly says something about us — and they’re not being treated right.”

Nim Kidd, chief of the Texas Division of Emergency Management, said at that senior facility operators are accountable if they do not keep residents safe. “That location is responsible for the health, safety, and welfare of the patients and residents that are there,” he . “It is that facility’s responsibility.”

Under , power restoration is supposed to be prioritized for nursing, assisted living, and hospice facilities.

The resistance to adding oversight or more governmental protections has not surprised , a senior manager at the Harris County Long-Term Care Ombudsman Program at UTHealth Houston’s Cizik School of Nursing. He said that while he believes the safety and health of residents are paramount, he recognizes that installing generators is expensive. He also said some people within the industry continue to believe extreme events are rare.

“But all of us in Houston this year already learned that they’re happening more frequently,” Shelley said. “This is already the third time since May that big portions of Houston have been without power for long periods of time.”

After the 2021 blackouts, Texas’ Health and Human Services Commission conducted a that found 47% of the assisted living and 99% of the nursing care facilities that responded reported having generators.

The U.S. Senate investigation following the 2021 Texas storm recommended a national requirement that assisted living facilities have emergency power supplies to both maintain safe temperatures and keep medical equipment running.

A from Texas’ long-term care ombudsman, Patty Ducayet, also recommended requiring generators at assisted living centers. The report suggested that all long-term care facilities maintain safe temperatures in a location that can be accessed by every resident. The report recommended requiring assisted living facilities to annually submit emergency response plans to state regulators to be reviewed by state officials. The recommendations have not been adopted.

On July 15 — more than a week after Beryl hit — Kitzmiller said she just wanted the power back on. She praised the staff at her facility but said she worried for residents who were isolated on her building’s second and third floors, which were hotter amid the outage. Some were unable to keep required medicine refrigerated, she said. And without functioning elevators, many couldn’t get to the first floor, where it was cooler.

Mostly, Kitzmiller said, she was frustrated with companies and politicians who hadn’t yet fixed the problem.

“It’s their mothers, their grandmothers, and their family in these homes, these facilities,” she said. “All I can think is ‘Shame on you.’”

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Although lead was banned from new water service lines in 1986, it’s estimated that still carry drinking water to homes and businesses throughout the country. Under the EPA’s proposal, water utilities would be required to replace within 10 years.

The proposal from the Biden administration builds on different rules put out in the waning days of the Trump term that allowed up to 30 years for service line replacement, triggered only when lead levels test higher than 15 parts per billion. The new proposal, which would largely supplant , calls for stricter monitoring, enhanced public education, and the 10-year pipe replacement mandate regardless of lead levels.

An October deadline looms for the new rules to be adopted; otherwise, enforcement of the less-stringent Trump administration rules will begin. And complicating matters more: November’s election results could shake up whose rules the nation must follow.

While many cities and states have begun to replace their lead pipes, some utilities and officials say the 10-year and too expensive. They say it would be difficult for water utilities to follow the rules while dealing with contaminants, known as “forever chemicals,” and , among other issues.

“Nobody will tell you that having lead in contact with water is a great idea,” said Steve Via, director of federal relations for the , the country’s largest nonprofit water utility industry group. “The question becomes: How urgent a matter is it, and at what pace does it need to be done?”

Already, have argued that the proposed rules infringe on states’ rights and chase “speculative” benefits. On the other side, said that the EPA should find more ways to ensure pipes are quickly replaced in low-income areas.

To be sure, to consume. Lead is a irreversible long-term organ damage, lower IQs, higher risk for miscarriage, asthma, cardiovascular disease, impotence, and elevated blood pressure.

Public health advocates say societal costs — in health care, social services, and lost productivity — far outweigh the cost of replacement. They say corrosion controls that have limited lead exposure can and do fail, pointing to human and systemic errors that prompted the , where thousands of people were exposed to high lead levels in their drinking water.

“That’s the whole thing about lead pipes: They unexpectedly release lead into drinking water,” said , who manages an initiative focused on reducing lead exposure from water with the , a national advocacy group. “I don’t think kicking the can down the road is the solution.”

According to a by , an instructor at Harvard’s T.H. Chan School of Public Health, the benefit of replacing lead pipes outweighs the costs by a 35:1 ratio.

Using the EPA’s estimated $335 million annual costs from the Trump rules, which include water sampling, corrosion control treatments, inventorying and replacement of lead service lines, and educational outreach, Levin’s analysis shows that $9 billion in annual health care costs could be avoided. An additional $2 billion in spending — through upgraded infrastructure and reduced corrosion damage to appliances — could be saved. The broad spectrum of health-related costs has historically been ignored in analyzing the actual costs of leaving lead service lines in place, said Levin, a former EPA scientist.

Estimates of the cost to replace the nation’s lead pipes range from to more than , far higher than the set aside in the . The Biden administration has framed those funds as a down payment, or principal forgiveness loans of the estimated number of lead pipes per state. Other can also be tapped.

Replacement costs vary widely by location, with average costs ranging from per service line to .

, legislative director for sustainability at the National League of Cities, said funding challenges could render the EPA’s 10-year timeline unrealistic. While her organization is encouraging local leaders to secure as much funding as possible, what’s available won’t be enough to cover replacement costs for some localities — especially low-income areas, which often have older infrastructure and more lead pipes.

Some direct costs could fall to property owners, such as replacing the lines connecting their water meters to their homes. And people could face indirect costs if utilities increase customer rates to offset the expense.

Still, some communities, such as Olathe, Kansas, are finding ways to move forward with a patchwork of funding. Out of 37,000 service lines there, 266 galvanized pipes were found serving downtown properties, where many of the city’s most vulnerable residents live. The coating for .

Workers will replace the lines at no cost to property owners in the city of 147,000 people outside Kansas City, said Megan Spence, who is . It is expected to cost around $2.3 million, paid for with from the Kansas Department of Health and Environment and about $1.2 million in federal infrastructure funding. About $500,000 for lawn restoration is included.

“We’re really looking at this as an opportunity and another way to protect public health,” said Spence. “There shouldn’t be any lead lines in any drinking water distribution systems.”

Elsewhere, some Republicans, such as Indiana state Sen. , are leading the charge to replace the pipes despite historical pushback in conservative states against federal mandates. He said lawmakers should consider the harm — and long-term costs — caused by delaying the cleanup of lead from drinking water.

In March, Indiana’s Republican Gov. signed a , which Koch authored, designed to lower costs for replacing customer-owned lead service lines. Under the law, landlords are required to enroll in a state-approved program to have their lead pipes removed at no cost by their water utility or pay for replacement themselves.

Koch said estimates for replacing customer-owned service lines are around $8,000, though the cost could be significantly higher for some properties. But by starting the work now, Koch said, utilities can avoid price inflation and ultimately remove pipes more cost efficiently.

Meanwhile, time is running out to publish the Biden administration’s proposed rules in the . Water utilities will be required to comply with the Trump rules as of Oct. 16 unless the EPA publishes the newer rules before then, said , a senior strategic director of the National Resources Defense Council, an advocacy group. It remains unknown what the June 28 Supreme Court , known as the “Chevron deference” decision, will mean for either set of rules.

A deadline is also looming for the 60-day “look-back” period under the , during which a regulation can be repealed. If control of Congress or the White House flips with the November election, the Biden administration’s rules could be repealed under an emboldened Congress even before the January swearing in of new officeholders.

“Depending on how the election goes, it could become a hot issue,” said , national director of the advocacy organization .

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“I was just trying to make a living,” said Brady, 56, a dealer and supervisor at Borgata in that New Jersey resort city. “You don’t think, you know, that you’re going to get sick at your job.”

Some casinos continue to allow indoor smoking even as the share of Americans who smoke fell from about and smoking is banned in at least some public spaces , the District of Columbia, and U.S. territories. Still, 13 of the that allow casino gambling permit smoking in at least part of their facilities.

Brady is among the casino employees, anti-smoking advocates, and public health experts who argue it is long past time to snuff out casino exemptions from smoking bans, given the dangers of secondhand smoke. But they’ve faced stiff pushback from some gambling industry leaders, including in Missouri, Louisiana, Kentucky, and New Jersey, who argue that smoking bans drive gamblers away — especially in places where patrons can go instead to a casino in a nearby jurisdiction that allows them to light up.

The covid-19 pandemic renewed this fight and sharpened the arguments on both sides — on the dangers of particulate matter for the anti-smoking side and the vulnerability of revenues for the casino industry, even as the American Gaming Association reported in 2022 for in-person casino gambling beyond the growth of sports betting and online gambling.

Casinos were for several months in spring 2020 as part of the nationwide effort to mitigate the spread of the coronavirus. Rules governing reopening, including masking and physical distancing requirements and bans on smoking, varied by state and, in some cases, by casino operator and community.

After suffering , some casino executives, and representing workers, leaned into commissioned by the Casino Association of New Jersey to combat efforts to ban or restrict smoking at their properties. Using data from 2019, the report suggests that as many as 2,500 Atlantic City casino workers could lose their jobs and tax revenue could fall by as much as $44 million in the first year if smoking is banned in New Jersey but not in neighboring Pennsylvania. Both states considered prohibitions on casino smoking in 2023; New Jersey lawmakers and Pennsylvania’s .

, a social media influencer specializing in casinos and gambling, said he has heard the arguments about lost business before — and is unconvinced. “People are not driving or flying to a casino to have a cigarette,” he said.

Still, officials in some places are persuaded by arguments about depressed tax revenue. Last spring, Shreveport, Louisiana, officials on smoking in casinos. Those pushing said local gambling taxes fell when gamblers left for nearby casinos where they could smoke. The new ordinance of the casino floor.

And announced in June it was planned for empty mall space in Owensboro, Kentucky, to a location outside the city limits. Though the company declined to comment for this article, the city’s mayor told the newspaper that a primary reason for the move was the city’s long-standing voter-approved smoking restrictions, which do not exempt casinos.

, director of the St. Louis County Department of Public Health in Missouri, was part of an effort last year to end a casino loophole in her county’s 2011 indoor smoking ban. But after pushback from the gambling company , a allowing smoking on 50% of a casino’s floor.

“It’s a balance and one that we feel the marketplace should determine, particularly in such a competitive environment with other gaming facilities nearby and in neighboring states,” said Jeff Morris, Penn Entertainment’s vice president of public affairs and government relations.

Penn Entertainment employs “state of the art ventilation systems, extremely high ceilings,” and “adequate separation of smoking and non-smoking areas,” he wrote in an email to Â鶹ŮÓÅ Health News.

The problem, Cunningham said, is that secondhand smoke cannot be contained to a single location in a big room.

“There’s no safe amount, and trying to restrict it to a certain area isn’t going to work,” she said.

Filtration systems can remove much of the visible smoke, as well as the odor, from indoor spaces even when lots of people are smoking, creating the impression of clean air. But existing technology does not eliminate the dangerous particulates in cigarette smoke, according to a from the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE.

A for the National Institutes of Health evaluated particulate matter at eight Las Vegas casinos that allowed smoking and one that did not. In casinos where smoking is allowed, particulate levels were significantly higher — even in areas designated as nonsmoking — than at the nonsmoking casino.

And in ventilated casinos where indoor smoking is allowed, , workers can have nicotine levels as much as 600% higher than employees exposed to smoking in other workplaces.

can cause coronary heart disease, stroke, lung cancer, and other diseases. Some studies have shown a link to breast cancer, although more research is needed, .

The pandemic raised awareness of the dangers of airborne particulates, giving smoking bans fresh momentum, said , co-founder of the independent industry consulting group C3 Gaming, which produced a largely refuting the economic risk of casinos going smoke-free.

Indeed, more than 1,000 U.S. casinos and other gambling properties , including more than 140 tribal casinos, according to Americans Nonsmokers’ Rights Foundation.

New Mexico’s tribal leaders collectively agreed to maintain smoking bans when pandemic restrictions were lifted, said , chief executive of Acoma Business Enterprises and in North Acomita Village. Employee health has improved, he said, qualifying the casino for rebates on its insurance premium. Cleaning and replacement costs for carpets and equipment fell, he said, and the tribes “haven’t missed a beat” on revenues.

Some guests have grumbled about having to go outside to smoke, Floge said, but that’s about it. “We don’t have anybody who jumps up and down, or throws a fit and says, ‘I’m leaving and never coming back!’” he said.

Casino executives who oppose smoking restrictions overlook people who want to enjoy the “great food and the great entertainment, but won’t step foot in a casino because they get hit by a blast of smoke as soon as they step in,” said Pete Naccarelli, a Borgata dealer and one of three co-founders of the advocacy organization

He said they founded the group, which has chapters in New Jersey, Kansas, Pennsylvania, Rhode Island, and Virginia, after his casino put out ashtrays at 12:01 a.m. the day the pandemic-related smoking ban officially ended. Borgata did not answer requests for comment.

The industry-commissioned report on New Jersey suggests that while more nonsmokers might frequent casinos once smoking is banned, they probably would not make up for the revenue lost if smokers choose other venues or when smokers take breaks from gambling to light up.

But Brady, now cancer-free after chemotherapy and a full mastectomy, believes that if policymakers spent some time breathing the same air she and her co-workers do they’d act more quickly to ban smoking in casinos, rather than prioritize tax revenues. “Our lives are more important,” she said.

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But, just five weeks after confirming her pregnancy, and the day after a gender-reveal party where she announced she was having a girl, she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain.

“I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.”

An ultrasound showed she had . Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby, Tabitha Winnie Denkins.

Black women are than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a that contribute to disproportionately high Black maternal mortality rates.

“This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said , who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.”

In fact, Harris County ranks third, behind only Chicago’s Cook County and Detroit’s Wayne County, in what are known as excess Black infant deaths, according to the federal . Those three counties, which also are among the nation’s most populated counties, 7% of all Black births in the country and 9% of excess Black infant deaths, said Ashley Hirai, a senior scientist at HRSA. The counties have the largest number of Black births but also that would not occur if Black babies had the same chance of reaching their 1st birthdays as white infants.

exist for Black infants to die at higher rates than white infants. Such deaths are often called “deaths of disparity” because they are likely attributable to systemic racial disparities. Regardless of economic status or educational attainment, the stress from experiencing persistent systemic racism leads to adverse health consequences for Black women and their babies, published in the journal Women’s Health Issues.

These miscarriages and deaths can occur even in communities that otherwise appear to have vast health resources. In Harris County, for example, home to two public hospitals and the — the largest medical complex in the world, with more than 54 medical-related institutions and 21 hospitals — mortality rates were 11.1 per 1,000 births for Black infants from 2014 through 2019, according to the March of Dimes, compared with 4.7 for white infants.

The abundance of providers in Harris County pregnant Black patients that they can find care that is timely, appropriate, or — care that acknowledges a person’s heritage, beliefs, and values during treatment.

Regardless of income or insurance status, studies show, medical providers Black women’s questions and concerns, , and fail to offer appropriate care. By contrast, a study of 1.8 million hospital births spanning 23 years in Florida found that the gap in mortality rates between Black and white newborns for Black babies when Black physicians cared for them.

In 2013, Houstonian Kay Matthews was running a successful catering business when she lost the daughter she’d named Troya eight months and three weeks into pregnancy.

Matthews hadn’t felt well — she’d been sluggish and tired — for several days, but her doctor told her not to worry. Not long afterward, she woke up realizing something was terribly wrong. She passed out after calling 911. When she woke up, she was in the emergency room.

None of the medical staffers would talk to her, she said. She had no idea what was happening, no one was answering her questions, and she started having a panic attack.

“It kind of felt like I was watching myself lose everything,” she recalled. She said the nurse seemed annoyed with her questions and demeanor and gave her a sedative. “When I woke up, I did not have a baby.”

Matthews recalled one staffer insinuating that she and her partner couldn’t afford to pay the bill, even though she was a financially stable business owner, and he had a well-paying job as a truck driver.

She said hospital staffers showed minimal compassion after she lost Troya. They seemed to dismiss her grief, she said. It was the first time she could remember feeling as if she was treated callously because she is Black.

“There was no respect at all, like zero respect or compassion,” said Matthews, who has since founded the , a Houston nonprofit focused on improving maternal mental health, primarily for Black patients.

To help combat these high mortality rates in Harris County, Robinson created a maternal child and health office and launched a home-visit pilot program to connect prenatal and postpartum patients with resources such as housing assistance, medical care, and social services. Limited access to healthy food and recreational activities are barriers to healthy pregnancy outcomes. Studies have also shown a .

For Hill, not having insurance was also likely a factor. While pregnant, Hill said, she had had just a single visit at a community health center before her miscarriage. She was working multiple jobs as a college student and did not have employer-provided medical coverage. She was not yet approved for Medicaid, the state-federal program for people with low incomes or disabilities.

Texas has the nation’s highest uninsured rate, with nearly 5 million Texans — or — lacking coverage, said Anne Dunkelberg, a senior fellow with , a nonprofit research and advocacy institute focused on equity in public policy. While non-Hispanic Black Texans have a slightly better rate — 17% — than that overall state level, it’s still higher than the 12% rate for non-Hispanic white Texans, according to census data. Health experts fear that many more people are losing insurance coverage as for Medicaid.

Without full coverage, those who are pregnant may avoid seeking care, meaning they skip being seen in the critical first trimester, said , medical director at Houston’s .

Texas had the receiving early prenatal care in the nation in 2020, according to the state’s 2021 Healthy Texas Mothers and Babies Databook, and non-Hispanic Black moms and babies were less likely to receive first-trimester care than other racial and ethnic groups. Babies were three times as likely to have a low birth weight and five times as likely to die as those whose mothers had care.

If Hill’s miscarriage reflects how the system failed her, the birth of her twins two years later demonstrates how appropriate support has the potential to change outcomes.

With Medicaid coverage from the beginning of her second pregnancy, Hill saw a high-risk pregnancy specialist. Diagnosed early with what’s called an , Hill was consistently seen, monitored, and treated. She also was put on bed rest for her entire pregnancy.

She had an emergency cesarean section at 34 weeks, and both babies spent two weeks in neonatal intensive care. Today, her premature twins are 3 years old.

“I believe God — and the high-risk doctor — saved my twins,” she said.

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They are part of a new migration of Americans who are uprooting their lives in response to a across the country restricting health care for transgender people.

Missouri, Florida, and Texas are among at least components of gender-affirming health care for trans youth. Those three states are also among the — the public health insurance for people with low incomes — from paying for key aspects of such care for patients of all ages.

More than a quarter of trans adults surveyed by late last year said they had moved to a different neighborhood, city, or state to find more acceptance. Now, new restrictions on health care and the possibility of more in the future provide additional motivation.

Many are heading to places that are passing laws to support care for trans people, making those states appealing sanctuaries. California, for example, passed a law last fall to from prosecution. And now, California providers are getting more calls from people seeking to relocate there to prevent disruptions to their care, said Scott Nass, a family physician and expert on transgender care based in the state.

But the influx of patients presents a challenge, Nass said, “because the system that exists, it can’t handle all the refugees that potentially are out there.”

In Florida, the legislative targeting of trans people and their health care has persuaded Arlo Dennis, 35, that it is time to uproot their family of five from the Orlando area, where they’ve lived for more than a decade. They plan to move to Maryland.

Dennis, who uses they/them pronouns, no longer has access to hormone replacement therapy after Florida’s Medicaid program stopped covering transition-related care in late August under the claim that the treatments are experimental and lack evidence of being effective. Dennis said they ran out of their medication in January.

“It’s definitely led to my mental health having struggles and my physical health having struggles,” Dennis said.

Moving to Maryland will take resources Dennis said their family does not have. They launched a in April and have raised more than $5,600, most of it from strangers, Dennis said. Now the family, which includes three adults and two children, plans to leave Florida in July. The decision wasn’t easy, Dennis said, but they felt like they had no choice.

“I’m OK if my neighbor doesn’t agree with how I’m living my life,” Dennis said. “But this was literally outlawing my existence and making my access to health care impossible.”

Mitch and Tiffany Tillison decided they needed to leave Texas after the state’s Republicans made anti-trans policies for youth central to their legislative agenda. Their 12-year-old came out as trans about two years ago. They asked for only her middle name, Rebecca, to be published because they fear for her safety due to threats of violence against trans people.

This year, the Texas Legislature limiting gender-affirming health care for youth under 18. It specifically bans physical care, but local LGBTQ+ advocates say recent crackdowns also have had a chilling effect on the availability of mental health therapy for trans people.

While the Tillisons declined to specify what treatment, if any, their daughter is getting, they said they reserve the right, as her parents, to provide the care their daughter needs — and that Texas has taken away that right. That, plus increasing threats of violence in their community, particularly in the wake of the by a professed neo-Nazi at Allen Premium Outlets, about 20 miles from their home in the Dallas suburbs, caused the family to decide to move to Washington state.

“I’ve kept her safe,” said Tiffany Tillison, adding that she often thinks back to the moment her daughter came out to her during a long, late drive home from a daylong soccer tournament. “It’s my job to continue to keep her safe. My love is unending, unconditional.”

For her part, Rebecca is pragmatic about the move planned for July: “It’s sad, but it is what we have to do,” she said.

A close call on losing key medical care in Missouri also pushed some trans people to rethink living there. In April, Missouri Attorney General Andrew Bailey seeking to limit access to transition-related surgery and cross-sex hormones for all ages, and restrict puberty-blocking drugs, which pause puberty but don’t alter gender characteristics. The next day, Dempsey, 24, who uses they/them pronouns, launched a for themself and their two partners to leave Springfield, Missouri.

“We are three trans individuals who all depend on the Hormone Replacement Therapy and gender affirming care that is soon to be prohibitively limited,” Dempsey wrote in the fundraising appeal, adding they wanted to “escape Missouri when our lease is up at the end of May.”

Dempsey said they also got a prescription for a three-month supply of hormone therapy from their doctor in Springfield to tide them over until the move.

Bailey withdrew his rule after the state legislature in May to such treatments for minors, but not adults like Dempsey and their partners. Still, Dempsey said their futures in Missouri didn’t look promising.

Neighboring Illinois was an obvious place to move; the legislature there that requires state-regulated insurance plans to cover gender-affirming health care at no extra cost. Where exactly was a bigger question. Chicago and its suburbs seemed too expensive. The partners wanted a progressive community similar in size and cost of living to the city they were leaving. They were looking for a Springfield in Illinois.

“But not Springfield, Illinois,” Dempsey quipped.

Gwendolyn Schwarz, 23, had also hoped to stay in Springfield, Missouri, her hometown, where she had recently graduated from Missouri State University with a degree in film and media studies. She had planned to continue her education in a graduate program at the university and, within the next year, get transition-related surgery, which can take a few months of recovery.

But her plans changed as Bailey’s rule stirred fear and confusion.

“I don’t want to be stuck and temporarily disabled in a state that doesn’t see my humanity,” Schwarz said.

She and a group of friends are planning to move west to Nevada, where state lawmakers have approved a measure that gender-affirming treatment for trans patients.

Schwarz said she hopes moving from Missouri to Nevada’s capital, Carson City, will allow her to continue living her life without fear and eventually get the surgery she wants.

Dempsey and their partners settled on Moline, Illinois, as the place to move. All three had to quit their jobs to relocate, but they have raised $3,000 on GoFundMe, more than enough to put a deposit down on an apartment.

On May 31, the partners packed the belongings they hadn’t sold and made the 400-mile drive to their new home.

Since then, Dempsey has already been able to see a medical provider at a clinic in Moline that caters to the LGBTQ+ community — and has gotten a new prescription for hormone therapy.

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Shelton had been taking medication for months for what her doctor said was toenail fungus, but one nail still looked gross.

After Shelton completed her purchase, the woman pulled her aside and said that, while she wasn’t a doctor, she thought Shelton was dealing with something more serious than fungus.

“She’s like: ‘I know I’m just a random stranger, but please, go get it checked out by someone else,’” said Shelton, who lives in a Maryland suburb of Washington, D.C.

Shelton, now 42, took the advice.

The initial lab work didn’t give a clear diagnosis, but her new doctor said he was confident she had acral lentiginous melanoma, a form of skin cancer. Additional testing proved him right. While rare, it is the most common subtype of melanoma in Black people, like Shelton. It is the disease that at age 36, and is most often found on skin less frequently exposed to the sun, such as the hands, the soles of the feet, and under nails. Researchers do not understand what causes acral lentiginous melanoma, and they don’t know how to prevent it. It is often overlooked in skin checks or misdiagnosed.

Skin cancer, in general, is often missed or misdiagnosed in Black patients.

Historically, Black people and those with dark skin have been left out of efforts to combat skin cancer. Long neglected by sunscreen manufacturers and a medical community lagging in diversity and cultural competency — the acknowledgment of a patient’s heritage, beliefs, and values — many have not been informed about sun safety or how to check their skin for signs of damage or cancer.

To be sure, skin cancer rates are lower for people with dark skin tones. Melanoma is more than 20 times as , with an overall lifetime risk of 1 in 38 for white people compared with 1 in 1,000 for Black people. Melanin does provide some protection against sun damage, so those with more of it — those with darker skin — are better protected than those with fairer skin.

But overall, Black patients are more likely to be diagnosed with various forms of skin cancer at more advanced stages, said , with the , a nonprofit that works to educate doctors and the public on skin health.

The five-year melanoma survival rate among non-Hispanic Black people is 66%, compared with 90% for non-Hispanic white people, according to . And 1 in 3 Black men or women diagnosed with melanoma in the U.S. die of the disease, compared with at least 1 in 7 for non-Hispanic white people, .

Given the known disparities in outcomes, Dr. , president of the Skin of Color Society, said two areas of research are needed: studying educational initiatives to see if awareness might lead to earlier diagnosis and improved survival; and determining risk factors in patients with dark skin, especially factors leading to the occurrence of melanoma in places less exposed to the sun.

Improving cultural competency and diversity within dermatology is just one step toward improving diagnosis and outcomes. According to the , fewer than 3% of dermatologists nationwide are Black. Orthopedics is the only medical specialty with a smaller share.

Dermatology has traditionally been one of the most competitive specialties in medicine, said Dr. , a clinical instructor of dermatology at . In addition to stiff academic requirements, admission to dermatology programs also depends on connecting with mentors and extensive networking, which can be expensive. And that, Henry said, has traditionally created barriers for Black medical students who want to pursue dermatology.

“There are so many hurdles that make it difficult for a lot of students of color to do the things that they need to do in such an uber-exclusive and small space,” she said.

Recent initiatives to help students overcome those barriers are beginning to work, said Dr. , vice chair for diversity, equity, and inclusion in the dermatology department at the University of Pennsylvania and founder of the Skin of Color Society. Initiatives from the include holistic reviews of residency applications, mentorships, and programs to increase interest among and prepare high school students for college and medical school.

Medical app company is working to reduce disparities in medicine through by creating a catalog of images reflecting various diseases in different skin colors. Skin cancers may appear different on fairer skin than on darker skin, and because doctors may have been trained only with fair-skin depictions, the chance for misdiagnosis in people with dark skin increases.

Change has also come to the sunscreen industry.

, senior vice president and partner with Chicago market research company , said failures within the medical community to provide adequate skin care for people with dark skin mirror the lack of availability of sunscreens to meet patients’ needs, especially for Black people.

“What that has done is that it has pushed Black entrepreneurs, from one day to the next, to come up with their own solutions and their own products,” Martínez-Bonilla said. “Not only from the lack of availability, but because these are the people who know their needs best.”

is one of those entrepreneurs. She wasn’t thrilled when, in her 30s and 40s, she noticed she was getting moles on her face and neck similar to those she’d seen on older family members while she was growing up. She assumed it was just part of aging. But her dermatologist said it was sun damage.

“I was, literally, shocked. I was like: ‘But I’m Black,’” she said, adding that she had no experience with sunscreen growing up. “It was so foreign to me. I believed we just didn’t need it.”

After struggling to find a sunscreen that didn’t leave a residue or feel like it was burning her skin, she worked with a chemist who helped her create a tinted mineral-based sunscreen. At first, she intended it just for her personal use, but she ultimately launched . The Los Angeles-based company educates about skin care and sells products designed for consumers with dark skin.

also struggled to find a sunscreen that didn’t “leave a blue, purple, or other-colored hue on my skin.” Until, she said, “I realized it didn’t exist.”

So, in 2016, she developed products that left no residue, ultimately launching .

Education is fundamental to her company’s advertising, Lundy said. “Our mission is to equip people of all ages and skin tones with the right sunscreen products to take their skin health seriously and protect themselves from sun damage.”

Shelton, whose chance encounter in a store’s checkout line led to her cancer diagnosis, said she has become an evangelist for skin self-checks and sunscreen, and is now known at her local pool as “the sunblock lady.” The kind of skin cancer she had may not have stemmed from sun exposure, but it increased her awareness about skin damage and other types of skin cancers.

She has been cancer-free since the doctor successfully removed the tumor on her toe and she underwent chemotherapy and radiation. But the experience was traumatic.

“It’s life-altering,” she said.

Still, she said, she’s resumed an active and full life. She said she will forever be grateful to the stranger who pulled her aside that day, as well as the doctor who disbelieved the first set of labs that came back, opting instead to trust his instincts to immediately begin treatment.

Tips for Avoiding Skin Cancer for All Skin Tones

• Avoid direct sun, especially between 10 a.m. and 4 p.m. Keep babies out of the sun entirely.

• Use a broad-spectrum sunscreen with an SPF of 30 or higher every day. Reapply every two hours or after swimming or activity/sweating.

• Don’t leave sunscreen in the car, because temperature fluctuations can cause it to break down and become less effective.

• Wear clothing that covers arms and legs.

• Wear a broad-brimmed hat to protect the face, ears, and neck.

• Wear UV-blocking sunglasses.

• Avoid indoor tanning beds.

• Examine skin from head to toe every month. Look for dark spots or patches, or growths that are growing, bleeding, or changing; sores that are slow to heal, or heal and return; patches of skin that feel rough and dry; and dark lines underneath or around fingernails or toenails. Be diligent in checking nail beds, palms, soles of the feet, the head, lower legs, the groin, and other places that get little sun. Contact a doctor if you have any concerns.

• See a board-certified dermatologist at least once a year for a full-body examination.

Sources: Skin Cancer Foundation, American Academy of Dermatology, Dr. Janiene Luke, Dr. Michelle Henry, Katonya Breaux

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After taking reversible puberty blockers that pause a teenager’s body changes, Cameron considered whether he wanted to begin hormone therapy to physically transition more permanently. He did not take the decision lightly. Cameron said his doctor made him spend almost a year mulling over the question, working with his therapist, and thinking through the life-altering implications before the doctor believed he was ready to start taking the medications in 2020.

“I thought about if I stayed a girl, life would be so much easier,” said Cameron, who uses the pronouns he and him. “But this is what I want, and I’m not going to let anything stop me from being who I want to be, whether it’s hard or not.”

Then in November 2021, the GENder Education and Care, Interdisciplinary Support clinic in Dallas, known as Genecis, stopped taking new patients for gender dysphoria hormone treatment because of . Although doctors can continue to see patients like Cameron whom they were already treating, the clinic was dismantled. Cameron and his family now have concerns about what this means for them.

The Texas attorney general, Ken Paxton, also into pharmaceutical companies whose products are used by transgender patients, and Republican Gov. Greg Abbott and the state GOP are increasingly on a that target transgender young people, their parents, and their doctors.

Since then, in Houston announced it would stop offering hormone therapy. that Legacy Community Health, also in Houston, quietly paused hormone therapy for teens as well. And doctors throughout the state are telling patients they will no longer prescribe the medications under pressure from insurance companies.

Transgender young people and their families across Texas are now scrambling to find providers and maintain access to their medications, with some exploring options outside the state. An estimated 17,000 transgender people ages 13-17 live in Texas, according to , an LGBTQ+ education and advocacy organization.

For Chloe Ross, 15, who uses the pronouns she and her, the crackdown on her care has been distressing. “I’m just as human as everyone else,” she said.

Chloe’s doctor is still seeing her and prescribing her hormones. But her mother, Kathryn Ross, has started researching options for out-of-state care. The family has been saving money in case they need to move, Ross said, but they hope it doesn’t come to that.

“Having just moved, and Chloe making good friends, the last thing we want to do is uproot her,” said Ross. “Moving would be the last option.”

During the pandemic, the family relocated to a larger city within Texas, leaving behind bullies, and the teen found acceptance from new schoolmates who know her only as Chloe, someone who loves theater and wants to study genetics. But Abbott’s orders to investigate parents who allow their children to receive gender-affirming care, and legislative threats to criminalize such care, weigh heavily on Chloe.

“I’m just trying to get through high school and stuff,” Chloe said through tears. “Having Gov. Abbott make me worry about that kind of stuff is terrible because I don’t get a normal life anymore, you know? Right now, I’m having to go to my teachers to ask them to please not turn me in for being trans. I shouldn’t have to worry about something like that.”

For as long as she can remember, Chloe said, she has favored wearing jewelry, playing volleyball, and participating in theater. She did not know how to express what she was feeling and thought she was gay. Chloe and her mom said strangers regularly assumed Chloe was a girl even as she presented as a boy and had not yet come out as transgender.

Echoing other parents, Chloe’s mother said that even though she was already deeply involved in LGBTQ+ support and advocacy, Chloe’s coming out as transgender was a “gut punch.” Never once did she disbelieve Chloe, but she feared for her daughter’s future. She feared for what is happening now.

Young people receiving include those who are socially transitioning — for example, wearing clothing that reflects their gender identity — and those taking puberty blockers or hormones.

Not all young people who identify as transgender, however, move beyond social transitioning or experience the condition known as gender dysphoria, which means that they experience psychological stress when their body doesn’t match their identity. And people who take puberty blockers don’t necessarily decide to take gender hormones. Surgery is not recommended for people younger than 18.

Although gender-affirming care for trans young people remains politically controversial in many parts of the U.S., by JAMA Network Open showed a reduction in suicidal ideation in trans youths who received such care. Health care organizations that include the , the , and the endorse gender-affirming health care.

Despite the changes to Genecis, Cameron is scheduled for a May appointment with , the doctor overseeing his care. His mom, Myriam Reynolds, however, worries it won’t take place. Lopez has filed against , which jointly operated Genecis with Children’s Medical Center Dallas, alleging that the facility discriminated against some patients by preventing them from receiving gender-affirming care based on their gender identity.

In the meantime, Reynolds picks up Cameron’s hormone refills as soon as they are available to maintain a constant supply. She also said the family is considering all options to ensure Cameron can continue receiving care despite the state crackdown.

“They don’t care at all about trying to help my kid,” Reynolds said. “It’s all political theater.”

It’s especially hard because access to Genecis was a consideration when the family decided to relocate from Colorado to Texas in 2017. Cameron had already come out as transgender, and, after researching the clinic, his mother believed he would receive compassionate, thoughtful care as he transitioned. Now the family is concerned about what kind of care Cameron will be able to get in Texas.

Cameron, who hopes to study music production or become a firefighter, tries to be optimistic that politicians will stop cracking down on medical care for people like him.

“I can’t control the way I am,” said Cameron. “This is not my mom’s doing or my doctor’s doing. This is just me trying to be myself.”

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But for childhood vaccine requirements were passed by the state Senate in March and now face the House when the legislature reconvenes April 25.

They are among the more than introduced in statehouses nationwide since Jan. 1, according to data from the . Of those bills, specifically relate to childhood vaccine requirements in 25 states.

In Missouri, for example, legislators are considering exempting private school students from vaccine requirements. In Louisiana, a would prohibit vaccinations on school property and at school-sponsored events.

Fewer than 10% of the bills will likely gain any traction, but the volume of attempts to roll back vaccine requirements is alarming, said , director of advocacy and public policy at the , a vaccine education organization.

“Those are all chipping away at one of the end goals for anti-vaccine activists, which is completely doing away with school requirements,” said Lakshmanan. “That’s what people need to be paying very close attention to.”

All states require specific childhood vaccinations for illnesses such as polio, measles, and mumps, but exemptions vary. They all allow exemptions for people with medical concerns, 44 states allow religious exemptions, and 15 allow philosophical exemptions, from the National Conference of State Legislatures.

Vaccinations are central to public health efforts at disease control and are foundational to the country’s social and economic system, said , CEO of the , a public health advocacy organization.

“Politicians are poking holes in our public safety net,” Castrucci said of the onslaught of anti-vaccine legislation. “Vaccines, in and of themselves, are not medicine. It’s all of us collectively protecting each other.”

To be sure, anti-vaccine activists have existed as long as vaccines. And legislation to limit requirements to vaccinate against diseases such as polio, measles, and meningitis are not new. But, according to public health experts, the movement has gained momentum amid the coronavirus pandemic, boosting the reach of high-profile anti-vaccine activists.

“If you had told me that a pandemic — and what I would consider a miraculous vaccine for that disease — would trigger an anti-vax surge, I would never have believed it,” said , executive director of , which works to improve children’s and family health in the Kansas City area of Missouri and Kansas. “But that’s exactly what happened.”

One would mandate that vaccine exemption requests be accepted without scrutiny if based on religion or personal beliefs. Currently, the state leaves it to day care centers and school districts to accept requests for religious exemptions.

State Sen. stands behind nullifying Kansas’ childhood vaccine requirements. The Republican, who said he is “not an anti-vaxxer in any shape or form,” lamented mandates he said were a vestige of a “kinder, gentler time” and suggested that individual rights supersede mandates designed to protect public health.

Steffen, an anesthesiologist who said he is by the Kansas Board of Healing Arts for prescribing ivermectin to covid patients, said suggestions that a resurgence of vaccine-preventable diseases could occur if vaccination rates fall amount to fearmongering by people paid off by the pharmaceutical industry.

But , a Kansas vaccine advocate who launched a to organize pro-vaccine Kansans, called such assertions insulting and said he doesn’t take any money from drug companies. He contracted meningitis B in 2004 before vaccines against it were available. He was in a coma for three weeks and had parts of all four limbs amputated.

“For me, this has been part of what helped me move on from that trauma,” Marso said. “I have a story that people need to know about.”

The legislative efforts to nullify the requirements fly in the face of widespread public support for vaccines and vaccine mandates, nationally and in Kansas, said Russell. More than 9 in 10 Kansas voters believe wellness vaccines are safe and support vaccine requirements, according to conducted this year for Nurture KC. Kansas voters overwhelmingly support religious exemptions, but a majority say they support tightening existing exemptions, according to the survey.

Before the pandemic, outbreaks of measles in , , Washington, and , as well as outbreaks of , had reinforced the idea that preventing disease spread required consistently high vaccination rates. And mandates, in part, helped create the mechanism for public health authorities to make vaccines widely available and accessible, said , spokesperson for , an advocacy organization.

“Lost in what has become a political conversation around requirements is the danger of these vaccine-preventable diseases,” said DeWald. “All it takes is one case.”

Previously, anti-vaccine activists relied on long-since-debunked narratives that vaccines cause autism, said , the research manager of the , which studies cyber policies and how people use the internet. But in the years leading up to the pandemic, the movement began to shift its focus to align more with the populist ideology of “individual freedoms” put forward by Second Amendment advocates and the tea party.

Donald Trump expressed vaccine skepticism long before becoming president. But it was when the then-president was said naming Robert F. Kennedy Jr., a well-known anti-vaccine activist, to “investigate” vaccine safety that the movement found its footing, said , assistant professor in the health policy and management department at Texas A&M University. The embrace of anti-vaccine messaging by prominent politicians — whether because they are “true believers” or just see it as political necessity — has “lent legitimacy that the movement lacked before,” Callaghan added.

The similarity of bills from state to state raises red flags to vaccine advocates because it suggests that a coordinated effort to dismantle vaccine requirements and public health infrastructure is underway.

“Because the anti-vax movement is becoming aligned with the far right, I think those information-sharing channels are becoming more sophisticated,” said , executive director of the , a pro-vaccine organization. “Their ability to attract far-right politicians who see vaccines as a cause has grown. That gets them attention, if not votes.”

Not all Republicans find common cause with anti-vaccine activists, said Kansas state Rep. , a Republican and family physician. He said he voted against some covid-related restrictions, like a statewide mask mandate, because he believed doing so might help defuse pandemic tensions. But he advocates for all vaccines, including covid shots.

Enough others in the Kansas legislature agreed in the case of one bill: Language targeting vaccines, under the auspices of parental rights, was ultimately removed before it was passed. Some observers are cautiously optimistic the House won’t pass the other bills as written.

While Eplee hopes the “passions” inflamed by covid die down with distance from the early days of the pandemic, he’s concerned that voters have forgotten the damage done by vaccine-controllable diseases, making them susceptible to disinformation from determined anti-vaccine activists and the politicians among their ranks.

“I hate to see human nature play out like that,” said Eplee. “But if people are vocal enough and loud enough, they can swing enough votes to change the world in a not-so-good way for public health and vaccinations.”

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