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

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

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

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

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

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

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

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

Threats to Physician Autonomy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Different Payment Model

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

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

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

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

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

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

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

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

IPAs Can Help, Depending on Who’s in Charge

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

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

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

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

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

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

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

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

This article is from a partnership with and .

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When federal immigration agents descended on their city, officers deported Gabi’s father and detained her aunt.

Gabi was born in the U.S. and is an American citizen. Her best chance to stand, or even walk, someday is a complex surgery on her legs and feet that was scheduled for January. But her mother, too terrified to take out the garbage let alone venture through the city to a hospital, canceled the procedure. Â鶹ŮÓÅ Health News agreed to only partially identify the patients and their families in this article because they fear becoming targets of President Donald Trump’s immigration crackdown.

“I want more than anything for my baby to walk,” her mother said in Spanish, as Gabi cooed and wriggled in her arms, a feeding tube snaking from her stomach to an IV pole. “But with the situation that’s happening, I canceled the surgery and all the physical therapy appointments” that would have followed. “Because I’m afraid to leave.”

The Department of Homeland Security has declared an end to what it called Operation Metro Surge, carried out by officers with the Immigration and Customs Enforcement and Customs and Border Protection agencies. Even so, health care workers say, immigration agents are still camping out in hospital parking lots. And drones fly overhead in agricultural areas beyond Minneapolis, where Somali and Latino immigrants have settled in recent years.

The Minnesota crackdown revealed the sweep of the surveillance and capture system the Trump administration is using to uproot immigrant communities in the United States, and the effect of its powerful brake on the medical system.

Similar health crises surfaced wherever immigration officers massed in the past year. In Dallas, public health clinics administered about 6,000 vaccinations to Latinos last August, half as many as during a similar program a year earlier. In Chicago, doctors rerouted patients daily from clinic to clinic depending on ICE activity. Across the country, crackdowns suppressed immigrants’ health care visits.

In Minnesota, medical systems have reported cancellation and no-show rates of up to 60% since December.

Tricia McLaughlin, a spokesperson for the Department of Homeland Security, blamed protesters for the disruption. “If anyone is impeding Americans from making appointments or picking up prescriptions,” she said, “its [sic] violent agitators who are blocking roadways, ramming vehicles, and vandalizing property.”

While Minnesotans rose up to oppose the surge in the streets, doctors and nurses have quietly operated informal, underground medical networks, dodging detection to care for patients at home.

“I used to look somebody in the eyes and say, with good faith, ‘You will be fine at the hospital,’” said Emily Carroll, a nurse practitioner at HealthFinders Collaborative, a community clinic in Faribault, some 50 miles south of Minneapolis. “But now, I can’t make that guarantee.”

As thousands of federal agents move on from Minneapolis, other communities need to prepare, said Minnesota Democratic state Sen. Alice Mann, a physician.

“I know it sounds crazy,” she said, but health care providers “need to start an underground network of how to get people care in their homes. Because letting people die at home or come close to death because they are terrified to go into the hospital, in 2026, is outrageous.”

The Surge Delivers Harm

Home visits, clinicians say, may be the only way to reach those who still feel under siege. In Los Angeles, starting last June, St. John’s Community Health brought medical care to some 2,000 immigrant families too frightened to leave home during an immigration sweep after the clinic’s no-show rates ballooned to more than 30%, said Jim Mangia, the organization’s president.

Many of Minnesota’s large health institutions have relied on telemedicine and only dabbled in home care.

Not Munira Maalimisaq, co-founder of Inspire Change Clinic in Minneapolis’ Ventura Village neighborhood. After about one-third of her patients stopped showing up for appointments, “I was like, ‘We have to do something,’” the nurse practitioner said. So she called a physician friend. What if they just started seeing patients at home?

“And she’s like, ‘You know what? Let’s do it.’”

They now have about 150 doctors — a volunteer “rapid response” team that has made more than 135 home visits. The first call was a woman whose husband had been deported. She was home with her children, was 39 weeks pregnant, and was in labor. Maalimisaq called an obstetrician volunteer, and they rushed to the patient’s house.

“She was 8 centimeters dilated,” Maalimisaq said, “and did not want us to call an ambulance. She says, ‘Can I have the baby here?’”

The woman was not a good candidate for a home birth, Maalimisaq said. They persuaded her to ride to the hospital in Maalimisaq’s car, a “small Tesla, white seats. Everything that could go wrong was there.”

But they made it to the hospital in time, and the woman had a safe, healthy delivery. “If we were not there, I can only imagine what would have happened.”

Maalimisaq’s caregiving follows a Hippocratic logic: “Someone was in need. I cannot just do nothing. And we cannot call an ambulance against her will and have her shoved in there. We had no choice but to do something, and that was the only thing that we could do safely.”

In other visits, she has seen “people so stressed out they pulled the hair out of their skull.” She said she met a mother who’d been rationing her child’s seizure medicine despite the child having experienced “one seizure after another.”

The Trump administration says its Minnesota operation improved public safety. “Since Operation Metro Surge began, our brave DHS law enforcement have arrested over 4,000 criminal illegal aliens including vicious murderers, rapists, child pedophiles and incredibly dangerous individuals,” according to McLaughlin, the DHS spokesperson. DHS announced last month that McLaughlin was leaving her post.

Minnesota correctional officials say many people accused of crimes were released directly to ICE by state or county prisons and jails. And of people arrested by ICE nationwide in January had criminal convictions, according to DHS data. Far fewer were convicted of violent crimes.

Agents Outside Hospitals, Clinics

On the first day of his second term, President Donald Trump rescinded a 2011 policy that prohibited immigration enforcement in “sensitive locations” such as schools, hospitals, and churches.

In Northfield, about 45 miles south of Minneapolis, ICE agents have been sitting in their cars for hours at least twice a week outside health clinics, including one run by the local hospital, said Carroll, the nurse practitioner. Agents have made arrests in the area almost every day, Carroll and her colleagues said.

“ICE does not conduct enforcement at hospitals — period,” McLaughlin said.

One recent morning, three ICE vehicles sat in a Baptist church parking lot across the street from an elementary school in Northfield as volunteers ferried 35 children of immigrants back and forth to the school so their parents could avoid going out, Carroll said.

“ICE is not going to schools to arrest children — we are protecting children,” McLaughlin said.

Drones that Carroll and others believe are operated by immigration agents hover most nights, and sometimes during the day, over a trailer park that mostly houses immigrants who have moved to the area to work in agriculture and manufacturing over the past 15 years. Families paper over trailer windows, Carroll said.

“You cannot feel safe anywhere,” she said. “On the way to school, on the way to clinic, you might pass ICE. The sort of crushing fear and feeling of being trapped that these families are going through is outrageous.”

That fear means patients with diabetes and heart disease are missing blood sugar and blood thinner tests. Patients aren’t getting exercise, and the chronically ill are getting sicker, said Calla Brown, a Minneapolis pediatrician.

At the Faribault clinic where Carroll works, staff members deliver medicine, food, and other necessities to patients. A staffer drives 12 middle and high school kids to and from class every day in a clinic van.

Some patients are treated at home. Carroll recently diagnosed a baby with influenza, telling the parents it wasn’t an immediate threat — yet.

“‘If you see the baby struggling to breathe, if the baby’s not eating, if the baby isn’t making wet diapers, you have to go to the hospital,’” Carroll said she told them. “‘I cannot promise it’s safe. But you’ve got to go.’”

‘We’re Nice to Each Other’

In Minneapolis, nurse-midwife Fernanda Honebrink spends most of her daylight hours calling, coordinating, and shuttling between a ballooning group of fearful people stuck in their homes. She prefers not to call it a medical underground.

“It’s more like, that’s how we function in Minnesota,” said Honebrink, a U.S. citizen who emigrated from Ecuador 23 years ago. “We’re nice to each other.”

Honebrink spent a recent afternoon at the home of a family with a baby boy. His parents, Alex and Isa, desperately want him to receive vaccinations and blood tests at his one-year well-child appointment.

But they haven’t left their apartment for more than a month. “You don’t know what is most important: whether to go out for his well-being, or to go out and think that you might not come back,” Alex said.

The couple, who were interviewed in Spanish, entered the U.S. legally from Venezuela in 2024 under a program called Humanitarian Parole, which Trump ended in May. Since then, federal agents have detained and deported workers at a company where Alex, a mechanical engineer by training, worked in construction.

Alex and Isa have seen government vehicles outside their home. They knew of a man, they said, who had legitimate work papers but was picked up while walking to church one Sunday, flown to Texas, then put on a plane to Venezuela. It was a terrifying prospect for those who’ve fled that country’s dictatorship and economic chaos.

“It feels like a psychological attack,” Alex said. “The possibility of being separated from your family.”

Isa, a lawyer back in Venezuela, has endured postpartum depression, cooped up for weeks in their apartment. The state program that provided health insurance to all immigrants ended Jan. 1. A therapist checks in occasionally by phone, free of charge.

She has tried to keep the family afloat by selling homemade cakes and necklaces, and babysitting.

Her worst fear is being separated from her son, who was born in the U.S. and is a citizen. The possibility hadn’t occurred to her until an acquaintance urged her to to designate someone to have temporary custody if she were deported.

“It was something I never imagined,” said Isa, who sobbed as she recalled the moment. “He’s my baby! He’s not someone else’s! What? My baby would remain here with someone?’’

Honebrink suddenly piped up: “I will guarantee him. I’ll sign the form.”

She later told a reporter, “I told my husband I wouldn’t do that. I’ve already signed as a sponsor for four kids.”

As soon as she left the apartment, Honebrink jumped back on the phone and traded favors with local pediatricians, clinic schedulers, and volunteers. Within hours, she’d set up a new well-child visit for the baby and found a vetted driver to transport the family.

“A white person,” Honebrink explained.

Two days later, Honebrink sent a picture of her small victory: Alex and Isa’s baby boy with a Band-Aid on his legs. “He got his vaccines,” she said via text. “I’m so happy.”

But other medical needs cannot be as swiftly addressed. One February evening, Honebrink greeted Gabi and her mother with a trunk full of donated baby wipes, diapers, and toys.

Gabi’s surgery is rescheduled for August. Her mother said she hoped by then it would be safe to leave home.

“I used to take the kids to the park, but now we don’t leave at all,” she said. “They grab people, they mistreat them. How I wish it would end soon!”

Â鶹ŮÓÅ Health News’ Jackie Fortiér contributed to this report.

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

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U.S. Immigration and Customs Enforcement agents have also shown up at community clinics. Health providers say that officers have tried to hosting a mobile clinic, waved a machine gun in the faces of clinicians serving the homeless, and hauled a passerby into an unmarked car outside a community health center.

In response to such immigration enforcement activity in and around clinics and hospitals, Democratic Gov. Gavin Newsom last month signed , which prohibits medical establishments from allowing federal agents without a valid search warrant or court order into private areas, including places where patients receive treatment or discuss health matters.

But while the bill received broad support from medical groups, health care workers, and immigrant rights advocates, legal experts say California can’t stop federal authorities from carrying out duties in public places, which include hospital lobbies and general waiting areas, health facility parking lots, and surrounding neighborhoods — places where recent ICE activities have sparked outrage and fear. Previous federal restrictions on immigration enforcement in or near sensitive areas, including health care establishments, were rescinded by the Trump administration in January.

“The issue that states encounter is the ,” said , a supervising attorney and clinical teaching fellow at Georgetown Law. She said the federal government does have the right to conduct enforcement activities, and there are limits to what the state can do to stop them.

California’s law designates a patient’s immigration status and birthplace as protected information, which like medical records cannot be disclosed to law enforcement without a warrant or court order. And it requires health care facilities to have clear procedures for handling requests from immigration authorities, including training staff to immediately notify a designated administrator or legal counsel if agents ask to enter a private area or review patient records.

Several other Democratic-led states have also taken up legislation to protect patients at hospitals and health centers. In May, Colorado Gov. Jared Polis signed the bill, which penalizes hospitals for unauthorized sharing of information about people in the country illegally and bars ICE agents from entering private areas of health care facilities without a judicial warrant. In Maryland, requiring the attorney general to create guidance on keeping ICE out of health care facilities went into effect in June. New Mexico has instituted , and Rhode Island has from asking patients about their immigration status.

Republican-led states have aligned with federal efforts to prevent health care spending on immigrants without legal authorization. Such immigrants are not eligible for comprehensive Medicaid coverage, but states do bill the federal government for in certain cases. Under a , Florida requires hospitals that accept Medicaid to ask about a patient’s legal status. In Texas, hospitals now have to report how much they spend on care for immigrants without legal authorization.

“Texans should not have to shoulder the burden of financially supporting medical care for illegal immigrants,” Gov. Greg Abbott said in issuing his last year.

California’s efforts to rein in federal enforcement come as the state, where more than a quarter of residents , has become a target of President Donald Trump’s immigration crackdown. Newsom signed SB 81 as part of a prohibiting immigration agents from entering schools without a warrant, requiring law enforcement officers to identify themselves, and banning officers from wearing masks. SB 81 was passed on a party-line vote with no formal opposition.

“We’re not North Korea,” Newsom said during a September bill-signing ceremony. “We’re pushing back against these authoritarian tendencies and actions of this administration.”

Some supporters of the bill and legal experts said California’s law can prevent ICE from violating existing patient privacy rights. Those include the Fourth Amendment, which without a warrant in places where people have a reasonable expectation of privacy. Valid warrants must be . But ICE agents frequently use administrative warrants to try to gain access to private areas they don’t have the authority to enter, Genovese said.

“People don’t always understand the difference between an administrative warrant, which is a meaningless piece of paper, versus a judicial warrant that is enforceable,” Genovese said. Judicial warrants are rarely issued in immigration cases, she added.

The Department of Homeland Security has said or identification requirements for law enforcement officers, slamming them as unconstitutional. The department did not respond to a request for comment on the state’s new rules for health care facilities, which went into immediate effect.

Tanya Broder, a senior counsel with the National Immigration Law Center, said immigration arrests at health care facilities appear to be relatively rare. But the federal decision to rescind protections around sensitive areas, she said, “has generated fear and uncertainty across the country.” Many of the most high-profile news reports of immigration agents at health care facilities have been in California, largely involving detained patients brought in for care.

The California Nurses Association, the state’s largest nurses union, was a co-sponsor of the bill and raised concerns about the treatment of Milagro Solis-Portillo, a 36-year-old Salvadoran woman who was under round-the-clock ICE surveillance at Glendale Memorial Hospital over the summer.

Union leaders also of agents at California Hospital Medical Center south of downtown Los Angeles. According to Anne Caputo-Pearl, a labor and delivery nurse and the chief union representative at the hospital, agents brought in a patient on Oct. 21 and remained in the patient’s room for almost a week. The reported that a TikTok streamer, Carlitos Ricardo Parias, was taken to the hospital that day after he was wounded during an immigration enforcement operation in South Los Angeles.

The presence of ICE was intimidating for nurses and patients, Caputo-Pearl said, and prompted visitor restrictions at the hospital. “We want better clarification,” she said. “Why is it that these agents are allowed to be in the room?”

Hospital and clinic representatives, however, said they are already following the law’s requirements, which largely reinforce put out by state Attorney General Rob Bonta in December.

Community clinics throughout Los Angeles County, which serve over 2 million patients a year, including a large portion of immigrants, have been implementing the attorney general’s guidelines for months, said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County. But she said the law should help ensure uniform standards across health facilities that clinics refer out to and reassure patients that procedures are in place to protect them.

Still, it can’t prevent immigration raids from happening in the broader community, which have made some patients and even health workers afraid to venture outside, McCarthy said. Some incidents have occurred near clinics, including an arrest of a passerby outside a clinic in East Los Angeles, which a security guard caught on video, she said.

“We’ve had clinic staff say, ‘Is it safe for me to go out?’” she said.

At St. John’s Community Health, a network of 24 community health centers and five mobile clinics in South Los Angeles and the Inland Empire, CEO Jim Mangia agreed that the new law can’t prevent all immigration enforcement activity, but he said it does give clinics a tool to push back if agents show up, something his staff has already had to do.

Mangia said St. John’s staff had two encounters with immigration agents over the summer. In one, he said, staff stopped armed officers from entering a gated parking lot at a drug and alcohol recovery center where doctors and nurses were seeing patients at a mobile health clinic.

Another occurred in July, when immigration agents MacArthur Park on horses and in armored vehicles, in a show of force by the Trump administration. Mangia said masked officers in full tactical gear surrounded a street medicine tent where St. John’s providers were tending to homeless patients, screamed at staff to get out, and pointed a gun at them. The providers were so shaken by the episode, Mangia said, that he had to bring in mental health professionals to help them feel safe going back out on the street.

A DHS spokesperson told CalMatters that in the rare instance where agents enter certain sensitive locations, officers would need “.”

Since then, St. John’s has doubled down on providing support and training to staff and has offered patients afraid to go out the option of home medical visits and grocery deliveries. Patient fears and ICE activity have decreased since the summer, Mangia said, but with DHS planning to , he doubts that will last.

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

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The Senate has passed — and sent back to the House — a bill that would allow the Trump administration to claw back some $9 billion in previously approved funding for foreign aid and public broadcasting. But first, senators removed from the bill a request to cut funding for the President’s Emergency Plan for AIDS Relief, President George W. Bush’s international AIDS/HIV program. The House has until Friday to approve the bill, or else the funding remains in place.

Meanwhile, a federal appeals court has ruled that West Virginia can ban the abortion pill mifepristone despite its approval by the Food and Drug Administration. If the ruling is upheld by the Supreme Court, it could allow states to limit access to other FDA-approved drugs.

This week’s panelists are Julie Rovner of Â鶹ŮÓÅ Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists

Among the takeaways from this week’s episode:

• The Senate approved the Trump administration’s cuts to foreign aid and public broadcasting, a remarkable yielding of congressional spending power to the president. Before the vote, Senate GOP leaders removed President Donald Trump’s request to cut PEPFAR, sparing the funding for that global health effort, which has support from both parties.
• Next Congress will need to pass annual appropriations bills to keep the government funded, but that is expected to be a bigger challenge than the recent spending fights. Appropriations bills need 60 votes to pass in the Senate, meaning Republican leaders will have to make bipartisan compromises. House leaders are already delaying health spending bills until the fall, saying they need more time to work out deals — and those bills tend to attract culture-war issues that make it difficult to negotiate across the aisle.
• The Trump administration is planning to destroy — rather than distribute — food, medical supplies, contraceptives, and other items intended for foreign aid. The plan follows the removal of workers and dismantling of aid infrastructure around the world, but the waste of needed goods the U.S. government has already purchased is expected to further erode global trust.
• And soon after the passage of Trump’s tax and spending law, at least one Republican is proposing to reverse the cuts the party approved to health programs — specifically Medicaid. It’s hardly the first time lawmakers have tried to change course on their own policies, though time will tell whether it’s enough to mitigate any political (or actual) damage from the law.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:Ìý

Julie Rovner: The New York Times’ “,” by David Enrich.

Joanne Kenen: The New Yorker’s “” by Dhruv Khullar.

Shefali Luthra: The New York Times’ “,” by Apoorva Mandavilli.

Sandhya Raman: The Nation’s “,” by Cecilia Nowell.

Also mentioned in this week’s podcast:

• The Atlantic’s “,” by Hana Kiros.
• Â鶹ŮÓÅ Health News’ “Vested Interests. Influence Muscle. At RFK Jr.’s HHS, It’s Not Pharma. It’s Wellness,” by Stephanie Armour.
• The Washington Post’s “,” by Hannah Knowles.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]Ìý

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for Â鶹ŮÓÅ Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 17, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.Ìý

Today we are joined via videoconference by Sandhya Raman of CQ Roll Call.Ìý

Sandhya Raman: Hello, everyone.Ìý

Rovner: Shefali Luthra of The 19th.Ìý

Shefali Luthra: Hello.Ìý

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.Ìý

Joanne Kenen: Hi, everybody.Ìý

Rovner: No interview this week, but more than enough news. So we will get right to it.Ìý

We’re going to start on Capitol Hill, where in the very wee hours of Thursday morning, the Senate approved the $9 billion package of rescissions of money already appropriated. It was largely for foreign aid and the Corporation for Public Broadcasting, which oversees NPR and PBS. Now, this bill represents pennies compared to the entire federal budget and even to the total of dollars that are appropriated every year, but it’s still a big deal because it’s basically Congress ceding more of its spending power back to the president. And even this small package was controversial. Before even bringing it to the floor, senators took out the rescission of funds for PEPFAR [the President’s Emergency Plan for AIDS Relief], the bipartisanly popular international AIDS/HIV program begun under President George W. Bush. So now it has to go back to the House, and the clock on this whole process runs out on Friday. Sandhya, what’s likely to happen next?Ìý

Raman: I think that the House has been more amenable. They got this through quicker, but if you look—Ìý

Rovner: By one vote.Ìý

Raman: Yeah. But I think if you look at what else has been happening in the House this week that isn’t in the health sphere, they’ve been having issues getting other things done, because of some pushback from the Freedom Caucus, who’s been kind of stalling the votes and having them to go back. And other things that should have been smoother are taking a lot longer and having a lot more issues. So it’s more difficult to say without seeing how all of that plays out, if those folks are going to make a stink again about something here because some of this money was taken out. It’s a work in progress this week in the House.Ìý

Rovner: Yeah, that’s a very kind way to put it. The House has basically been stalled for the last 24 hours over, as you say, many things, completely unrelated, but there is actually a clock ticking on this. They had 45 days from when the administration sent up this rescission request, and we’re now on Day 43 because Congress is the world’s largest group of high school students that never do anything until the last minute. So Democrats warned that this bill represents yet another dangerous precedent. They reached a bipartisan agreement on this year of spending bills in the spring, and this basically rolls at least some of that back using a straight party-line vote. What does this bode for the rest of Congress’ appropriations work for the fiscal year that starts in just a couple of months?Ìý

Raman: I think that the sense has been that once this goes through, I think a lot of people have just been assuming that it’ll take time but that things will get passed on rescissions. It really puts a damper on the bipartisan appropriations process, and it’s going to make it a lot harder to get people to come to the table. So earlier this week we had the chair of the Appropriations Committee and the chair of the Labor, HHS [Health and Human Services], Education subcommittee in the House say that the health appropriations they were going to do next week for the House are going to get pushed back until September because they’re not ready. And I think that health is also one of the hardest ones to get through. There’s a lot more controversial stuff. It’s setting us up to go, kind of like usual at this point, for another CR [continuing resolution], because it’s going to be a really short timeline before the end of the fiscal year. But if you look at some—Ìý

Rovner: Every year they say they’re going to do the spending bills separately, and every year they don’t.Ìý

Raman: Yeah, and I think if you look at how they’ve been approaching some of the things that have been generally a little bit less controversial and how much pushback and how much more difficulties they’ve been having with that, even this week, I think that it’s going to be much more difficult to get that done. And the rescissions, pulling back on Congress’ power of the purse, is not going to make that any easier.Ìý

Rovner: I think what people don’t appreciate, and I don’t think I appreciated it either until this came up, is that the rescissions process is part of the budget act, which is one of these things that Congress can do on an expedited basis in the Senate with just a straight majority. But the regular appropriations bills, unlike the budget reconciliation bill that we just did, need 60 votes. They can be filibustered. So the only way to get appropriations done is on a bipartisan basis, and yet they’re using this rather partisan process to take back some of the deal that they made. The Democrats keep saying it, and everybody’s like, Oh, process, process. But that actually could be a gigantic roadblock, to stopping everything in its tracks, right?Ìý

Raman: I really think so. And if you look at who are the two Republicans in the Senate that voted against the rescissions, one of them is the Senate Appropriations chair, Susan Collins. And throughout this, one of her main concerns was when we still had the PEPFAR in there. But it just takes back her power as the highest-ranking appropriator in the Senate to do it through this process, especially when she wasn’t in favor of the rescissions package.Ìý

So it’s going to make things, I think, a lot more complicated, and one of her concerns throughout has just been that there wasn’t enough information. She was pulling out examples of rescissions in the past and how it was kind of a different process. They were really briefed on why this was necessary. And it was just different now. So I think what happens with appropriations and how long it’ll take this year is going to be interesting to watch.Ìý

Rovner: And it’s worth remembering that it’s when the appropriations don’t happen that the government shuts down. So, but that doesn’t happen until October. Well, separately we learned that — oh, go ahead, Joanne.Ìý

Kenen: There’s also sort of a whole new wrinkle, is that rescissions is, if you’re a Republican and you don’t like something and you end up, to avoid a government shutdown or whatever reason, you end up having to vote for a bill, you just have the president put out a statement saying, If this goes through, I’m going to cut it afterwards. And then the Republican who doesn’t like it can give a floor speech saying, I’m voting for it because I like this in it and I know that the president’s going to take care of that. It really — appropriations is always messy, but there’s this whole unknown. The constitutional balance of who does what in the American government is shifting. And at the end of the day, the only thing we do know after both the first term and what’s happened so far even more so in the second term, is what [President Donald] Trump wants, Trump tends to get.Ìý

So, Labor-H [the appropriations for Labor, HHS, Education and related agencies], like Sandhya just pointed out, the health bill is one of the hardest because there’s so much culture-war stuff in it. But, although, the Supreme Court has put some of that off the table. But I just don’t know how things play out in the current dynamic, which is unprecedented.Ìý

Rovner: And of course, Labor-HHS also has the Department of Education in it.Ìý

Kenen: The former Department of Education.Ìý

Rovner: To say, which is in the process of being dismantled. So that’s going to make that even more controversial this year. Moving back to the present, separately we learned this week that the administration plans to spend hundreds of thousands of dollars of taxpayer money to destroy stocks of food and contraceptives and other medical devices rather than distribute them through some of the international aid programs that they’re canceling. Now, in the case of an estimated 500 tons of high-energy biscuits bought by USAID [the U.S. Agency for International Development] at the end of the Biden administration, you can almost understand it because they’re literally about to expire next week. According to The Atlantic, which first reported , this is only a small part of 60,000 metric tons of food already purchased from U.S. farmers and sitting in warehouses around the world, where the personnel who’d be in charge of distributing them would’ve been fired or transferred or called back to the U.S.Ìý

At the same time, there are apparently also plans to destroy an estimated $12 million worth of HIV prevention supplies and contraceptives originally purchased as part of foreign aid programs rather than turn them over or even sell them to other countries or nonprofits. This feels like maybe the not most efficient use of taxpayer dollars?Ìý

Luthra: I think this is something we’ve talked about before, but it really bears repeating. As a media ecosphere, we’ve sort of moved on from the really rapid dismantling of USAID. And it was not only without precedent. It was incredibly wasteful with the sudden way it was done, all of these things that were already purchased no longer able to be used, leases literally broken. And people had to pay more to break leases for offices set up in other countries, all these sorts of things that really could have already been used because they had been paid for. And instead, the money is simply lost.Ìý

And I think the important thing for us to remember here is not only the immense waste financially to taxpayers but the real trust that has been lost, because these were promises made, things purchased, programs initiated, and when other countries see us pulling back in such a, again, I keep saying wasteful, but truly wasteful manner, it’s just really hard to ever imagine that the U.S. will be a reliable partner moving forward.Ìý

Rovner: Yeah, absolutely. I understand the food thing to some extent because the food’s going to expire, but the medical supplies that could be distributed by somebody else? I’m still sort of searching for why that would make any sense in any universe, but yeah I guess this is the continuation of, We’re going to get rid of this aid and pretend that it never happened.Ìý

Well, meanwhile, it’s only been a couple of weeks, but we’re starting to see the politics of that big Trump tax and spending measure play out. One big question is: Why didn’t Republicans listen to the usually very powerful hospital industry that usually gets its way but did not this time? And relatedly, will those Republicans who voted with Trump but against those powerful hospital interests do an about-face between now and when these Medicaid cuts are supposed to take effect? We’ve already seen Sen. Josh Hawley, the Republican from Missouri who loudly proclaimed his opposition to those Medicaid cuts before he voted for them anyway, introduce legislation to rescind them. So is this the new normal? I think, Joanne, you were sort of alluding to this, that you can now sort of vote for something and then immediately say: Didn’t mean to vote for that. Let’s undo it.Ìý

Kenen: You could even do it before you vote for it, if they play it right. If Congress passes these things, we’re not going to pay attention. We’re already in that moment. But also, when I was working on a Medicaid piece, the magazine piece like four or five months ago, one of the most cynical people I know in Washington told me, he said, Oh, they’ll pass these huge cuts because they need the budget score to get the taxes through, and then they’ll start repealing it. And it seemed so cynical at the time, only he might’ve been right.Ìý

So I don’t think they’re going to cut all of it. Republicans ideologically want a smaller Medicaid program. They want less spending. They want work requirements. You’re not going to see the whole thing go away. Could you see some retroactive tinkering or postponement or something? Yeah, you could. It’s too soon to know. Hospitals are the biggest employer in many, many congressional districts. This is a power—Ìý

Rovner: Most of them.Ìý

Kenen: Most, yeah. I don’t think it’s quite all, but like a lot. It’s the biggest single employer, and Medicaid is a big part of their income. And they still by law have to stabilize people who come in sick, and there’s emergency care and all sorts of other things, right? They do charity care. They do uninsured people. They do all sorts. They still treat people under certain circumstances even when they can’t pay. But right now, the threat of a primary opponent is more powerful than the threat of your local hospital being mad at you and harming health care access in your community. So much in the Republican world revolves around not getting the president mad enough that he threatens to get you beaten in a primary. We’ve seen that time and again already.Ìý

Rovner: Right. And I will also say there’s precedent for this, for passing something and then unpassing it. Joanne and I covered in 19—Ìý

Kenen: But it wasn’t the plan.Ìý

Rovner: Yeah, I know. But remember, back in 1997 when they passed the Balanced Budget Act, every year for the next — was it three or four years? They did what we came to call “give back” bills.Ìý

Kenen: Or punting, right?Ìý

Rovner: Yeah, where they basically undid, they unspooled, some of those cuts, mostly because they’d cut more deeply than they’d intended to. And then we know with the Affordable Care Act, I’ve said this several times, they passed all of these financing mechanisms for it and then one by one repealed them.Ìý

Kenen: And the individual mandate — I mean everything-Ìý

Rovner: And the individual mandate, right.Ìý

Kenen: They kept the dessert and they gave away everything. They undid everything that paid for the dessert, basically.Ìý

Rovner: Right. Right.Ìý

Kenen: And so it was the Cadillac — because people don’t remember anymore — the Cadillac tax, the insurance tax, the device tax. They all were like, One at a time! And they were repealed because lobbying works.Ìý

Rovner: The tanning tax just went.Ìý

Kenen: Right, right. So that dynamic existed, passing something unpopular and then redoing it, but the dynamic now really just comes — basically this is Donald Trump’s town. He has had a remarkable success in not only getting Congress to do what he wants but getting Congress to surrender some of its own powers, which have been around since Congress began. This is the way our government was set up. So there’s a very, very different dynamic, and it’s still unpredictable. None of us thought that the biggest crisis would be the [Jeffrey] Epstein case, right? Which is not a health story, and we don’t have to spend any time on it except to acknowledge—Ìý

Rovner: Please.Ìý

Kenen: —that there’s stuff going on in the background that people who had been extremely loyal to the president are now mad. And we don’t know how long. He’s very good at neutralizing things, too. He’s blaming it on the Democrats.Ìý

But there is a different dynamic. Congress has less power because Congress gave up some of its power. Are they going to want to reassert themselves? There is no sign of it right now, but who knows what happens. I thought they would cut Medicaid. I thought they would do work requirements. I thought they would let the enhanced ACA subsidies expire. But I did not think the cuts would go this deep and this extensive — really transformationally pretty historic cuts.Ìý

Rovner: Shefali, you wanted to say something?Ìý

Kenen: Not pretty historic cuts, very historic cuts. Unprecedented.Ìý

Luthra: I was thinking Joanne made such a good point about how, for all of the talk now about trying to mitigate that backlash, a lot of this is in line ideologically with what Republicans want. They do want a smaller Medicaid program. And I think a really interesting and still open question is whether they are willing and able to actually create policy that does reverse some of these cuts or not, and even if they do, if it’s sufficient to change voters’ perception, because we know that these cuts are very unpopular. Democrats are talking about them a lot. Hospitals are talking about them a lot. And just the failed attempt to repeal the ACA led to the 2018 midterms. And I think there is a real chance that this is the dominant topic when we head into next year’s elections. And it’s hard to say if Josh Hawley putting out a bill can undo that damage, so—.Ìý

Rovner: Well, I’m so glad you mentioned that, because The Washington Post has a about a clinic closing in rural Nebraska, with its owners publicly blaming the impending Medicaid cuts. Yet its Trump-supporting patients are just not buying it. Now in 2010, Republicans managed to hang the Affordable Care Act around Democrats’ necks well before the vast majority of the changes took place. Are Democrats going to be able to do that now? There’s a lot of people saying, Oh, well, they’re not going to be able to blame this on the Republicans, because most of it won’t have happened yet. This is really going to be a who-manages-to-push-their-narrative, right?Ìý

Kenen: This really striking thing about that story is that the people who were losing access, they’re not losing their Medicaid yet, but they’re losing access to the only clinic within several — they have to drive hours now to get medical care. And when they were told this was because the Republican Congress and President Trump, they said, Oh no, it can’t be. First of all, a lot of people just don’t pay attention to the news. We know that. And then if you’re paying attention to news that never says anything negative about the president, that blames everything on Joe Biden no matter — if it rains yesterday, it was his fault, right?Ìý

So the sort of gap between — there are certain things that are matters of opinion and interpretation, and there are certain things that are matters of fact, but those facts are not getting through. And we do not know whether the Democrats will be able to get them through, because the resistance, it’s almost magical, right? My clinic closed because of a Republican Medicaid bill? Oh no, it’s hospital greed. They just don’t want to treat us anymore. They just, it doesn’t compute, because it doesn’t fit into what they have been reading and hearing, to the extent that they read and hear.Ìý

Rovner: Sandhya, you want to add something?Ìý

Raman: The one thing that as I’ve been asking around on Capitol Hill about the Hawley bill — and there was one from Sen. Rand Paul, and a House counterpart, from [Rep.] Greg Steube, does sort of the opposite — it wants to move up the timeline for one of the provisions. So one important thing to consider is neither of these bills have had a lot of buy-in from other members of Congress. They’ve been introduced, but the people that I’ve talked to have said, I’m not sure.Ìý

And I think something interesting that Sen. Thom Tillis had said was: If Republicans had a problem with what some of the impacts would be, then why were they denying that there would be an effect on rural health or some of those things to begin with? And I think a lot of it will take some time to judge to see if people will move the needle, but if we’re going to change any of these deadlines through not reconciliation, you need 60 votes in the Senate and you’ll need Democrats on board as well as Republicans. And I think one interesting thing to watch there is that I think some of the Democrats are also looking at this in a political way. If there’s a Republican that has a bill that is trying to tamp down some of the effects of their signature reconciliation law, do they want to help them and sign on to that bill or kind of illustrate the effects of the bill before the midterms or whatever?Ìý

Rovner: A lot more politics to come.Ìý

Raman: Yeah. Yeah.Ìý

Rovner: Meanwhile, over at HHS [the Department of Health and Human Services], there is also plenty of news. Many of the workers who’ve been basically in limbo since April when a judge temporarily halted the Trump administration’s efforts to downsize have now been formally let go after the Supreme Court last week lifted that injunction. What are we hearing about how things are going over at HHS? We’ve talked sort of every week about this sort of continuing chaos. I assume that the hammer falling is not helping. It’s not adding to things settling down.Ìý

Kenen: No. And then Secretary [Robert F.] Kennedy [Jr.] just fired two top aides because — no one knows exactly the full story but it’s — and I certainly do not know the full story. But what I have read is that the personality conflict with his top aide — and that happens in offices, and he’s not the first person in the history of HHS to have people who don’t get along with one another. But it’s just more unsettled stuff in an agency already in flux, because now in addition to all these people being let go in all sorts of programs and programs being rolled back, you also have some leadership chaos at the top.Ìý

Rovner: Well, meanwhile, HHS Secretary Kennedy took office with vows to eliminate the financial influence of Big Pharma, Big Food, and other industries with potential conflicts of interests. But shoutout here to my Â鶹ŮÓÅ Health News colleague Stephanie Armour, who has a story this week about how the new vested interests at HHS are the wellness industry. Kennedy and four top advisers, three of whom have been hired into the department, wrote Stephanie, quote, “earned at least $3.2 million in fees and salaries from their work opposing Big Pharma and promoting wellness in 2022 and 2023, according to a Â鶹ŮÓÅ Health News review of financial disclosure forms filed with the U.S. Office of Government Ethics and the Department of Health and Human Services; published media reports; and tax forms filed with the IRS. That total doesn’t include revenue from speaking fees, the sale of wellness products, or other income sources for which data is not publicly available.” Have we basically just traded one form of regulatory capture for another form of regulatory capture?Ìý

Kenen: And one isn’t covered by insurance. Some of it is, but there’s a lot of stuff in the, quote, “wellness” industry that providers and so forth, certain services are covered if there’s licensed people and an evidence base for them, but a lot of it isn’t. And these providers charge a lot of money out-of-pocket, too.Ìý

Rovner: And they make a lot of money. This is a totally — unlike Big Pharma, Big Food, and Big Medicine, which is regulated, Big Wellness is largely not regulated.Ìý

Kenen: I think Stephanie — that was a really good piece — and I think Stephanie said it was, what, $6.3 trillion industry? Was that—Ìý

Rovner: Yeah, it’s huge.Ìý

Kenen: Am I remembering that number right? It’s largely unregulated. Many of the products have never gone through any review for safety or efficacy. And insurance doesn’t cover a lot of it. It doesn’t mean it’s all bad. There are certain things that are helpful, but as an industry overall, it leaves something for us to worry about.Ìý

Rovner: Well, in HHS-adjacent breaking news that could turn out to be nothing or something really big, an appeals court in Richmond on Tuesday ruled 2-1 that West Virginia may in fact limit access to the abortion pill, even though it’s approved by the FDA [Food and Drug Administration]. It’s the first time a federal appeals court has basically said that states can effectively override the FDA’s nationwide drug approval authority. And it’s the question that the Supreme Court has already ducked once, in that case out of Texas last year where the justices ruled that the doctors who were suing didn’t have standing, so they didn’t have to get to that question. But, Shefali, this has implications well beyond abortion, right?Ìý

Luthra: Oh, absolutely. We are seeing efforts across the country to restrict access to certain medications that are FDA-approved. Abortion pills are the obvious one, but, of course, we can think about gender-affirming care. We can think about access to all sorts of other therapeutics and even vaccines that are now sort of coming under political fire. And if FDA approval means less than state restrictions, as we are seeing in this case, as we very possibly could see as these kinds of arguments and challenges make their way to the Supreme Court. The case you alluded to earlier with the doctors who didn’t have standing is still alive, just with different plaintiffs now. And so these questions will probably come back. There are just such vast ramifications for any kind of medication that could be politicized, and it’s something that industry at large has been very worried about since this abortion pill became such a big question. And it is something that this decision is not going to alleviate.Ìý

Rovner: Yes. Speaking of Big Pharma, they’re completely freaked out by this possibility because it does have implications for every FDA-approved drug.Ìý

Luthra: And they invest so much money in trying to get products that have FDA approval. There’s a real promise that with this global gold standard, you will be able to keep a drug on the market and really make a lot of money on it. There’s also obviously concerns for birth control, which we aren’t seeing legally restricted in the same way as abortion yet, but it is something that is so deeply subject to politics and culture-war issues that that’s something that we could see coming down the line if trends continue the way they are.Ìý

Rovner: Well, we will watch that space. Moving on. Wednesday was the third anniversary of the federal 988 federal crisis line, which has so far served an estimated 16 million people with mental health crises via call, text, or chat. An estimated 10% of those calls were routed through a special service for LGBTQ+ youth, which is being cut off today by the Trump administration, which accused the program, run by the Trevor Project, as, quote, “radical gender ideology.” Now, LGBTQ+ youth are among those at the highest risk for suicide, which is exactly what the 988 program was created to prevent. Yet there’s been very little coverage of this. I had to actually go searching to find out exactly what happened here. Is this just kind of another day in the Trump administration?Ìý

Raman: I think a lot of it stems back to some of those initial executive orders related to gender ideology and DEI [diversity, equity, and inclusion] and things like that. The Trump administration’s kind of argument is that it shouldn’t be siloed. It should be all general. There shouldn’t be sort of special treatment, even though we do have specialized services for veterans who call in to these services and things. But I—Ìý

Rovner: Although that was only saved when members of Congress complained.Ìý

Raman: Yeah. But I do think that when we have so much happening in this space focused on LGBTQ issues, it’s easier for things to get missed. I think the one thing that I did notice was that California announced yesterday that they were going to step up to do a partnership with the Trevor Project to at least — the LGBTQ youth calling from California to any of those local 988 centers would be reaching people that have been trained a little bit more in cultural competency and dealing with LGBTQ youth. But that’s not going to be all the states and it’s going to take time. Yeah.Ìý

Rovner: Yeah, we’re going to continue to see this cobbled together state by state. It feels like increasingly what services are available to you are going to be very much dependent on where you live. That’s always been true, but it feels like it’s getting more and more and more true. Shefali, I see you nodding.Ìý

Luthra: Something you alluded to that I think bears making explicit is public health interventions are typically targeted toward people who are in greater danger or are at greater risk. That’s not discrimination — that’s public health efficiency. And suggesting that we shouldn’t have resources targeted toward people at higher risk of suicide is counter to what public health experts have been arguing for a very long time. And that’s just something that I think really bears noting and keeping in mind as we see what the impact of this is moving forward.Ìý

Rovner: Yeah, I think that’s a very good point. Thank you.Ìý

Well, speaking of popular things that are going away, a federal judge appointed by President Trump last week struck down the last-minute Biden administration rule from the Consumer Financial Protection Bureau that tried to bar medical debt from appearing on credit reports. This had been hailed as a major step for the 100 million Americans with medical debt, which is not exactly the same as buying a car or a TV that you really can’t afford. People don’t go into medical debt saying, Oh, I think I’m going to go run up a big medical bill that I can’t pay. But this strikes me as yet another way this administration is basically inflicting punishment on its own voters. Yes?Ìý

Kenen: Yes, except we just don’t know. Some red states are so red that you don’t need every voter. We don’t know who actually votes, and we don’t know whether people make these connections, right? What we were talking about before with Medicaid — do they understand that this is something that President Trump not just urged but basically ordered Congress to do? So do people pay attention? How many people even know if their medical debt is or is not on their credit report? They know they have the medical debt, but I’m not sure everybody understands all the implication, particularly if you’re used to being in debt. You may be somebody who’s lost a job or couldn’t pay your mortgage or couldn’t pay your rent. Some of the people who have medical debt have so many other financial — not all — that it’s just part of a debt soup and it’s just one more ingredient.Ìý

So how it plays out and how it’s perceived? It’s part of this unpredictable mix. Trump is openly talking about gerrymandering more, and so it won’t matter what voters do, because they’ll have more Republican seats. That’s just something he’s floating. We don’t know whether it’ll actually happen, but he floated it in public, so—Ìý

Rovner: So much of this is flooding the zone, that people — there’s so much happening that people have no idea who’s responsible for what. There’s always the pollster question: Is your life better or worse than it was last year? Or four years ago, whatever. And I think that when you do so much so fast, it’s pretty hard to affix blame to anybody.Ìý

Raman: And most people aren’t single-issue voters. They’re not going to the polls saying, My medical debt is back on my credit report. There’s so many other things, even if with the last election, health care was not the number one issue for most voters. So it’s difficult to say if it will be the top issue for the next election or the next one after that.Ìý

And I guess just piggybacking that a lot of the times when there’s these big changes, they don’t take effect for a while. So it’s easier to rationalize, Oh, it may have been this person or that person or the senator then, or who was president at a different time, just because of how long it takes to see the effects in your daily life.Ìý

Rovner: Politics is messy. All right, well, this is as much time for the news as we have this week? Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?Ìý

Luthra: Sure. My piece is from The New York Times, by Apoorva Mandavilli. The headline is “” And she takes a look at when the head of the OMB [Office of Management and Budget] told the Senate that PEPFAR had spent almost $10 million advising Russian doctors on abortions and gender analysis. And she goes through and says this isn’t true. PEPFAR hasn’t been in Russia. They cannot fund abortions. And she talks with people who were there and can say this simply isn’t true and this is very easy to disprove. And I like this piece because it’s just a reminder that a lot of things are being said about government spending that are not true. And it is a public service to remind readers that they are very easily disproven.Ìý

Rovner: Yeah, and to go ahead and do that. Sandhya.Ìý

Raman: My extra credit is “,” and it’s from Cecilia Nowell for The Nation, my co-fellow through AHCJ [the Association of Health Care Journalists] this year. Cecilia went to Kiruna, which is an Arctic village in Sweden, to look at how they’re using mifepristone for abortions up to 22 weeks in pregnancy, compared to up to 10 weeks in the U.S. And it’s a really interesting look at how they’re navigating rural access to abortion in very remote areas. Almost all abortions in Sweden are done through medication abortion, and while the majority here are in the 60% versus high 90s. So just interesting how they’re taking their approach there as rural access is limited here.Ìý

Rovner: Really interesting story. Joanne.Ìý

Kenen: This is a piece in The New Yorker by Dhruv Khullar, and it’s “” And what I found interesting, we’ve been hearing about: Can AI do this? It’s sort of been in the air since AI came around. But what was so interesting about this article is there’s a nonprofit that is actually doing it, and they have this sort of whole sort of hierarchy of why a drug may be promising and why a disease may be a good target. And then the AI look at genetics and diseases, and they have four or five factors they look at. And then there’s this just sort of hierarchy of which are the ones we can make accessible.Ìý

So A, it’s actually happening. B, it has promise. It’s not a panacea, but there’s promise. And C, it’s being done by a nonprofit. It’s not a cocktail for an individual patient. It’s trying to figure out: What are the smartest drugs to be looking at and what can they treat? And they give examples of people who have gone into remission from rare diseases. And also it says there are 18,000 diseases and only 9,000 have treatment. So this is huge, right? Rare diseases may only affect a few people, but there are lots of rare diseases. So cumulatively some of the people they strike are young. So for someone who doesn’t always read about AI, I found this one interesting.Ìý

Rovner: Also, we read somebody’s story about how AI is terrible for this, that, and the other thing. It is very promising for an awful lot of things.Ìý

Kenen: No. Right.Ìý

Rovner: There’s a reason that everybody’s looking at it.Ìý

All right, my extra credit this week is also from The New York Times. It’s called “,” by David Enrich, who’s The Times’ deputy investigations editor and, notably, author of a book on attacks on press freedoms. That’s because the story chronicles how UnitedHealth, the mega health company we have talked about a lot on this show, is taking a cue from President Trump and increasingly taking its critics to court, in part by claiming that critical reporting about the company risks inciting further violence like the Midtown Manhattan murder of United executive Brian Thompson last year.Ìý

I hasten to add, this isn’t a matter of publications making stuff up. United, as we have pointed out, is a subject of myriad civil and criminal investigations into potential Medicare fraud as well as antitrust violations. This is still another chapter unfolding in the big United story.Ìý

OK, that is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us to review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, , or on Bluesky, . Where are you folks hanging these days? Shefali?Ìý

Raman: I’m at Bluesky, .Ìý

Rovner: Sandhya.Ìý

Raman: I’m and , @SandhyaWrites.Ìý

Rovner: Joanne?Ìý

Kenen: I’m mostly at Bluesky, , and I’ve been posting things more on , and there are more health people hanging out there.Ìý

Rovner: So we are hearing. We will be back in your feed next week. Until then, be healthy.Ìý

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Bonta’s office said the city’s then-mayor, city attorney, and city manager pressured DuPont Clinic’s landlord last spring to cancel the lease and that city officials also delayed permits to the clinic. They went so far as to warn the building owner that it could be liable for bomb threats and shootings at the medical office building in the wealthy city’s business district.

The Washington, D.C.-based reproductive health provider is of clinics nationwide that advertise abortions past 28 weeks of gestation. It had secured a lease and begun preparations to open a second U.S. location in Beverly Hills.

Concerned about potential anti-abortion protests and negative media coverage, city officials “engaged in a pressure campaign under the guise of public safety,” according to Bonta’s complaint. The actions “blatantly violated” state law, Bonta said in the complaint. It’s the state’s first action under the voter-passed initiative known as Proposition 1, which enshrined abortion rights in the state constitution.

“It’s a stark reminder that there are efforts right here in California to undermine reproductive freedom,” Bonta said in an interview with Â鶹ŮÓÅ Health News ahead of the announcement. “These are city officials who took an oath to uphold the state constitution and state law, and they did the opposite.”

In signing the agreement, the city did not admit fault or liability. In a statement, Mayor Lester Friedman said the city disagreed with the allegations in the attorney general’s complaint.

“Beverly Hills is already home to medical facilities that offer complete reproductive health services,” Friedman said in a statement. “The city reaffirms and pledges that it did not and will not discriminate against any reproductive healthcare provider and strongly supports a woman’s right to choose.”

As part of the agreement which has been approved by the Beverly Hills City Council and must be approved by the Los Angeles County Superior Court, city officials will be required to train employees about state and federal protections for abortion clinics, create a protocol for handling complaints of potential violations, and appoint a “reproductive justice compliance officer” to manage the training program and materials.

Beverly Hills council member John Mirisch said in a statement that Bonta had unfairly singled out the city for “political showmanship.”

“I have seen no evidence that the Dupont Clinic’s failure to open in Beverly Hills was a result of the City’s actions or was essentially anything other than a tenant/landlord dispute,” said Mirisch, who was in office at the time the clinic was preparing to open there.

In a statement, a DuPont representative lauded Bonta’s intervention.

“Beverly Hills blocked our clinic from opening, knowing it would limit abortion access not just for the people of their city, but for Californians and people living under abortion bans across the country,” said Jennefer Russo, who was the Beverly Hills clinic.

California prohibits abortions past the point of fetal viability, around 24 weeks, except in cases in which the life or health of the woman is at risk. Proposition 1 strengthened reproductive freedom protections in the state constitution.

Approved by an overwhelming majority of statewide voters in 2022, the law says that the state, and by extension local governments, “shall not deny or interfere with an individual’s reproductive freedom in their most intimate decisions, which includes their fundamental right to choose to have an abortion and their fundamental right to choose or refuse contraceptives.”

Bonta said the measure, which at the time was widely regarded as a largely symbolic measure in deeply progressive California, provided a strong legal basis for the state’s case against the city of Beverly Hills and led directly to the settlement agreement.

“There are protections, both constitutional and statutory, that protect reproductive freedom in California,” Bonta said. “Cities need to honor and follow those rights and protections and when they’re not, we will get involved.”

DuPont Clinic had announced plans in October 2022 to expand to the Los Angeles area, according to Bonta’s office. The following month, flyers opposing the clinic’s opening appeared in and around the building.

Beverly Hills police officials later drafted a plan to send a letter to other tenants of the building warning them of the potential security risks, something Bonta said they’d never done with previous properties targeted by protesters.

The city attorney instructed city officials to not issue permits to DuPont until he’d spoken with the clinic about “whether the proposed use is allowed or not.” He later suggested DuPont provide a letter “confirming its intention to comply with California law” as it relates to abortions later in pregnancy.

“They acted differently and inserted themselves in delayed permits and launching a pressure campaign based on the fact that reproductive freedom is at stake,” Bonta said. “They targeted DuPont because of the fact that it provided fully legal reproductive health care.”

During a City Council meeting in April 2023, City Manager Nancy Hunt-Coffey sent an email to council members alerting them of the controversy over the new clinic, just before several activists spoke in opposition. The clinic could, she warned, “be the focus of protests, rallies and unfortunately other more violent actions on occasion.”

“How did this get through?” council member Sharona Nazarian immediately wrote back.

Hunt-Coffey replied: “Well, it’s a private business renting space in a private building. ÌýWe don’t have anything in our code that prevents it…”

What followed was a series of attempts by then-mayor Julian Gold, Hunt-Coffey, and the Beverly Hills police chief to stymie the clinic’s opening, Bonta said. Gold and the police chief met with building owner Douglas Emmett Inc., warning that the clinic could become a “lightning rod” for the city and that the landlord would be “responsible” and “liable” if anything were to happen. Gold also raised the possibility of bomb threats and active shooters, and the safety of other tenants in the building.

The clinic never opened.

Bonta said his office is prepared to go after local governments that shirk their responsibility to uphold state laws that protect abortion rights. He also suggested he would support amending state law to levy financial penalties on those who violate it.

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It’s the second new clinic the regional affiliate has opened in Kansas in a little over two years, to accommodate the growing number of patients coming from Texas, Missouri, Oklahoma, Arkansas and even Louisiana.

For many people in the South, Kansas is now the nearest place to get a legal abortion.

Fourteen states have with few exceptions since the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision in 2022 left policies on abortion to the states. Many more have limited access.

And yet, the estimated number of abortions in the United States last year , the highest number in a decade, according to the Guttmacher Institute, a national nonprofit that supports abortion rights. That’s due in part to the efforts of groups such as Planned Parenthood Great Plains to fill the void left in the states with bans.

Over 170,000 people traveled out of their own state to receive abortion care in 2023, according to Guttmacher. That’s a big jump after Dobbs even though the share of out-of-state patients has been .

Not all of the increase in abortions comes from interstate travel, of course. Telehealth has made medication abortions easier to obtain without traveling. The number of self-managed abortions, including those involving the medication mifepristone, has risen.

And Guttmacher data scientist said the majority of the overall abortion increase in recent years came from those in states without total bans. The increased attention on the issue since Dobbs and efforts to expand access for people in the states with bans bolstered access for people locally as well.

“That speaks, in a lot of ways, to the way in which abortion access really wasn’t perfect pre-Dobbs,” Maddow-Zimet said. “There were a lot of obstacles to getting care.”

Abortion opponents, meanwhile, hailed an estimated drop in the procedure in the 14 states with near-total bans.

“It’s encouraging that pro-life states continue to show massive declines in their in-state abortion totals, with a drop of over abortions since Dobbs,” Kelsey Pritchard, a spokeswoman for, wrote in a statement.

Organizations in states where abortion remains legal feel the ripples of every new ban almost instantly.

One Planned Parenthood affiliate with a clinic in southern Illinois, for example, reported a roughly 10 percent increase in call volume in the two weeks following the enactment of in May. Both sides now await the next round of policy decisions on abortion, which voters will make in November. Ballot initiatives in 10 states.

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Billings-based RiverStone Health is eliminating 42 jobs this spring, cutting nearly 10% of its workforce. The cuts have shuttered an inpatient hospice facility, will close a center for patients managing high blood pressure, and removed a nurse who worked within rural schools. It also reduced the size of the clinic’s behavioral health care team and the number of staffers focused on serving people without housing.

RiverStone Health CEO Jon Forte said clinic staffers had anticipated a shortfall as the cost of business climbed in recent years. But a $3.2 million loss in revenue, which he largely attributed to Montana officials disenrolling a high number of patients from Medicaid, pushed RiverStone’s deficit much further into the red than anticipated.

“That has just put us in a hole that we could not overcome,” Forte said.

RiverStone is one of federally funded clinics in the U.S. that adjust their fees based on what individuals can pay. They’re designed to reach people who face disproportionate barriers to care. Some are in rural communities, where offering primary care can come at a financial loss. Others concentrate on vulnerable populations falling through cracks in urban hubs. Altogether, these clinics serve more than 30 million people.

The health centers’ lifeblood is revenue received from Medicaid, the state-federal subsidized health coverage for people with low incomes or disabilities. Because they serve a higher proportion of low-income people, the federally funded centers tend to have a larger share of patients on the program and rely on those reimbursements.

But Medicaid enrollment is undergoing a seismic shift as states reevaluate who is eligible for it, a process known as the Medicaid “unwinding.” It follows a two-year freeze on disenrollments that protected people’s access to care during the covid public health emergency.

As of May 23, people had lost coverage, including about 134,000 in Montana — 12% of the state’s population. Some no longer met income eligibility requirements, but the vast majority were booted because of paperwork problems, such as people missing the deadline, state documents going to outdated addresses, or system errors.

That means health centers increasingly offer care without pay. Some have seen patient volumes drop, which also means less money. When providers like RiverStone cut services, vulnerable patients have fewer care options.

Jon Ebelt, communications director of the Montana Department of Public Health and Human Services, said the agency isn’t responsible for individual organizations’ business decisions. He said the state is focused on maintaining safety-net systems while protecting Medicaid from being misused.

Nationwide, health centers face a similar problem: a perfect financial storm created by a sharp rise in the cost of care, a tight workforce, and now fewer insured patients. In recent months, clinics in California and Colorado have also announced cuts.

“It’s happening in all corners of the country,” said Amanda Pears Kelly, CEO of Advocates for Community Health, a national advocacy group representing federally qualified health centers.

Nearly a quarter of community health center patients who rely on Medicaid were cut from the program, from George Washington University and the National Association of Community Health Centers. On average, each center lost about $600,000.

One in 10 centers either reduced staff or services, or limited appointments.

“Health centers across the board try to make sure that the patients know they’re still there,” said Joe Dunn, senior vice president for public policy and advocacy at the National Association of Community Health Centers.

Most centers operate on shoestring budgets, and some started reporting losses as the workforce tightened and the cost of business spiked.

Meanwhile, federal assistance — money designed to cover the cost of people who can’t afford care —remained largely flat. Congress increased those funds in March to roughly $7 billion over 15 months, though health center advocates said that still doesn’t cover the tab.

Until recently, RiverStone in Montana had been financially stable. Before the pandemic, the organization was making money, according to financial audits.

In summer 2019, a $10 million expansion was starting to pay off. RiverStone was serving more patients through its clinic and pharmacy, a revenue increase that more than offset increases in operating costs, according to documents.

But in 2021, at the height of the pandemic, those growing expenses — staff pay, building upkeep, the price of medicine, and medical gear — outpaced the cash coming in. By last summer, the company had an operational loss of about $1.7 million. With the Medicaid redetermination underway, RiverStone’s pool of covered patients shrank, eroding its financial buffer.

Forte said the health center plans to ask state officials to increase its Medicaid reimbursement rates, saying existing rates don’t cover the continuum of care. That’s a tricky request after the state slightly last year following much debate around which services needed more money.

Some health center cuts represent a return to pre-pandemic staffing, after temporary federal pandemic funding dried up. But others are rolling back long-standing programs as budgets went from stretched to operating in the red.

California’s Petaluma Health Center in March laid off 32 people hired during the pandemic, reported, or about 5% of its workforce. It’s one of the largest primary care providers in Sonoma County, based on where people live and poverty is more prevalent in largely Hispanic neighborhoods.

Clinica Family Health, which has clinics throughout Colorado’s Front Range, laid off 46 people, or about 8% of its staff, in October. It has consolidated its dental program from three clinics to two, closed a walk-in clinic meant to help people avoid the emergency room, and ended a home-visit program for patients recently discharged from the hospital.

Clinica said 37% of its patients on Medicaid before the unwinding began lost their coverage and are now on Clinica’s discount program. This means the clinic now receives between $5 and $25 for medical visits that used to bring in $220-$230.

“If it’s a game of musical chairs, we’re the ones with the last chair. And if we have to pull it away, then people hit the ground,” said CEO Simon Smith.

Stephanie Brooks, policy director of the Colorado Community Health Network, which represents Colorado health centers, said some centers are considering consolidating or closing clinics.

Colorado and Montana have among the nation’s . Officials in both states have defended their Medicaid redetermination process, saying most people dropped from coverage likely no longer qualify, and they point to low unemployment rates as a factor.

In many states, health providers and patients alike have provided examples in which people cut from coverage still qualified and had to spend months entangled in system issues to regain access.

Forte, with RiverStone, said reducing services on the heels of a pandemic adds insult to injury, both for health care workers who stayed in hard jobs and for patients who lost trust that they’ll be able to access care.

“This is so counterproductive and counterintuitive to what we’re trying to do to meet the health care needs of our community,” Forte said.

Â鶹ŮÓÅ Health News correspondent Rae Ellen Bichell in Longmont, Colorado, contributed to this report.

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Out of desperation, her husband scraped together $600 for the first of six rounds of intravenous ketamine therapy at Ketamine Clinics Los Angeles, which administers the generic anesthetic for off-label uses such as treating depression. When Gutilla got into an Uber for the 75-mile drive to Los Angeles, it was the first time she had left her home in Llano, California, in two years. The results, she said, were instant.

“The amount of relief I felt after the first treatment was what I think ‘normal’ is supposed to feel like,” she said. “I’ve never felt so OK, and so at peace.”

For-profit ketamine clinics have proliferated over the past few years, offering infusions for a wide array of mental health issues, including obsessive-compulsive disorder, depression, and anxiety. Although the off-label use of ketamine hydrochloride, a Schedule III drug approved by the FDA as an anesthetic in 1970, was considered radical just a decade ago, now between have cropped up across the nation.

Market researcher Grand View Research pegged industry revenues at $3.1 billion in 2022, and projects them to more than double to $6.9 billion by 2030. Most insurance doesn’t cover ketamine for mental health, so patients must pay out-of-pocket.

While it’s legal for doctors to prescribe ketamine, the FDA hasn’t approved it for mental health treatment, which means that individual practitioners must develop their own treatment protocols. The result is wide variability among providers, with some favoring gradual, low-dosage treatments while others advocate larger amounts that can induce hallucinations, as the drug is psychedelic at the right doses.

“Ketamine is the wild West,” said Dustin Robinson, the managing principal of Iter Investments, a venture capital firm specializing in hallucinogenic drug treatments.

Ketamine practitioners stress that the drug’s emergence as a mental health treatment is driven by a desperate need. Depression is the in the United States for individuals ages 15-44, according to the National Institute of Mental Health, and experience a diagnosable mental disorder in any given year.

Meanwhile, many insurance plans cover mental health services at lower rates than physical health care, . Thus many patients with disorders receive little or no care early on and are desperate by the time they visit a ketamine clinic, said , chair of psychiatry and the behavioral sciences at the University of Southern California’s Keck School of Medicine.

But the revelation that died in part from a large dose of ketamine, along with , has piqued fresh scrutiny of ketamine and its regulatory environment, or lack thereof.

Commercial ketamine clinics often offer same-day appointments, in which patients can pay out-of-pocket for a drug that renders immediate results. The ketamine is administered intravenously, and patients are often given blankets, headphones, and an eye mask to heighten the dissociative feeling of not being in one’s body. A typical dose of ketamine to treat depression, which is 10 times lower than the dosage used in anesthesia, costs clinics about $1, but clinics charge $600-$1,000 per treatment.

Ketamine is still shadowed by its reputation as the party drug known as “Special K”; Siegel’s first grant from the National Institutes of Health was to study ketamine as a drug of abuse. It has the potential to send users down a “K hole,” otherwise known as a bad trip, and can induce psychosis. Research in animals and has shown chronic use of the drug impairs both short- and long-term cognition.

Perry’s death in October raised alarms when the initial toxicology screening attributed his death to the acute effects of ketamine. A December report revealed Perry received infusion therapy a week before his death but that the fatal blow was a high dose of the substance taken with an opioid and a sedative on the day of his death — indicating that medical ketamine was not to blame.

A Variety of Protocols

Sam Mandel co-founded Ketamine Clinics Los Angeles in 2014 with his father, Steven Mandel, an anesthesiologist with a background in clinical psychology, and Sam said the clinic has established its own protocol. That includes monitoring a patient’s vital signs during treatment and keeping psychiatrists and other mental health practitioners on standby to ensure safety. Initial treatment starts with a low dose and increases as needed.

While many clinics follow the Mandels’ graduated approach, the dosing protocol at MY Self Wellness, a ketamine clinic in Bonita Springs, Florida, is geared toward triggering a psychedelic episode.

Christina Thomas, president of MY Self Wellness, said she developed her clinic’s procedures against a list of “what not to do” based on the bad experiences people have reported at other clinics.

The field isn’t entirely unregulated: State medical and nursing boards oversee physicians and nurses, while the FDA and Drug Enforcement Administration regulate ketamine. But most anesthesiologists don’t have a background in mental health, while psychiatrists don’t know much about anesthesia, Sam Mandel noted. He said a collaborative, multidisciplinary approach is needed to develop standards across the field, particularly because ketamine can affect vital signs such as blood pressure and respiration.

The protocols governing Spravato, an FDA-approved medication based on a close chemical cousin of ketamine called esketamine, are illustrative. Because it has the potential for serious side effects, it falls under the FDA’s Risk Evaluation and Mitigation Strategies program, which puts extra requirements in place, said Robinson. Spravato’s REMS requires two hours of monitoring after each dose and prohibits patients from driving on treatment days.

Generic ketamine, by contrast, has no REMS requirements. And because it is generic and cheap, drugmakers have little financial incentive to undertake the costly clinical trials that would be required for FDA approval.

That leaves it to the patient to assess ketamine providers. Clinics dedicated to intravenous infusions, rather than offering the treatment as an add-on, may be more familiar with the nuances of administering the drug. Ideally, practitioners should have mental health and anesthesia expertise, or have multiple specialties under one roof, and clinics should be equipped with hospital-grade monitoring equipment, Mandel said.

Siegel, who has researched ketamine since 2003, said the drug is especially useful as an emergency intervention, abating suicidal thoughts for long enough to give traditional treatments, like talk therapy and SSRI antidepressants, time to take effect. “The solutions that we have and have had up until now have failed us,” Mandel said.

The drug is now popular enough as a mental health treatment that the name of Mandel’s clinic is a daily sight for thousands of Angelenos as it appears on 26 Adopt-A-Highway signs along the 405 and 10 freeways.

And the is accelerating. A drug containing MDMA, known as ecstasy or molly, is expected to receive FDA approval in 2024. A drug with psilocybin, the active ingredient in “magic mushrooms,” could launch as early as 2027, the same year a stroke medicine with the active ingredient of DMT, a hallucinogen, is expected to debut.

Robinson said many ketamine clinics have opened in anticipation of the expanded psychedelic market. Since these new drugs will likely be covered by insurance, Robinson advises clinics to offer FDA-approved treatments such as Spravato so they’ll have the proper insurance infrastructure and staff in place.

For now, Sarah Gutilla will pay out-of-pocket for ketamine treatments. One year after her first round of infusions, she and her husband are saving for her second. In the meantime, she spends her days on her ranch in Llano where she rescues dogs and horses, and relies on telehealth therapy and psychiatric medications.

While the infusions aren’t “a magic fix,” they are a tool to help her move in the right direction.

“There used to be no light at the end of the tunnel,” she said. “Ketamine literally saved my life.”

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The added services would provide care to patients who live in largely rural eastern Iowa, including some of the hundreds previously treated at a University of Iowa clinic, saving them half-day drives to clinics in larger cities like Chicago and Minneapolis.

By June, The Project of the Quad Cities, as the Illinois clinic is called, had hired a provider who specializes in transgender health care. So, Andy Rowe, The Project’s health care operations director, called the clinic’s insurance broker to see about getting the new provider added to the nonprofit’s malpractice policy.

“I didn’t anticipate that it was going to be a big deal,” Rowe said. Then the insurance carriers’ quotes came. The first one specifically excluded gender-affirming care for minors. The next response was the same. And the one after that. By early November, more than a dozen malpractice insurers had declined to offer the clinic a policy.

Rowe didn’t know it at the time, but he wasn’t alone in his frustrating quest.

Nearly half the states for transgender youth. Independent clinics and medical practices located in states where such care is either allowed or protected have moved to fill that void for patients commuting or relocating across state lines. But as the risk of litigation rises for clinics, obtaining malpractice insurance on the commercial marketplace has become a quiet barrier to offering care, even in states with legal protections for health care for trans people. In extreme cases, lawmakers have deployed malpractice insurance regulations against gender-affirming care in states where courts have slowed or blocked anti-trans legislation.

Five months after starting his search for malpractice insurance, Rowe said, he received a quote for a policy that would allow The Project to treat trans youth. That’s when he realized finding a policy was only the first hurdle. He expected the coverage to cost $8,000 to $10,000 a year, but he was quoted $50,000.

Rowe said he hadn’t experienced anything like it in his 20 years working in health care administration.

Insurance industry advocates argue that higher premiums are justified because the rise in legislation surrounding gender-affirming care for minors means clinics are at increased risk of being sued.

“If state laws increase the risk of civil liability for health professionals, premiums will be adjusted accordingly and appropriately to reflect the level of financial risk incurred by the insured,” Mike Stinson, vice president of public policy and legal affairs at the Medical Professional Liability Association, an insurance trade association, said in an emailed statement. If state laws make an activity illegal, then insurance will not cover it at all, he said.

Only a few states have passed laws preventing malpractice insurers from treating gender-affirming care differently than other care. Massachusetts was the first, when that says insurers could not increase rates for health care providers for offering services that are illegal in other states.

Since then, five other states have passed laws requiring malpractice insurers to treat gender-affirming health care as they do any other legally protected health activity: , , New York, , and (similar legislation is pending in ).

“This was a preventative measure, and it was met with full acceptance by both the insured and the insurers,” said Vermont , a Democrat who co-sponsored the state’s law. She said lawmakers consulted with both physicians and malpractice insurance companies to make sure the language was accurate. Insurers just wanted to be able to clearly assess the risk, she said.

Lyons said she hadn’t heard of any providers in Vermont who had trouble with their malpractice insurance before the law was enacted, but she was concerned politics might get in the way of doctors’ ability to offer care. In March 2022, reported that one Texas doctor had stopped offering care because his malpractice provider had stopped covering hormone therapy for minors.

Lawmakers in some states have gone further and revised malpractice provisions to restrict access to gender-affirming care, often while bans on offering that care to trans youth are stalled in court. In 2021, Arkansas became the first state to ban gender-affirming care for trans children. When that ban was held up in court last year, the a new law allowing anyone who received gender-affirming care as a minor to file a malpractice lawsuit up to 15 years after they turn 18.

Similar laws followed in , , and all extending the statute of limitations on filing a malpractice claim anywhere from 15 to 30 years. (Another was introduced but that would have stretched the statute of limitations to the length of the patient’s life.) Typically, malpractice suits within one to three years of injury.

The civil liability that those laws created has forced at least one clinic to stop offering some treatments. The Washington University Transgender Center in Missouri subjected the clinic to “unacceptable level of liability.”

Alejandra Caraballo, a civil rights attorney and clinical instructor at the Harvard Law School Cyberlaw Clinic, said there has been “a concerted effort on the part of anti-trans activists to utilize malpractice insurance as a means of eliminating care.”

She likens the strategy to laws that have long targeted abortion providers by increasing “legal liability to chill a certain type of conduct.”

Anti-trans activists have drawn attention to a small number of “detransitioners,” who have filed lawsuits against the doctors who provided them with gender-affirming care, she said. She believes those lawsuits, filed in such states as California, Nebraska, and North Carolina, will be used to lobby for longer statutes of limitations and to create the perception that liability for providers is increasing.

For independent clinics, like The Project in the Quad Cities, and small medical practices that purchase their malpractice insurance on the commercial marketplace, those tactics are restricting their ability to offer care. Many providers of gender-affirming care are protected from rising premiums such as health centers that receive federal funding, which are covered under the Federal Tort Claims Act, or academic medical centers and Planned Parenthood clinics, which are self-insured. But a small number of independent clinics have been priced out.

In Albuquerque, New Mexico, a state that, like Illinois, has protected access to gender-affirming care, family medicine physician Anjali Taneja said the clinic where she works is running into the same trouble getting coverage.

Casa de Salud, where Taneja is the executive director, has provided gender-affirming care to adults for years, but when the clinic decided to start offering that care to younger patients, insurers wouldn’t issue a malpractice policy. The clinic was quoted “double what we paid a few years ago,” just to cover the gender-affirming care it offers to adults, Taneja said.

The red tape both Casa de Salud and The Project are encountering has prevented treatment for patients. When Iowa’s ban on gender-affirming care took effect Sept. 1, officials at The Project had hoped to offer services to the transgender youth who previously sought care an hour west at the University of Iowa’s LGBTQ Clinic. Instead, Rowe said, patients are making the difficult decision between going without treatment or commuting four hours to Chicago or Minneapolis.

After months of fundraising, The Project has almost enough money to pay for the $50,000 malpractice policy. But, Rowe said, “it’s a tough swallow.”

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A woman lifted a child from the back of an SUV and walked into the store. A dog barked from a black pickup truck before its owner returned with cases of soda. Another woman checked her hair in a convertible’s rearview mirror before shopping.

Each went right by a sign exclaiming “Quick, Easy Health Visits,” with an image of a mobile clinic.

Just after 10 a.m., registered nurse Kimberly French arrived to work at the DocGo mobile clinic parked in the store’s lot. She checked her schedule.

“We don’t have any appointments so far today, but that could change,” French said. “Last night we didn’t have any appointments and three or four people showed up all at one time.”

Dollar General, the nation’s largest retailer by number of stores, with more than 19,000, partnered with New York-based mobile medical services company DocGo to test whether they could draw more customers and tackle persistent health inequities.

Deploying mobile clinics to fill care gaps in underserved areas isn’t a new idea. But pairing them with Dollar General’s ubiquitous small-town presence has been heralded by investment analysts and some rural health experts as a way to ease the health care drought in rural America.

Dollar General’s latest annual report notes that about 80% of the company’s stores are in towns with populations of fewer than 20,000 — precisely where medical professionals are scarce.

Catering to those who want urgent or primary care, the mobile clinics take private insurance as well as Medicaid and Medicare. The company’s website says DocGo’s self-pay rates for patients without insurance or who are out of network. DocGo officials said Tennessee patients may be charged different rates but declined to provide details.

On the ground in Tennessee, primary care doctors and patients are skeptical.

“Honestly, they don’t really grasp, I don’t think, what they’re getting into,” said Brent Staton, a family medicine doctor and the leader of the Cumberland Center for Healthcare Innovation, a statewide organization that helps small-town family care doctors coordinate care and negotiate with insurers, including Medicare.

Michelle Green manages the popular Sweet Charlotte grill about 10 miles south of Dollar General’s most rural test site. Green, who was handing out hamburgers and hand-cut fries during a Saturday rush, said she hadn’t heard of the mobile clinic. She said with a shrug that Dollar General and health care clinics “don’t go together.”

“I wouldn’t want to go to a health care clinic in a parking lot; that’s just me,” Green said, adding that someone might go if “you’re sick and you can’t go anywhere else.”

Bumps in the Road

The Clarksville-area pilot, which launched last fall, is in a federally designated for low-income residents.

About 1,000 patients have been seen in the company’s clinics, either at Dollar General sites or community pop-up events, and some became repeat visitors, according to DocGo. Payment is taken outside on a mobile device and, once inside, patients meet with an on-site staff member, like French, and connect via telehealth on an iPad screen with a physician assistant or nurse practitioner.

The clinic rotates between three Dollar General pilot sites each week. The stores are in the Clarksville area and, early this summer, the van stopped going to the most rural site, near Cumberland Furnace, because of low utilization, according to company leaders. DocGo moved that location’s time slot to busy Fort Campbell Boulevard in Clarksville.

“We do try for months in a given area to see where it makes sense and where it doesn’t,” former DocGo CEO Anthony Capone said in a July interview. “Our goal is to align the supply we have with the demand of the local community.”

Capone, though, said he thought the pilot would work in rural areas when insurers are signed on to refer their members to the mobile clinic. DocGo recently with Blue Cross Blue Shield of Tennessee.

Capone on Sept. 15 after the Albany Times Union reported he lied about having a graduate degree.

Dollar General stores have a “tremendous opportunity” to have “a major impact on health there and really bond themselves as a member of the community,” said Tom Campanella, the healthcare executive-in-residence at Baldwin Wallace University, who has managed mobile clinics in rural places.

Near tiny Cumberland Furnace, south of Clarksville, William “Bubba” Murphy stopped on his way into a Dollar General, paused to wave and holler hello to friends getting out of their cars, and shared that multiple family members — his sister-in-law, nephew, and niece’s boyfriend — used and liked “the little clinic on wheels.”

“We don’t have to go to town and fight all that traffic,” he said. “They come to us. That’s a wonderful thing. It helps a lot of people.”

Over on busy Fort Campbell Boulevard in Clarksville, Marina Woolever, a mother of three, said she might use the clinic if she didn’t have insurance. Natural health professional Nichole Clemmer glanced toward the clinic and called it a “ploy” to make more money.

Jefferies lead equity analyst Corey Tarlowe, who follows discount retailers, said the clinics will help “democratize” access to health care and simultaneously boost traffic to Dollar General stores.

With its rapid growth in recent years, Dollar General has faced accusations that its stores local grocery stores and other businesses, reduce employment, and the creation of food deserts. More recently, the U.S. Labor Department said the chain “continues to discount safety” for employees as it has piled up more than $21 million in .

Crystal Luce, senior director of public relations for Dollar General, said the company believes each new store provides “positive economic benefits,” including new jobs, low-cost products, and its literacy foundation. On the federal fines, Luce said Dollar General is “committed to providing a safe work environment for its associates and shopping experience for its customers.” The company declined to provide an interview.

The DocGo pilot, she wrote, is intended to “complement” the DG Wellbeing initiative, which is a corporatewide push. Dollar General wants to increase “access to basic health care products and, ultimately, services over time, particularly in rural America,” Luce wrote.

States away, DocGo is under fire for a no-bid contract to provide housing, busing, and other services for asylum-seekers in New York. State Attorney General Letitia James is levied by migrants under the company’s care. In August, DocGo officials said claims aired by sources in that first reported the problems were “not reflective of the overall scope and quality” of the services the company has provided.

The company’s pilot with Dollar General is “supported with funding from the state of Tennessee,” DocGo’s Capone said during the company’s . The Dollar General partnership is DocGo’s Rapid Reliable Testing LLC submitted to the state, according to records Â鶹ŮÓÅ Health News obtained through public information requests.

In the grant filing, DocGo listed Dollar General along with other organizations as “trusted messengers” in building vaccine awareness.

Dollar General declined to respond to a question about its involvement in the grant. Instead, Luce stated, “We continue to test and learn through the DocGo pilot.”

‘Relational Care’

The goal of , funded by the Centers for Disease Control and Prevention and distributed by the Tennessee Department of Health, is to administer covid-19 vaccines. In a written response provided by DocGo’s marketing director, Amanda Shell Jennings, the company said, “Dollar General has no involvement with the TN Department of Health grant funding or allocations.”

The grant covers storage and maintenance of covid-19 vaccines on the DocGo mobile clinics, Jennings’ statement said, adding that, as of September, DocGo has held 41 vaccine events and provided 66 vaccines to rural Tennesseans.

Lulu West, 72, was visiting a friend at the Historic Cumberland Furnace Iron Museum when she stopped to consider the mobile clinic. West said she would rather go to her primary care doctor.

“When you say mobile clinic outside a Dollar General it just kind of has a connotation that you may not be comfortable with. You know what I mean?” she said.

That kind of response doesn’t surprise Carlo Pike, a doctor who for years has practiced family medicine in Clarksville. He said he’s not worried about the competition because providing primary care is about developing relationships.

“If I can do this relationship right,” Pike said, “maybe we can keep you from getting a [blood] sugar of 500 [mg/dL] or from Grandpa climbing up a ladder and trying to fix something he has no business with and falling off and breaking his leg.”

Staton said the Cumberland Center for Healthcare Innovation, his accountable care organization, has saved Medicare and Medicare Advantage companies more than $100 million by focusing on preventive care and reducing hospitalizations and emergency visits for patients.

“We’re just small rural primary care docs doing our jobs with a process that works,” Staton said. In another interview, Staton called it “relational care.”

DocGo surveyed its patients and found that 19% of them did not have a primary care physician or hadn’t seen theirs in more than a year. In the written responses Jennings provided, DocGo said it follows up with every patient after the initial visit, offers telemedicine support between visits, and provides ongoing preventive care on a regular schedule.

But despite its outreach, DocGo struggled to get a foothold in rural Cumberland Furnace.

Lottie Stokes, the president of the community center in Cumberland Furnace, said DocGo’s team had “called and asked to come down here.” Stokes said she would rather use the local emergency medical technicians and firefighters, who she knows are “legit.”

Her father-in-law, Bobby Stokes, who’s nearly 80 years old, said he used the mobile clinic before it moved locations.

His wife couldn’t breathe. They pulled into the parking lot and climbed onto the van.

“We wasn’t in there five minutes,” he said. “They done the blood pressure test and what they need to do and put her in the car and said, ‘Get her to the hospital, to the emergency room.’”

The DocGo staff, he said, did not ask for payment: “Nothing.”

“They were more concerned with her than they were with I guess getting their money,” he said, adding that his wife is doing well now. “They told me to get there, and I took them at their word. My car runs fast.”

Â鶹ŮÓÅ Health News correspondent Brett Kelman contributed to this report.

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

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