HAY SPRINGS, Neb.— The sun was just warming the horizon as Mark Pieper left his house near his cattle ranch on a crisp February morning.

It’s not unusual for the rancher to wake up early to tend to livestock, but at 5:45 a.m. this day his cattle wouldn’t come first. For the past 3½ years, three days a week, Pieper has made an early-morning commute to get dialysis at the nearest hospital.

Pieper lives outside Hay Springs, which has 599 residents, according to a sign at the edge of town. He makes sure not to forget his chocolate-brown cowboy hat before starting up his pickup truck for the half-hour drive to Chadron.

That February morning was one of his last dialysis sessions there before the hospital shuttered the service at the end of March.

“I guess I’ll just bloat up and die in a month,” Pieper remembered thinking when he learned the center was closing, eliminating the only option near his home.

He needs dialysis to survive after cancer treatment damaged his kidneys.

Pieper and 16 other patients relied on Chadron Hospital for the life-sustaining therapy that filters waste and fluid from their blood — a job their failing kidneys could no longer do. Treatment lasts about four hours.

The closure is just one example of the long decline of health care services in rural America, where people have higher rates of many chronic conditions but less access to care than elsewhere.

The Trump administration promised to address this problem, when it launched the $50 billion federal Rural Health Transformation Program in September. It may not be enough to stop the trend.

“[President Donald] Trump says he is going to help the rural health care,” Pieper said. Dialysis “is one thing that we really need here.”

Some patients have moved to live closer to care, including several nursing home residents. Their new facilities may be farther from their families.

Others are making long drives to dialysis centers. Pieper eventually found treatment in Scottsbluff, which, with about 14,000 residents, is the biggest city in the rural Panhandle region of western Nebraska. The hour-and-a-half drive will triple his time on the road to more than nine hours each week.

Jim Wright and his wife reduced their drive time — but are spending more money — by renting a small home near Rapid City, South Dakota, and living there on weekdays so he can get dialysis. Wright said he understands that rural hospitals face financial challenges.

“But we’re talking about something that’s lifesaving. It’s not a matter of, ‘Oh, I would like to be there’” getting treatment, he said. “It’s a case that if you don’t, you die.”

An Influx of Money That’s Out of Reach

Jon Reiners, CEO of the independent, nonprofit Chadron Hospital, wrestled with the decision to end dialysis services. He and several patients said that the closure was announced as the $219 million the state will receive in first-year funding from the .

But the five-year program is aimed at exploring new, creative ways to improve rural health, not to help existing services stay afloat. States can use only up to 15% of their funding to pay providers for patient care.

At least 11 states — Nebraska is not among them — have mentioned using funding for rural dialysis programs, according to a Â鶹ŮÓÅ Health News review of applications. Their ideas include starting a mobile dialysis unit and helping people get treatment at home or in long-term care facilities.

Reiners said Chadron Hospital lost $1 million a year on its dialysis service due to low reimbursement rates that didn’t cover operational costs.

The facility is a critical access hospital, a designation that allows certain small, mostly rural hospitals to get increased reimbursement rates for their Medicare patients. While most of the affected patients were on Medicare, the critical access program doesn’t cover outpatient dialysis, Reiners said.

Reiners said the hospital worked for more than a year to find solutions, such as reaching out to four private companies to potentially take over the center. But he said they all passed after realizing they would lose money.

Nephrologist Mark Unruh said the dialysis closure in Chadron reflects a wider trend of staffing and funding challenges.

“You do end up in situations where you have people who are displaced like this, and it’s just sad,” said Unruh, chair of the Internal Medicine Department at the University of New Mexico.

People in rural America face significant disparities in kidney health and treatment, published in 2024 in the American Journal of Nephrology. They’re and face after diagnosis, according to data from the National Institutes of Health.

The best way to address this is to focus on prevention, Unruh said. He pointed to a that helps primary care doctors in rural and other underserved areas prevent end-stage renal failure.

Another idea, Unruh said, is boosting the rate of kidney transplantation for rural patients. He’s looking at whether it’s helpful to “fast-track” tests patients need to get approved for a transplant by scheduling all of them over a couple of days to limit travel time.

Unruh said the U.S. health system also needs to recruit more staff who can train patients and their caregivers to administer dialysis at home.

Exploring the Option of Home Dialysis

Rural dialysis patients are more likely than urban ones to get home dialysis, according to . In 2023, the rate was nearly 18% for rural patients and about 14% for urban ones.

One type of home dialysis requires surgery to get a catheter placed in the abdomen and . The other kind requires . The nearest facility to Chadron that offers training for the first option is in Scottsbluff. The nearest that offers training for the latter kind is three hours away in Cheyenne, Wyoming.

Pieper said doctors told him he’s not a candidate for home dialysis or a transplant. The Panhandle has a nonprofit, rural transit system, but its schedule won’t work for Pieper. He said that leaves him with no choice but to get treatment in Scottsbluff, a 200-mile round trip.

It takes Linda Simonson even longer — more than four hours round trip — to drive her husband, Alan, from their ranch to his treatment in Scottsbluff.

Linda sat in the waiting room with a yellow legal pad during one of Alan’s final treatments in Chadron. The paper was scrawled with phone numbers of politicians to call and driving distances to dialysis centers in the region. She said facilities closer to their ranch either don’t have room for new patients or lack good spots along the route to take a driving break in bad weather.

“It’s just unreal,” she said.

She said even if Alan took a bus, she’d have to ride along to support him during the trip and his treatment.

Jim and Carol Wright, the couple staying near Rapid City on weekdays, said they can’t afford to rent a second home forever. Their weekly commute is already taking a physical and emotional toll. They said they’ll eventually have to move to a bigger city, giving up the house they love in the scenic Nebraska National Forest.

Carol said she feels for the dialysis staffers in Chadron, who are wonderful.

“It just doesn’t seem right to sacrifice one unit that’s so vital,” she said while standing next to a pile of moving boxes stacked inside their rental.

The Wrights wrote letters to politicians and hospital leaders to share their concerns and ideas for keeping the unit open, including using the federal rural health funding.

Simonson said she spoke with aides for the governor and her state representatives but none of the leaders called her back.

“It feels like they don’t know that we exist at this end of the state,” she said.

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After his mom finally saw a specialist in Glasgow, about an hour away, she was diagnosed with stage 4 colon cancer, Bighorn said.

Now, 16 years after his mother’s death, Bighorn has access to regular screenings for cancer and other specialty care that she didn’t have, through a health insurance program the Fort Peck Tribes created in 2016. The program, which covers most of the costs for the roughly 1,000 tribal citizens enrolled, is among a growing number of tribally sponsored health insurance programs.

Such programs vary by tribe, but they essentially screen and enroll people living within tribal boundaries in Affordable Care Act marketplace plans. They allow participating Native Americans flexibility to go to outside doctors and clinics when care through the Indian Health Service is unavailable.

“I’d be in a bind otherwise,” said Bighorn, a 65-year-old tribal game warden and member of the Dakota community.

But the Fort Peck Tribes now limit who has access to that coverage. Other tribal organizations that offer Native Americans similar coverage are struggling with rising costs, too.

The financial crunch began when congressional lawmakers allowed enhanced subsidies under the Affordable Care Act to expire on Dec. 31. Those tax credits, created under the Biden administration during the covid-19 pandemic, expanded subsidized health coverage for millions of people. By late 2025, ACA plans saw about 24 million enrollees, more than twice the number of pre-pandemic annual sign-ups. The cost of coverage shot up for most of those people as the expanded subsidies expired, and enrollment has dropped by , according to federal health officials.

The subsidies had also boosted tribal health insurance programs, like the one Bighorn is enrolled in. The programs pay the price of each person’s share of premiums after subsidies, and the coverage lowers patients’ treatment costs. Now that premium prices have ballooned, so have tribes’ costs.

Rae Jean Belgarde, who directs Fort Peck Tribes’ program, said the higher costs leave the tribes with one option at this point: “Start limiting who gets help.”

The tribes are helping people shift to other insurance options and, in some cases, find state programs to cover their premiums. Tribal leaders also sent a letter to Montana’s all-Republican congressional delegation asking them to support extending the subsidies.

“Our program is saving lives,” the letter read. Belgarde said she didn’t know whether the lawmakers responded.

Scrambling for Solutions

U.S. a temporary extension of the enhanced subsidies in January. But that measure . Lawmakers are scrambling for an alternative after President Donald Trump an extension if a bill reaches his desk. On Jan. 15, the president released that includes creating savings accounts for people to pay their health costs — an idea Senate Republicans as an alternative to the subsidies.

A.C. Locklear, CEO of the , a nonprofit that works to improve health in Native communities, said tribes are “looking at ways to cut back just as much as everyone else.”

Native Americans as a group continue to face disproportionately high rates of chronic diseases. Their median age at death is than that of white Americans.

“Reducing access to even just general primary care has a significant impact on those disparities,” Locklear said.

Tribal leaders have said letting the subsidies expire further undermines the federal government’s duty to ensure adequate care for Native Americans.

In exchange for taking tribal land through colonization, the U.S. government made long-standing promises to provide for the health and well-being of tribes. Native Americans are guaranteed free health care at clinics and hospitals operated or funded by the Indian Health Service. But that agency’s chronic underfunding has created massive blackouts in care. It sometimes pays for patients’ outside care through its Purchased/Referred Care program, but that’s limited too. Due to , the agency prioritizes which treatments it will pay for.

To help fill the coverage gaps, some tribal nations have built their own health insurance programs. When tribes pay health premiums, clinics and hospitals in their areas can bill for services that might otherwise go unpaid. Some tribes have leveraged that money to expand services.

“I don’t see tribes getting rid of these programs,” Locklear said. “But it will drastically shift how much tribes can really put back in their community.”

For example, Tuba City Regional Health Care Corp., in northern Arizona within the Navajo Nation, is unique in providing comprehensive cancer treatment on a reservation, Locklear said. The corporation, he said, estimates its costs to cover patients this year are increasing by roughly 170% to nearly $38,000 per month without the enhanced subsidies.

One of the newer programs is on the Blackfeet reservation in northwestern Montana, where basic health services can be hard to find. Medical visits are often offered on a first-come, first-served basis, and services vanish when staff positions go unfilled, said Lyle Rutherford, a Blackfeet Nation council member.

“Some of it is just getting a regular eye appointment, or a primary care appointment,” Rutherford said.

The tribe has been slowly building its health insurance program since launching it in 2024. Rutherford said the enhanced subsidies made that possible. Fewer than 400 people are enrolled out of an estimated 3,000 who qualify. In January, the tribe paused the employer-sponsored coverage portion of its insurance program, which at the time included 52 people.

He said tribal leaders are seeking extra funding to keep the program afloat, and he hopes Congress finds a solution.

Lives on the Line

The impact goes beyond tribes’ insurance programs. The Urban Institute, a Washington, D.C.-based economic and social policy research nonprofit, will become uninsured in 2026 due to the higher costs.

Patients at the Oyate Health Center in Rapid City, South Dakota, are already reporting sky-high premium increases for ACA plans. CEO Jerilyn Church said it’s too soon to know how many will forgo coverage. But she said more uninsured patients would further strain the IHS Purchased/Referred Care program — with officials raising the bar for how sick patients must be to cover care outside of tribal health sites.

“There will be people that will not be able to get the care they need,” Church said, adding that could translate to “people losing their lives.”

Bighorn, the game warden on the Fort Peck Reservation, is among those still covered by the tribes’ insurance program. He has put it to use.

Soon after enrolling, Bighorn needed two hip replacements, surgeries that require off-reservation care and are ranked as low-priority procedures by the Indian Health Service. Bighorn said that in pre-surgery tests, specialists found the cause for his long-standing, dangerously high blood pressure. The diagnosis: untreated lifelong asthma and sleep apnea.

“I was a miserable man, tired all the time,” he said.

Without the tribe’s coverage, Bighorn may have eventually gotten those diagnoses but said it would have likely taken years to get help through the Indian Health Service. That would have meant getting much sicker before receiving care.

Â鶹ŮÓÅ Health News correspondent Arielle Zionts contributed to this report.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? to contact Â鶹ŮÓÅ Health News and share your story.

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Then 25 years old and six months pregnant, she drove herself to the emergency room in Ronan, Montana, on the Flathead Indian Reservation, where an ambulance transferred her to a larger hospital 60 miles away in Missoula. Once she arrived, the staff couldn’t detect her baby’s heartbeat. Swaney began to bleed heavily. She delivered a stillborn baby and was hospitalized for several days. At one point, doctors told her to call her family. They didn’t expect her to survive.

“It certainly changed my life — the experience — but my life has not been a bad life,” she told Â鶹ŮÓÅ Health News.

Though her experiences were nearly 50 years ago, Swaney, a member of the Confederated Salish and Kootenai Tribes, said Native Americans continue to receive inadequate maternal care. The data appears to support that belief.

In 2024, the most recent year for which data for the population is available, Native American and Alaska Native people had the among major demographic groups, according to the Centers for Disease Control and Prevention.

In response to this disparity, Native organizations, the CDC, and some states are working to boost tribal participation in state maternal mortality review committees to better track and address pregnancy-related deaths in their communities. Native organizations are also considering ways tribes could create their own committees.

State maternal mortality review committees investigate deaths that occur during pregnancy or within a year after pregnancy, analyze data, and issue policy recommendations to lower death rates.

According to 2021 CDC data, compiled from 46 maternal mortality review committees, 87% of maternal deaths in the U.S. were deemed preventable. Committees reported that , deaths among Native American and Alaska Native people were considered preventable.

Our matriarchs, our moms, are what carries a nation forward.

Kim Moore-Salas

State committees have received federal money through the Preventing Maternal Deaths Act, which President Donald Trump signed in 2018.

But the money is scheduled to dry up on Jan. 31, when the short-term spending bill that ended the government shutdown expires.

Funding for the committees is included in the Labor, Health and Human Services, Education, and Related Agencies for fiscal year 2026. That bill must be approved by the House, Senate, and president to take effect.

Native American leaders said including members of their communities in maternal mortality review committee activities is an important step in addressing mortality disparities.

In 2023, tribal leaders and federal officials met to discuss four models: a mortality review committee for each tribe, a committee for each of the 12 Indian Health Service administrative regions, a national committee to review all Native American maternal deaths, and the addition of Native American subcommittees to state committees.

Whatever the model, tribal sovereignty, experience, and traditional knowledge are important factors, said Kim Moore-Salas, a co-chair of the Arizona Maternal Mortality Review Committee. She’s also the chairperson of the panel’s American Indian/Alaska Native mortality review subcommittee and a member of the Navajo Nation.

“Our matriarchs, our moms, are what carries a nation forward,” she said.

Mental health conditions and infection were the leading underlying causes of pregnancy-related death among Native American and Alaska Native women as of 2021, according to the CDC report analyzing data from 46 states.

The CDC found an estimated 68% of pregnancy-related deaths among Native American and Alaska Native people happened within a week of delivery to a year postpartum. The majority of those happened between 43 days and a year after birth.

The federal government has a responsibility under signed treaties to provide health care to the 575 federally recognized tribes in the U.S. through the Indian Health Service. Tribal members can receive limited services at no cost, but the agency is .

A that analyzed data from 2016 to 2020 found that approximately 75% of Native American and Alaska Native pregnant people didn’t have access to care through the Indian Health Service around the time of giving birth, meaning many likely sought care elsewhere. More than 90% of Native American and Alaska Native births occur outside of IHS facilities, . For those who did deliver at IHS facilities, a from the Department of Health and Human Services’ Office of Inspector General found that 56% of labor and delivery patients received care that did not follow national clinical guidelines.

The 2024 study’s authors also found that members of the population were less likely to have stable insurance coverage and more likely to have a lapse in coverage during the period close to birth than non-Hispanic white people.

Cindy Gamble, who is Tlingit and a tribal community health consultant for the American Indian Health Commission in Washington, has been a member of the state’s maternal mortality review panel for about eight years. In the time she’s been on the state panel, she said, its composition has broadened to include more people of color and community members.

The panel also began to include suicide, overdose, and homicide deaths in its data analysis and added racism and discrimination to the risk factors considered during its case review process.

Solutions need to be tailored to the tribe’s identity and needs, Gamble said.

“It’s not a one-size-fits-all,” Gamble said, “because of all the beliefs and different cultures and languages that different tribes have.”

Gamble’s tenure on the state committee is distinctive. Few states have tribal representation on maternal mortality review committees, according to the National Indian Health Board, a nonprofit organization that advocates for tribal health.

The National Council of Urban Indian Health is also the participation of Urban Indian health organizations, which provide care for Native American people who live outside of reservations, in state maternal mortality review processes. As of 2025, the council had connected Urban Indian health organizations to state review committees in California, Kansas, Oklahoma, and South Dakota.

Native leaders such as Moore-Salas find the current efforts encouraging.

“It shows that state and tribes can work together,” she said.

In March 2024, Moore-Salas became the first Native American co-chair of Arizona’s Maternal Mortality Review Committee. In 2025 she and other Native American members of the committee developed guidelines for the American Indian/Alaska Native subcommittee and reviewed the group’s first cases.

The subcommittee is exploring ways to make the data collection and analysis process more culturally relevant to their population, Moore-Salas said.

But it takes time for policy changes to create widespread change in the health of a population, Gamble said. Despite efforts around the country, other factors may hinder the pace of progress. For example, maternity care deserts are growing nationally, caused by rapid hospital and labor and delivery unit closures. Health experts have that upcoming cuts to Medicaid will hasten these closures.

Despite her experience and the ongoing crisis among Native American and Alaska Native people, Swaney hopes for change.

She had a second complicated pregnancy soon after her stillbirth. She went into labor about three months early, and the doctors said her son wouldn’t live to the next morning. But he did, and he was transferred about 525 miles away from Missoula to the nearest advanced neonatal unit, in Salt Lake City.

Her son, Kelly Camel, is now 48. He has severe cerebral palsy and profound deafness. He lives alone but has caregivers to help with cooking and other tasks, said Swaney, 73.

He “has a good sense of humor. He’s kind to other people. We couldn’t ask for a more complete child.”

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Â鶹ŮÓÅ Health News senior correspondent Julie Appleby discussed changes to the Affordable Care Act in 2026 and how enrollees may be affected on WUNC’s Due South on Jan. 7.

• (begins 33:00).
• Read Appleby’s “.”

Â鶹ŮÓÅ Health News South Dakota correspondent Arielle Zionts discussed rural health funding on South Dakota Public Broadcasting on Dec. 22.

• Read Zionts’ “,” co-reported with Sarah Jane Tribble.

Â鶹ŮÓÅ Health News senior correspondent Renuka Rayasam discussed ACA subsidy expiration on WUGA’s The Georgia Health Report on Dec. 19.

• Read Julie Appleby’s “.”

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

Â鶹ŮÓÅ Health News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

Â鶹ŮÓÅ Health News South Dakota correspondent Arielle Zionts contributed to this report.

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The outbreaks are fueled by falling vaccination rates, fading immunity, and delays in public health tracking systems, according to interviews with state and federal health officials. Babies too young to be fully vaccinated are most at risk.

“Pertussis cases increase in a cyclical fashion driven by waning immunity, but the size of the outbreak and the potential for severe outcomes in children who cannot be vaccinated can be mitigated by high coverage and good communication to folks at risk,” said Demetre Daskalakis, a former head of the Centers for Disease Control and Prevention’s immunization program, who resigned in August.

Before the first pertussis vaccine became available in the , whooping cough was one of the most common childhood diseases and a in the United States. Today, children get a series of DTaP shots (full-dose version) starting at 2 months old, and teens and adults receive a Tdap booster (lower-dose version) every 10 years. (Both vaccines target diphtheria and tetanus in addition to pertussis.)

Until recently, had received four doses of the DTaP vaccine by age 2, and case rates were controlled. But vaccine coverage has declined since the covid pandemic and increases in state nonmedical exemptions have widened immunity gaps, which is when the proportion of individuals who are immune falls below the level needed to contain spread.

Texas logged in 2024. By October 2025, the state had . National numbers are just as stark: In the first three months of 2025, the U.S. tallied — four times last year’s pace and 25 times 2023’s. Several states are posting their highest case totals in a decade, and outbreaks from Louisiana to South Dakota to Idaho make clear this surge isn’t regional. It’s everywhere.

Key Factors Behind These Numbers

Texas lawmakers recently passed a law that for parents to claim nonmedical exemptions from school vaccine requirements by allowing them to download exemption forms online. These forms now go straight to schools, not health departments, making the exemptions harder to track.

Dallas County Health and Human Services Director Phil Huang said the full impact of the new exemption rule is not yet known because it began this school year, but he expects it will make school-level vaccination rates fall even more.

He’s already noted a dramatic drop in vaccinations. Normally, during back-to-school season, “our whole front downstairs area is packed,” he said. “We did not see that this year.”

Huang believes fear of immigration enforcement may be keeping at least some families, especially Hispanic families, from getting vaccinated. Dallas County is about 40% Hispanic. “We think that a lot of them are deterred by the ICE activity,” he said, referring to Immigration and Customs Enforcement.

More complications: These vaccines protect against severe disease, but protection against infection fades over time, as is the case with the covid and influenza vaccines.

The U.S. switched in the 1990s from whole-cell pertussis vaccines to “acellular” ones, which cause fewer side effects but do not last as long. Because more adults today than in the past received the acellular vaccine as children, many have lost immunity over time and may unknowingly pass the infection to babies.

Babies Face the Greatest Risk

Whooping cough is especially dangerous for infants under a year old. Some stop breathing during coughing fits. Many need hospital care, about of whom develop pneumonia, and about 1% of whom die.

Because of this high risk, the CDC urges pregnant women to get a . This allows the mother’s antibodies to pass to the baby before birth.

Health officials once promoted “cocooning,” vaccinating all family members and caregivers around the baby, but that strategy was hard to carry out in real life and is . Vaccination of pregnant women and babies at 2 months of age remains the strongest protection.

Better Testing Finds More Cases

Modern is also than in the past. Many clinics now routinely use this lab-based technology to test for several respiratory infections at once, including pertussis. Ten years ago, these panels were uncommon.

CDC experts say this explains part of the rise in case counts. But the large number of infant hospitalizations and the size of state outbreaks show that true transmission has also increased.

A Growing Worry: Antibiotic Resistance

Doctors normally treat pertussis with , such as erythromycin, azithromycin, and clarithromycin. These drugs work best early in the illness and help stop spread. Another drug, trimethoprim-sulfamethoxazole, is an option for some older infants and adults.

But has become common abroad, especially in China, and recent reports show resistance rising in Peru. In the U.S., resistant cases have been rare.

CDC officials warn that resistant strains could spread more easily through international travel. Because treatment options are limited, especially for very young infants, health workers are watching this closely.

Huang said macrolide resistance has not been seen yet in Dallas County. But he is aware of the national concern.

What Happens Now

The resurgence of whooping cough has no single cause. Instead, several problems are occurring at once: falling vaccine coverage, only of pregnant women receiving Tdap, waning immunity, improved testing, and early signs of antibiotic resistance.

Health experts say solutions must match the problem’s complexity.

Across the nation, clinicians are being told to have a higher suspicion for pertussis when they see patients, especially children or caregivers of newborns with a persistent cough or coughing fits followed by vomiting. Babies who stop breathing or turn blue need immediate care.

Obstetricians are encouraged to discuss Tdap during every pregnancy. Pediatricians and family doctors are urged to check booster status for teens and adults.

Several states have issued health advisories over the past two years, including , which has in both 2024 and 2025 urging clinicians to stay vigilant.

Huang said Dallas County is trying to rebuild public health outreach programs that were cut when covid funding ended. But staffing is still limited. “There’s just a lot of different things that are making it more difficult,” he said.

He also noted that Dallas County now receives immunization registry data only once a month, rather than daily, making it harder to track vaccine coverage. “We don’t have that yet. … It’s not real time,” he said.

Protecting the Youngest

As the holiday season approaches, experts urge families with newborns to take extra care:

• Ensure infants and children are up to date with their childhood vaccines and that everyone in the family is up to date with their vaccines for influenza, covid, and RSV, or respiratory syncytial virus.
• Keep sick visitors away.
• Seek care quickly if an infant has a cough or pauses breathing.

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Kopplin, a physician assistant who works with seniors, low-income people, and mental health patients in the rural Black Hills, shared her thoughts at a meeting hosted by state officials.

South Dakota’s leaders did a “good job of diving in” and asking questions to get “deeper at the root of the problem,” she said.

Kopplin later told Â鶹ŮÓÅ Health News how one of her rural patients recently missed two appointments because of a broken-down car and no access to public transportation.

Nationwide, health care workers like Kopplin and thousands of others — from patient advocates to technology executives — flocked to town halls or online portals during the seven weeks state leaders had to craft and submit their applications for the Rural Health Transformation Program to the federal Centers for Medicare & Medicaid Services. That deadline was Nov. 5.

“We will give $50 billion away by the end of the year,” CMS Administrator Mehmet Oz said Nov. 6 at a Milken Institute event in Washington. He said all 50 states had submitted applications.

The program will “allow us to right-size the health care system,” Oz said, adding that innovations from the rural work “will spill over to suburban and urban America as well.”

Among applications and summaries publicly shared by states, themes include workforce development, telehealth, and access to healthy food. In Kansas, leaders want to build a “Food is Medicine” program. Wyoming officials propose a new program called “BearCare,” a state-sponsored health insurance plan that patients could use only after medical emergencies.

But many health policy experts and Democrats are raising alarms that the Republican-backed program will become a “slush fund.” Critics worry it will fail to reach the small-town patients they say need it most, especially as states face nearly a trillion dollars in Medicaid spending reductions over the next decade. Medicaid, a joint federal-state program, serves nearly rural Americans.

“The status quo is tremendous distress in rural communities,” said Heather Howard, a professor of the practice at Princeton University and director of the university’s State Health and Value Strategies program, which is tracking the rural health fund. The new funding won’t be enough to offset the Medicaid losses, she said.

Congressional Republicans added the five-year, $50 billion Rural Health Transformation Program as a last-minute sweetener to President Donald Trump’s massive tax-and-spending legislation. The move helped win support for the One Big Beautiful Bill Act from conservative holdouts who worried that the Medicaid cuts in the bill would harm rural hospitals in their states.

In Montana, which hosted an online public forum before submitting its application, a nonprofit director pitched youth peer support as a way of battling high suicide rates. A registered nurse asked state leaders to “think maybe even bigger” and consider statewide universal health care.

And in Georgia, a technology-focused chain of primary care clinics that serves seniors proposed expanding its operations into that state in its online public comment. A rural grant writer asked for “safe and stable housing.”

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be doled out according to a points-based system. Of , $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that, in part, mirror the Trump administration’s “” objectives.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who a federal watchdog agency to investigate the fairness and implementation of the fund. Taylor Harvey, a Wyden aide, said the Government Accountability Office has confirmed it will investigate.

According to , no less than a quarter of states with an approved application may share the second half of the funding each fiscal year, CMS spokesperson Catherine Howden said. The agency plans to publish summaries of approved state projects, .

A handful of conservative-leaning states — including Texas, Arkansas, Louisiana, and Oklahoma — have already instituted regulatory and legislative initiatives, such as prohibiting “non-nutritious” foods in benefit programs, that in the program application process.

Michael Chameides, a county supervisor in rural New York, said he fears the money could “be used in ways that would hurt certain states or reward certain states.” Chameides is also the communications and policy director with the Rural Democracy Initiative, a national advocacy organization that released last month.

Edwin Park, a research professor at Georgetown University’s Center for Children and Families, said federal lawmakers gave Oz and his agency “really excessive discretion” when awarding the money.

Federal administrators have added rules that aren’t within the statute that created the program, Park said. For example, its application guidelines say states cannot use more than 15% of their funding to pay providers for patient care — payments that are expected to take a hit due to the Medicaid cuts.

Georgetown’s health policy experts and Democrats aren’t the only ones with concerns. and in Ohio worry the money will go to large health systems instead of smaller, independent hospitals that serve people within their rural communities.

CMS’ Oz repeated the idea of getting “big hospitals to adopt smaller institutions” at the Washington gathering after applications were filed. He used similar language at a rural health summit hosted by South Dakota-based Sanford Health. “How do we get big hospitals to adopt smaller hospitals? Not to take them over, but to keep them viable by giving them good telehealth services, specialty support, radiology support,” he said at the October event.

Sanford owns or manages dozens of hospitals and hundreds of clinics and long-term care centers, as well as a health insurance company. The system reported about $81 million in operating income during the first six months of fiscal year 2025, according to .

Last year, Sanford opened a “command center” for its systemwide telehealth initiative. It launched a telehealth expansion in 2021 and offers virtual care for 78 medical specialties, Sanford President and CEO Bill Gassen said.

“We’ve tried to imagine, what if that number doubles?” Gassen said. The startup costs for telehealth are high, he said, and the rural fund could be a unique opportunity “for us to make virtual care available to more patients, to more communities, to more hospitals and health systems across the country.”

Gassen, who is set to chair the American Hospital Association in 2027, said Sanford leaders have met with state and federal officials, including Oz, whom he’s known for years, and Chris Klomp, a top deputy at CMS and a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

The word “telehealth” appears 36 times in the rural health program’s 124-page application guidelines. But Don Robbins Jr., chief executive of a small hospital on the Illinois-Kentucky border, chuckled at the idea of using the funding for that purpose.

Robbins, whose 25-bed Massac Memorial Hospital averages five to seven patients in its beds each day, said his hospital does not regularly offer telehealth. Even if it did, he said, patients living more than a mile outside of town couldn’t use it because they don’t have a good internet connection.

The small hospital reported a $31,314 loss in September, Robbins said. “I think if we get anything out of it,” Robbins said of the rural health program, “we’ll be lucky.”

Kopplin, the physician assistant who attended the South Dakota meeting, is cautiously optimistic about the rural health fund. She views it as a wonderful chance for states to test out ideas and learn from what works and what doesn’t.

But “in a lot of ways this bill is going to be a band-aid approach” for rural health, she said. “It’s not really going to fix the problem.”

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Despite progress in some mostly blue states this year, however, recent setbacks in more conservative legislatures underscore the persistent challenges in strengthening patient protections.

Bills to shield patients from medical debt failed this year in Indiana, Montana, Nevada, South Dakota, and Wyoming in the face of industry opposition. And advocates warn that states need to step up as millions of Americans are expected to lose insurance coverage because of President Donald Trump’s tax and spending law.

“This is an issue that had been top of mind even before the change of administrations in Washington,” said Kate Ende, policy director of Maine-based Consumers for Affordable Health Care. “The pullback at the federal level made it that much more important that we do something.”

This year, Maine joined a growing list of states that have barred medical debt from residents’ credit reports, a key protection that can make it easier for consumers to get a home, a car, or sometimes a job. The with bipartisan support.

An in the U.S. have some form of health care debt.

The federal government was poised to bar medical debt from credit reports under in the waning days of former President Joe Biden’s administration. That would have helped an estimated 15 million people nationwide.

But the Trump administration did not defend the regulations from lawsuits brought by debt collectors and the credit bureaus, who argued that the Consumer Financial Protection Bureau exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

Now, only patients in states that have enacted their own credit reporting rules will benefit from such protections. More than a dozen have such limits, including California, Colorado, Connecticut, Minnesota, New York, and Vermont, which, like Maine, enacted a ban this year.

Still more states have passed in recent years, including caps on how much interest can be charged on such debt and limits on the use of wage garnishments and property liens to collect unpaid medical bills.

In many cases, the medical debt rules won bipartisan support, reflecting the overwhelming popularity of these consumer protections. In Virginia, the state’s conservative Republican governor this year restricting wage garnishment and capping interest rates.

And several GOP lawmakers in California joined Democrats to make it easier for patients to access financial assistance from hospitals for big bills.

“This is the kind of commonsense, pocketbook issue that appeals to Republicans and Democrats,” said Eva Stahl, a vice president at Undue Medical Debt, a nonprofit that buys up and retires patients’ debts and has pushed for expanded patient protections.

But in several statehouses, the drive for more safeguards hit walls.

Bills to ban medical debts from appearing on credit reports failed in and , despite support from some GOP lawmakers. And measures to limit aggressive collections against residents with medical debt were derailed in , , and .

In some states, the measures faced stiff opposition from debt collectors, the credit reporting industry, and banks, who told legislators that without information about medical debts, they might end up offering consumers risky loans.

In Maine, the Consumer Data Industry Association, which represents credit bureaus, that regulating medical debt should be left to the federal government. “Only national, uniform standards can achieve the dual goals of protecting consumers and maintaining accurate credit reports,” warned Zachary Taylor, the group’s government relations director.

In South Dakota, state Rep. Lana Greenfield, a Republican, echoed industry objections in urging her colleagues to vote against a credit reporting ban. “Small-town banks could not receive information on a mega, mega medical bill. And so, they would in good faith perhaps loan money to somebody without knowing what their credit was,” Greenfield said on the House floor.

Under the Biden administration, that medical debt, unlike other debt, was not a good predictor of creditworthiness.

But South Dakota state Rep. Brian Mulder, a Republican who chairs the health committee and authored the legislation, noted the power of the banking industry in South Dakota, where favorable regulations have made the state a magnet for financial institutions.

In Montana, legislation to shield a portion of debtors’ assets from garnishment easily passed a committee. Supporters hoped the measure would be particularly helpful to Native American patients, who are by medical debt.

But when the bill reached the House floor, opponents “showed up en masse,” talking one-on-one with Republican lawmakers an hour before the vote, said Rep. Ed Stafman, a Democrat who authored the bill. “They lassoed just enough votes to narrowly defeat the bill,” he said.

Advocates for patients and legislators who backed some of these measures said they’re optimistic they’ll be able to overcome industry opposition in the future.

And there are signs that legislation to expand patient protections may make headway in other conservative states, including Ohio and Texas. A to force nonprofit hospitals to expand aid to patients facing large bills picked up support from leading conservative organizations.

“These things can sometimes take time,” said Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society. The patients’ group has been pushing for state medical debt protections in recent years, including in Montana and South Dakota.

More concerning, Culp said, is the wave of uninsured patients expected as millions of Americans lose health coverage due to cutbacks in the recently passed GOP tax law. That will almost certainly make the nation’s medical debt problem more dire.

“States are not ready for that,” Culp said.

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Patients begin lining up before dawn at , an annual five-day health clinic in Texas’ Rio Grande Valley. Many residents in this predominantly spanning the Mexican border lack insurance, making the health fair a major source of free medical care in South Texas for more than 25 years.

Until this year. The Trump administration’s plan to strip in federal public health and pandemic funds from Texas helped prompt just before its scheduled July 21 start.

“Some people come every year and rely on it,” said Hidalgo County Health and Human Services Director Dairen Sarmiento Rangel. “Some people even camp out outside of Border Health so they can be the first in line to receive services. This event is very important to our community.”

States and local governments have made painful program cuts in the wake of major reductions in federal health funding that have already taken effect. Now, they’re sizing up the financial hits to come — some not until late next year or beyond — from the “,” the tax and spending law congressional Republicans passed in July that enacts much of President Donald Trump’s domestic agenda.

Texas, for instance, expects to see its federal Medicaid funds reduced by as much as over 10 years due to new barriers for enrollment, such as more frequent eligibility checks, according to a July analysis by Â鶹ŮÓÅ.

Taken together, the reductions amount to a seismic shift in how state health programs are provided and paid for. The administration is, in effect, pushing a significant amount of health costs to states. That will force their leaders to make difficult choices, as many state budgets are already strained by declining tax revenues, a slowdown in federal pandemic spending, and economic uncertainty.

Revenue forecasters have lowered expectations for the coming year, according to a .

“It’s almost inevitable that states will enact a number of cuts to health services because of the fiscal pressure,” said Wesley Tharpe, senior adviser for state tax policy at the left-leaning .

Some are proactively trying to stanch the impact.

Hawaii lawmakers are looking to aid nonprofits that are already contending with federal funding cuts. They’re in grants to health, social service, and other nonprofits hit by federal funding cuts. To get the money, nonprofits must show a termination or drop in funding, or that they have otherwise been harmed by the cuts.

“It is not fair that organizations dedicated to supporting the people of Hawaii are being forced to scale back due to federal funding cuts,” Democratic Gov. Josh Green .

Other states are scaling back projects to contend with cuts. Delaware Gov. Matt Meyer, a Democrat, received notice in March that the Trump administration was in public health funding from the state. The next month, state legislative leaders halted a planned project to upgrade and expand the Capitol complex as a result.

“We recognized that the reckless federal cuts to the social safety nets of thousands of Delawareans called for us to hold back resources to protect our most vulnerable,” said , president pro tempore of the Delaware Senate.

In New Mexico, the state with the , a bipartisan group of lawmakers voted to create a trust fund to boost funding for the program. About 10% of the more than covered by Medicaid and the related Children’s Health Insurance Program could lose their health coverage under the federal spending law, based on .

Some state leaders are warning constituents that the worst may be yet to come.

At an Aug. 18 event at a hospital in the South Bronx section of New York City, New York Gov. Kathy Hochul, a Democrat, stood on stage among health care workers in white coats to skewer Trump’s new law.

“What Republicans in Washington have done through the ‘Big Ugliest Bill’ I’ve ever seen is literally screwing New Yorkers,” she said. The state’s health system is bracing for in annual cuts.

And in California, lawmakers weighed the impact of the coming cuts from the federal law at a general assembly , where some Democratic legislators said state efforts to protect reproductive health services and other programs were in jeopardy.

“We’ve been bracing for this reality: President Trump’s so-called ‘Big, Beautiful Bill’ is now law,” Democratic lawmaker Gregg Hart said at the hearing, calling it a “direct assault on California’s core programs and our values.”

“Sadly, the reality is, the state does not have the capacity to backfill all of these draconian federal funding cuts in the current budget,” Hart said. “We cannot simply write a check and make this go away.”

The sweeping budget law, which passed without any Democratic support, will reduce federal spending on Medicaid by about over the next decade, based on estimates from the . The spending reductions largely come from the imposition of a on people who’ve obtained Medicaid under the Affordable Care Act’s expansion, as well as other new barriers to coverage.

The law will mean more than 7.5 million people will lose Medicaid coverage and become uninsured, according to the Congressional Budget Office, while extending tax cuts for wealthy people who, Democrats say, don’t need them. Republicans and Trump have said the spending package and its accompanying program cuts were necessary to prevent fraud and waste, and to sustain Medicaid, a state-federal program for people with disabilities and lower incomes.

“The One Big Beautiful Bill removes illegal aliens, enforces work requirements, and protects Medicaid for the truly vulnerable,” the White House said in a .

The Medicaid cuts won’t begin until after the midterm elections in November 2026, but other cuts have already hit.

The Trump administration has sought to claw back earmarked to states because of the pandemic, spurring a with a coalition of Democratic-led states. It also in for mental health services in schools, and halted grants from the National Institutes of Health that provided money to more than 90 public universities.

HHS press secretary Emily Hilliard said the agency is prioritizing investments that advance Trump’s mandate to confront chronic disease. She defended some of the cuts and said, erroneously, that the spending law doesn’t cut Medicaid.

“The covid-19 pandemic is over, and HHS will no longer waste billions of taxpayer dollars responding to a crisis that Americans moved on from years ago,” she said.

State leaders say the pandemic funding the administration wants returned was earmarked for other public health measures, such as tracking emerging diseases, outbreak responses, and staffing. State attorneys general in May won a against the administration.

“What we’re seeing now is states anticipating big cuts in Medicaid coming, but they’re also dealing with a whole variety of federal cutbacks in public health programs that are smaller but still quite meaningful,” said , executive vice president for health policy at Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

Part of the challenge for states is simply understanding the changes.

“I think it’s fair to say there is concern, confusion, and uncertainty,” said Kathryn Costanza, a Medicaid expert at the National Conference of State Legislatures.

States are struggling to sort it all out, forming that are , suing to try to block the cuts, and reallocating funding.

In Colorado, lawmakers to let state Medicaid dollars pay for non-abortion care at Planned Parenthood of America clinics after Trump’s law banned federal funding for such care. Whether the ban holds up in court .

The Louisiana Legislature to state universities to make up for cuts to federal research funding, much of which goes to health-related research.

And in South Dakota, the state’s largest food bank has to make up for funding cuts to the U.S. Department of Agriculture.

States must balance their budgets every year, so cuts put many services at risk if state lawmakers are unwilling to raise taxes. The work will begin in earnest in January, when many states begin new legislative sessions.

And the tough choices are likely to continue. Congressional House Republicans are considering legislation that could , including by slashing the generous cost sharing the federal government provides for 20 million adults who enrolled in Medicaid under the ACA’s Medicaid expansion.

Some states will roll back their Medicaid expansions and cut more health programs as a result.

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Wieder is a member of the Confederated Salish and Kootenai Tribes in Montana and can access some health services free of charge through her tribe’s health clinics. But funding is limited, so, like a lot of Native American people, she relied on Medicaid for herself and Oakleigh.

Months before Oakleigh’s 1st birthday, the date when Wieder’s postpartum coverage would come to an end, Wieder completed and returned paperwork to enroll her daughter in Healthy Montana Kids, the state’s version of the Children’s Health Insurance Program. But her paperwork, caught up in the lengthy delays and processing times for applications, did not go through.

“As soon as she turned 1, they cut her off completely,” Wieder said.

It took six months for Wieder to get Oakleigh covered again through Healthy Montana Kids. Before health workers in her tribe stepped in to help her resubmit her application, Wieder repeatedly called the state’s health department. She said she would dial the call center when she arrived at her job in the morning and go about her work while waiting on hold, only for the call to be dropped by the end of the day.

“Never did I talk to anybody,” she said.

Wieder and Oakleigh’s experience is an example of the chaos for eligible Medicaid beneficiaries caused by the process known as the “unwinding,” which led to millions of people in the U.S. losing coverage due to paperwork or other procedural issues. Now, tribal health leaders fear their communities will experience more health coverage disruptions when new federal Medicaid work and eligibility requirements are implemented by the start of 2027.

The tax-and-spending law that President Donald Trump signed this summer exempts Native Americans from the new requirement that some people work or do another qualifying activity a minimum number of hours each month to be eligible for Medicaid, as well as from more frequent eligibility checks. But as Wieder and her daughter’s experience shows, they are not exempt from getting caught up in procedural disenrollments that could reemerge as states implement the new rules.

“We also know from the unwinding that that just doesn’t always play out necessarily correctly in practice,” said Joan Alker, who leads Georgetown University’s Center for Children and Families. “There’s a lot to worry about.”

The new law is projected to increase the number of people who are uninsured .

The lessons of the unwinding suggest that “deep trouble” lies ahead for Native Americans who rely on Medicaid, according to Alker.

Changes to Medicaid

Trump’s new law changes Medicaid rules to require some recipients ages 19 to 64 to log 80 hours of work or other qualifying activities per month. It also requires states to recheck those recipients’ eligibility every six months, instead of annually. Both of these changes will be effective by the .

The Congressional Budget Office that the law would reduce federal Medicaid spending by more than $900 billion over a decade. In addition, more than 4 million people enrolled in health plans through the Affordable Care Act marketplace are projected to become uninsured if Congress allows pandemic-era enhanced premium tax credits to expire at the end of the year.

Wieder said she was lucky that the tribe covered costs and her daughter’s care wasn’t interrupted in the six months she didn’t have health insurance. Citizens of federally recognized tribes in the U.S. can access some free health services through the Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives.

But free care is limited because Congress has historically failed to fully fund the Indian Health Service. Tribal health systems rely heavily on Medicaid to fill that gap. Native Americans are enrolled in Medicaid than the white population and have higher rates of chronic illnesses, die more from preventable diseases, and have less access to care.

Medicaid is to the Indian Health Service and other tribal health facilities and organizations. Accounting for about two-thirds of the outside revenue the Indian Health Service collects, it helps tribal health organizations pay their staff, maintain or expand services, and build infrastructure. Tribal leaders say protecting Medicaid for Indian Country is a responsibility Congress and the federal government must fulfill as part of their trust and treaty obligations to tribes.

Lessons Learned During the Unwinding

The Trump administration prevented states from disenrolling most Medicaid recipients for the duration of the public health emergency starting in 2020. After those eligibility checks resumed in 2023, nearly 27 million people nationwide were disenrolled from Medicaid during the unwinding, according to by the Government Accountability Office published in June. The majority of disenrollments — about 70% — occurred for procedural reasons, according to the federal Centers for Medicare & Medicaid Services.

CMS did not require state agencies to collect race and ethnicity data for their reporting during the unwinding, making it difficult to determine how many Native American and Alaska Native enrollees lost coverage.

The lack of data to show how the unwinding affected the population makes it difficult to identify disparities and create policies to address them, said Latoya Hill, senior policy manager with Â鶹ŮÓÅ’s Racial Equity and Health Policy program. Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health News.

The National Council of Urban Indian Health, which advocates on public health issues for Native Americans living in urban parts of the nation, analyzed the Census Bureau’s 2022 American Community Survey and Â鶹ŮÓÅ data in an effort to understand how disenrollment affected tribes. The council estimated had lost coverage as of May 2024. About 2.7 million Native Americans and Alaska Natives were enrolled in Medicaid in 2022, according to the council.

The National Indian Health Board, a nonprofit that represents and advocates for federally recognized tribes, has been working with federal Medicaid officials to ensure that state agencies are prepared to implement the exemptions.

“We learned a lot of lessons about state capacity during the unwinding,” said Winn Davis, congressional relations director for the National Indian Health Board.

Nevada health officials say they plan to apply lessons learned during the unwinding and launch a public education campaign on the Medicaid changes in the new federal law. “A lot of this will depend on anticipated federal guidance regarding the implementation of those new rules,” said Stacie Weeks, director of the Nevada Health Authority.

Staff at the Fallon Tribal Health Center in Nevada have become authorized representatives for some of their patients. This means that tribal citizens’ Medicaid paperwork is sent to the health center, allowing staff to notify individuals and help them fill it out.

Davis said the unwinding process showed that Native American enrollees are uniquely vulnerable to procedural disenrollment. The new law’s exemption of Native Americans from work requirements and more frequent eligibility checks is the “bare minimum” to ensure unnecessary disenrollments are avoided as part of trust and treaty obligations, Davis said.

Eligibility Checks Are ‘Complex’ and ‘Vulnerable to Error’

The GAO said the process of determining whether individuals are eligible for Medicaid is “complex” and “vulnerable to error” in a .

“The resumption of Medicaid eligibility redeterminations on such a large scale further compounded this complexity,” the report said.

It highlighted weaknesses across state systems. By April 2024, federal Medicaid officials had found nearly all states were out of compliance with redetermination requirements, according to the GAO. Eligible people lost their coverage, the accountability office said, highlighting the need to improve federal oversight.

In Texas, for example, federal Medicaid officials found that 100,000 eligible people had been disenrolled due to, for example, the state system’s failure to process their completed renewal forms or miscalculation of the length of women’s postpartum coverage.

Some states were not conducting ex parte renewals, in which a person’s Medicaid coverage is automatically renewed based on existing information available to the state. That reduces the chance that paperwork is sent to the wrong address, because the recipient doesn’t need to complete or return renewal forms.

But poorly conducted ex parte renewals can lead to procedural disenrollments, too. in Nevada were disenrolled by September 2023 through the ex parte process. The state had been conducting the ex parte renewals at the household level, rather than by individual beneficiary, resulting in the disenrollment of still-eligible children because their parents were no longer eligible. in the state were for procedural reasons — the highest in the nation, according to Â鶹ŮÓÅ.

Another issue the federal agency identified was that some state agencies were not giving enrollees the opportunity to submit their renewal paperwork through all means available, including mail, phone, online, and in person.

State agencies also identified challenges they faced during the unwinding, including an unprecedented volume of eligibility redeterminations, insufficient staffing and training, and a lack of response from enrollees who may not have been aware of the unwinding.

Native Americans and Alaska Natives have unique challenges in maintaining their coverage.

Communities in rural parts of the nation experience issues with receiving and sending mail. Some Native Americans on reservations . Others may not have permanent housing or change addresses frequently. In Alaska, mail service is often disrupted by severe weather. Another issue is the lack of reliable internet service on remote reservations.

Tribal health leaders and patient benefit coordinators said some tribal citizens did not receive their redetermination paperwork or struggled to fill it out and send it back to their state Medicaid agency.

The Aftermath

Although the unwinding is over, many challenges persist.

Tribal health workers in Montana, Oklahoma, and South Dakota said some eligible patients who lost Medicaid during the unwinding had still not been reenrolled as of this spring.

“Even today, we’re still in the trenches of getting individuals that had been disenrolled back onto Medicaid,” said Rachel Arthur, executive director of the Indian Family Health Clinic in Great Falls, Montana, in May.

Arthur said staff at the clinic realized early in the unwinding that their patients were not receiving their redetermination notices in the mail. The clinic is identifying people who fell off Medicaid during the unwinding and helping them fill out applications.

Marlena Farnes, who was a patient benefit coordinator at the Indian Family Health Clinic during the Medicaid unwinding, said she tried for months to help an older patient with a chronic health condition get back on Medicaid. He had completed and returned his paperwork but still received a notice that his coverage had lapsed. After many calls to the state Medicaid office, Farnes said, state officials told her the patient’s application had been lost.

Another patient went to the emergency room multiple times while uninsured, Arthur said.

“I felt like if our patients weren’t helped with follow-up, and that advocacy piece, their applications were not being seen,” Farnes said. She is now the behavioral health director at the clinic.

Montana was one of five states where more than 50% of enrollees lost coverage during the unwinding, . The other states are Idaho, Oklahoma, Texas, and Utah. who lost coverage were disenrolled for procedural reasons.

In Oklahoma, eligibility redeterminations remain challenging to process, said Yvonne Myers, a Medicaid and Affordable Care Act consultant for Citizen Potawatomi Nation Health Services. That’s causing more frequent coverage lapses, she said.

Myers said she thinks Republican claims of “waste, fraud, and abuse” are overstated.

“I challenge some of them to try to go through an eligibility process,” Myers said. “The way they’re going about it is making it for more hoops to jump through, which ultimately will cause people to fall off.”

The unwinding showed that state systems can struggle to respond quickly to changes in Medicaid, leading to preventable erroneous disenrollments. Individuals were often in the dark about their applications and struggled to reach state offices for answers. Tribal leaders and health experts are raising concerns that those issues will continue and worsen as states implement the requirements of the new law.

Georgia, the only state with an active Medicaid work requirement program, has shown that the changes can be difficult for individuals to navigate and costly for a state to implement. More than 100,000 people have applied for Georgia’s Pathways program, but only as of the end of July.

Alker, of Georgetown, said Congress took the wrong lesson from the unwinding in adding more restrictions and red tape.

“It will make unwinding pale in comparison in terms of the number of folks that are going to lose coverage,” Alker said.

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

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HAY SPRINGS, Neb.— The sun was just warming the horizon as Mark Pieper left his house near his cattle ranch on a crisp February morning.

It’s not unusual for the rancher to wake up early to tend to livestock, but at 5:45 a.m. this day his cattle wouldn’t come first. For the past 3½ years, three days a week, Pieper has made an early-morning commute to get dialysis at the nearest hospital.

Pieper lives outside Hay Springs, which has 599 residents, according to a sign at the edge of town. He makes sure not to forget his chocolate-brown cowboy hat before starting up his pickup truck for the half-hour drive to Chadron.

That February morning was one of his last dialysis sessions there before the hospital shuttered the service at the end of March.

“I guess I’ll just bloat up and die in a month,” Pieper remembered thinking when he learned the center was closing, eliminating the only option near his home.

He needs dialysis to survive after cancer treatment damaged his kidneys.

Pieper and 16 other patients relied on Chadron Hospital for the life-sustaining therapy that filters waste and fluid from their blood — a job their failing kidneys could no longer do. Treatment lasts about four hours.

The closure is just one example of the long decline of health care services in rural America, where people have higher rates of many chronic conditions but less access to care than elsewhere.

The Trump administration promised to address this problem, when it launched the $50 billion federal Rural Health Transformation Program in September. It may not be enough to stop the trend.

“[President Donald] Trump says he is going to help the rural health care,” Pieper said. Dialysis “is one thing that we really need here.”

Some patients have moved to live closer to care, including several nursing home residents. Their new facilities may be farther from their families.

Others are making long drives to dialysis centers. Pieper eventually found treatment in Scottsbluff, which, with about 14,000 residents, is the biggest city in the rural Panhandle region of western Nebraska. The hour-and-a-half drive will triple his time on the road to more than nine hours each week.

Jim Wright and his wife reduced their drive time — but are spending more money — by renting a small home near Rapid City, South Dakota, and living there on weekdays so he can get dialysis. Wright said he understands that rural hospitals face financial challenges.

“But we’re talking about something that’s lifesaving. It’s not a matter of, ‘Oh, I would like to be there’” getting treatment, he said. “It’s a case that if you don’t, you die.”

An Influx of Money That’s Out of Reach

Jon Reiners, CEO of the independent, nonprofit Chadron Hospital, wrestled with the decision to end dialysis services. He and several patients said that the closure was announced as the $219 million the state will receive in first-year funding from the .

But the five-year program is aimed at exploring new, creative ways to improve rural health, not to help existing services stay afloat. States can use only up to 15% of their funding to pay providers for patient care.

At least 11 states — Nebraska is not among them — have mentioned using funding for rural dialysis programs, according to a Â鶹ŮÓÅ Health News review of applications. Their ideas include starting a mobile dialysis unit and helping people get treatment at home or in long-term care facilities.

Reiners said Chadron Hospital lost $1 million a year on its dialysis service due to low reimbursement rates that didn’t cover operational costs.

The facility is a critical access hospital, a designation that allows certain small, mostly rural hospitals to get increased reimbursement rates for their Medicare patients. While most of the affected patients were on Medicare, the critical access program doesn’t cover outpatient dialysis, Reiners said.

Reiners said the hospital worked for more than a year to find solutions, such as reaching out to four private companies to potentially take over the center. But he said they all passed after realizing they would lose money.

Nephrologist Mark Unruh said the dialysis closure in Chadron reflects a wider trend of staffing and funding challenges.

“You do end up in situations where you have people who are displaced like this, and it’s just sad,” said Unruh, chair of the Internal Medicine Department at the University of New Mexico.

People in rural America face significant disparities in kidney health and treatment, published in 2024 in the American Journal of Nephrology. They’re and face after diagnosis, according to data from the National Institutes of Health.

The best way to address this is to focus on prevention, Unruh said. He pointed to a that helps primary care doctors in rural and other underserved areas prevent end-stage renal failure.

Another idea, Unruh said, is boosting the rate of kidney transplantation for rural patients. He’s looking at whether it’s helpful to “fast-track” tests patients need to get approved for a transplant by scheduling all of them over a couple of days to limit travel time.

Unruh said the U.S. health system also needs to recruit more staff who can train patients and their caregivers to administer dialysis at home.

Exploring the Option of Home Dialysis

Rural dialysis patients are more likely than urban ones to get home dialysis, according to . In 2023, the rate was nearly 18% for rural patients and about 14% for urban ones.

One type of home dialysis requires surgery to get a catheter placed in the abdomen and . The other kind requires . The nearest facility to Chadron that offers training for the first option is in Scottsbluff. The nearest that offers training for the latter kind is three hours away in Cheyenne, Wyoming.

Pieper said doctors told him he’s not a candidate for home dialysis or a transplant. The Panhandle has a nonprofit, rural transit system, but its schedule won’t work for Pieper. He said that leaves him with no choice but to get treatment in Scottsbluff, a 200-mile round trip.

It takes Linda Simonson even longer — more than four hours round trip — to drive her husband, Alan, from their ranch to his treatment in Scottsbluff.

Linda sat in the waiting room with a yellow legal pad during one of Alan’s final treatments in Chadron. The paper was scrawled with phone numbers of politicians to call and driving distances to dialysis centers in the region. She said facilities closer to their ranch either don’t have room for new patients or lack good spots along the route to take a driving break in bad weather.

“It’s just unreal,” she said.

She said even if Alan took a bus, she’d have to ride along to support him during the trip and his treatment.

Jim and Carol Wright, the couple staying near Rapid City on weekdays, said they can’t afford to rent a second home forever. Their weekly commute is already taking a physical and emotional toll. They said they’ll eventually have to move to a bigger city, giving up the house they love in the scenic Nebraska National Forest.

Carol said she feels for the dialysis staffers in Chadron, who are wonderful.

“It just doesn’t seem right to sacrifice one unit that’s so vital,” she said while standing next to a pile of moving boxes stacked inside their rental.

The Wrights wrote letters to politicians and hospital leaders to share their concerns and ideas for keeping the unit open, including using the federal rural health funding.

Simonson said she spoke with aides for the governor and her state representatives but none of the leaders called her back.

“It feels like they don’t know that we exist at this end of the state,” she said.

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After his mom finally saw a specialist in Glasgow, about an hour away, she was diagnosed with stage 4 colon cancer, Bighorn said.

Now, 16 years after his mother’s death, Bighorn has access to regular screenings for cancer and other specialty care that she didn’t have, through a health insurance program the Fort Peck Tribes created in 2016. The program, which covers most of the costs for the roughly 1,000 tribal citizens enrolled, is among a growing number of tribally sponsored health insurance programs.

Such programs vary by tribe, but they essentially screen and enroll people living within tribal boundaries in Affordable Care Act marketplace plans. They allow participating Native Americans flexibility to go to outside doctors and clinics when care through the Indian Health Service is unavailable.

“I’d be in a bind otherwise,” said Bighorn, a 65-year-old tribal game warden and member of the Dakota community.

But the Fort Peck Tribes now limit who has access to that coverage. Other tribal organizations that offer Native Americans similar coverage are struggling with rising costs, too.

The financial crunch began when congressional lawmakers allowed enhanced subsidies under the Affordable Care Act to expire on Dec. 31. Those tax credits, created under the Biden administration during the covid-19 pandemic, expanded subsidized health coverage for millions of people. By late 2025, ACA plans saw about 24 million enrollees, more than twice the number of pre-pandemic annual sign-ups. The cost of coverage shot up for most of those people as the expanded subsidies expired, and enrollment has dropped by , according to federal health officials.

The subsidies had also boosted tribal health insurance programs, like the one Bighorn is enrolled in. The programs pay the price of each person’s share of premiums after subsidies, and the coverage lowers patients’ treatment costs. Now that premium prices have ballooned, so have tribes’ costs.

Rae Jean Belgarde, who directs Fort Peck Tribes’ program, said the higher costs leave the tribes with one option at this point: “Start limiting who gets help.”

The tribes are helping people shift to other insurance options and, in some cases, find state programs to cover their premiums. Tribal leaders also sent a letter to Montana’s all-Republican congressional delegation asking them to support extending the subsidies.

“Our program is saving lives,” the letter read. Belgarde said she didn’t know whether the lawmakers responded.

Scrambling for Solutions

U.S. a temporary extension of the enhanced subsidies in January. But that measure . Lawmakers are scrambling for an alternative after President Donald Trump an extension if a bill reaches his desk. On Jan. 15, the president released that includes creating savings accounts for people to pay their health costs — an idea Senate Republicans as an alternative to the subsidies.

A.C. Locklear, CEO of the , a nonprofit that works to improve health in Native communities, said tribes are “looking at ways to cut back just as much as everyone else.”

Native Americans as a group continue to face disproportionately high rates of chronic diseases. Their median age at death is than that of white Americans.

“Reducing access to even just general primary care has a significant impact on those disparities,” Locklear said.

Tribal leaders have said letting the subsidies expire further undermines the federal government’s duty to ensure adequate care for Native Americans.

In exchange for taking tribal land through colonization, the U.S. government made long-standing promises to provide for the health and well-being of tribes. Native Americans are guaranteed free health care at clinics and hospitals operated or funded by the Indian Health Service. But that agency’s chronic underfunding has created massive blackouts in care. It sometimes pays for patients’ outside care through its Purchased/Referred Care program, but that’s limited too. Due to , the agency prioritizes which treatments it will pay for.

To help fill the coverage gaps, some tribal nations have built their own health insurance programs. When tribes pay health premiums, clinics and hospitals in their areas can bill for services that might otherwise go unpaid. Some tribes have leveraged that money to expand services.

“I don’t see tribes getting rid of these programs,” Locklear said. “But it will drastically shift how much tribes can really put back in their community.”

For example, Tuba City Regional Health Care Corp., in northern Arizona within the Navajo Nation, is unique in providing comprehensive cancer treatment on a reservation, Locklear said. The corporation, he said, estimates its costs to cover patients this year are increasing by roughly 170% to nearly $38,000 per month without the enhanced subsidies.

One of the newer programs is on the Blackfeet reservation in northwestern Montana, where basic health services can be hard to find. Medical visits are often offered on a first-come, first-served basis, and services vanish when staff positions go unfilled, said Lyle Rutherford, a Blackfeet Nation council member.

“Some of it is just getting a regular eye appointment, or a primary care appointment,” Rutherford said.

The tribe has been slowly building its health insurance program since launching it in 2024. Rutherford said the enhanced subsidies made that possible. Fewer than 400 people are enrolled out of an estimated 3,000 who qualify. In January, the tribe paused the employer-sponsored coverage portion of its insurance program, which at the time included 52 people.

He said tribal leaders are seeking extra funding to keep the program afloat, and he hopes Congress finds a solution.

Lives on the Line

The impact goes beyond tribes’ insurance programs. The Urban Institute, a Washington, D.C.-based economic and social policy research nonprofit, will become uninsured in 2026 due to the higher costs.

Patients at the Oyate Health Center in Rapid City, South Dakota, are already reporting sky-high premium increases for ACA plans. CEO Jerilyn Church said it’s too soon to know how many will forgo coverage. But she said more uninsured patients would further strain the IHS Purchased/Referred Care program — with officials raising the bar for how sick patients must be to cover care outside of tribal health sites.

“There will be people that will not be able to get the care they need,” Church said, adding that could translate to “people losing their lives.”

Bighorn, the game warden on the Fort Peck Reservation, is among those still covered by the tribes’ insurance program. He has put it to use.

Soon after enrolling, Bighorn needed two hip replacements, surgeries that require off-reservation care and are ranked as low-priority procedures by the Indian Health Service. Bighorn said that in pre-surgery tests, specialists found the cause for his long-standing, dangerously high blood pressure. The diagnosis: untreated lifelong asthma and sleep apnea.

“I was a miserable man, tired all the time,” he said.

Without the tribe’s coverage, Bighorn may have eventually gotten those diagnoses but said it would have likely taken years to get help through the Indian Health Service. That would have meant getting much sicker before receiving care.

Â鶹ŮÓÅ Health News correspondent Arielle Zionts contributed to this report.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? to contact Â鶹ŮÓÅ Health News and share your story.

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Then 25 years old and six months pregnant, she drove herself to the emergency room in Ronan, Montana, on the Flathead Indian Reservation, where an ambulance transferred her to a larger hospital 60 miles away in Missoula. Once she arrived, the staff couldn’t detect her baby’s heartbeat. Swaney began to bleed heavily. She delivered a stillborn baby and was hospitalized for several days. At one point, doctors told her to call her family. They didn’t expect her to survive.

“It certainly changed my life — the experience — but my life has not been a bad life,” she told Â鶹ŮÓÅ Health News.

Though her experiences were nearly 50 years ago, Swaney, a member of the Confederated Salish and Kootenai Tribes, said Native Americans continue to receive inadequate maternal care. The data appears to support that belief.

In 2024, the most recent year for which data for the population is available, Native American and Alaska Native people had the among major demographic groups, according to the Centers for Disease Control and Prevention.

In response to this disparity, Native organizations, the CDC, and some states are working to boost tribal participation in state maternal mortality review committees to better track and address pregnancy-related deaths in their communities. Native organizations are also considering ways tribes could create their own committees.

State maternal mortality review committees investigate deaths that occur during pregnancy or within a year after pregnancy, analyze data, and issue policy recommendations to lower death rates.

According to 2021 CDC data, compiled from 46 maternal mortality review committees, 87% of maternal deaths in the U.S. were deemed preventable. Committees reported that , deaths among Native American and Alaska Native people were considered preventable.

Our matriarchs, our moms, are what carries a nation forward.

Kim Moore-Salas

State committees have received federal money through the Preventing Maternal Deaths Act, which President Donald Trump signed in 2018.

But the money is scheduled to dry up on Jan. 31, when the short-term spending bill that ended the government shutdown expires.

Funding for the committees is included in the Labor, Health and Human Services, Education, and Related Agencies for fiscal year 2026. That bill must be approved by the House, Senate, and president to take effect.

Native American leaders said including members of their communities in maternal mortality review committee activities is an important step in addressing mortality disparities.

In 2023, tribal leaders and federal officials met to discuss four models: a mortality review committee for each tribe, a committee for each of the 12 Indian Health Service administrative regions, a national committee to review all Native American maternal deaths, and the addition of Native American subcommittees to state committees.

Whatever the model, tribal sovereignty, experience, and traditional knowledge are important factors, said Kim Moore-Salas, a co-chair of the Arizona Maternal Mortality Review Committee. She’s also the chairperson of the panel’s American Indian/Alaska Native mortality review subcommittee and a member of the Navajo Nation.

“Our matriarchs, our moms, are what carries a nation forward,” she said.

Mental health conditions and infection were the leading underlying causes of pregnancy-related death among Native American and Alaska Native women as of 2021, according to the CDC report analyzing data from 46 states.

The CDC found an estimated 68% of pregnancy-related deaths among Native American and Alaska Native people happened within a week of delivery to a year postpartum. The majority of those happened between 43 days and a year after birth.

The federal government has a responsibility under signed treaties to provide health care to the 575 federally recognized tribes in the U.S. through the Indian Health Service. Tribal members can receive limited services at no cost, but the agency is .

A that analyzed data from 2016 to 2020 found that approximately 75% of Native American and Alaska Native pregnant people didn’t have access to care through the Indian Health Service around the time of giving birth, meaning many likely sought care elsewhere. More than 90% of Native American and Alaska Native births occur outside of IHS facilities, . For those who did deliver at IHS facilities, a from the Department of Health and Human Services’ Office of Inspector General found that 56% of labor and delivery patients received care that did not follow national clinical guidelines.

The 2024 study’s authors also found that members of the population were less likely to have stable insurance coverage and more likely to have a lapse in coverage during the period close to birth than non-Hispanic white people.

Cindy Gamble, who is Tlingit and a tribal community health consultant for the American Indian Health Commission in Washington, has been a member of the state’s maternal mortality review panel for about eight years. In the time she’s been on the state panel, she said, its composition has broadened to include more people of color and community members.

The panel also began to include suicide, overdose, and homicide deaths in its data analysis and added racism and discrimination to the risk factors considered during its case review process.

Solutions need to be tailored to the tribe’s identity and needs, Gamble said.

“It’s not a one-size-fits-all,” Gamble said, “because of all the beliefs and different cultures and languages that different tribes have.”

Gamble’s tenure on the state committee is distinctive. Few states have tribal representation on maternal mortality review committees, according to the National Indian Health Board, a nonprofit organization that advocates for tribal health.

The National Council of Urban Indian Health is also the participation of Urban Indian health organizations, which provide care for Native American people who live outside of reservations, in state maternal mortality review processes. As of 2025, the council had connected Urban Indian health organizations to state review committees in California, Kansas, Oklahoma, and South Dakota.

Native leaders such as Moore-Salas find the current efforts encouraging.

“It shows that state and tribes can work together,” she said.

In March 2024, Moore-Salas became the first Native American co-chair of Arizona’s Maternal Mortality Review Committee. In 2025 she and other Native American members of the committee developed guidelines for the American Indian/Alaska Native subcommittee and reviewed the group’s first cases.

The subcommittee is exploring ways to make the data collection and analysis process more culturally relevant to their population, Moore-Salas said.

But it takes time for policy changes to create widespread change in the health of a population, Gamble said. Despite efforts around the country, other factors may hinder the pace of progress. For example, maternity care deserts are growing nationally, caused by rapid hospital and labor and delivery unit closures. Health experts have that upcoming cuts to Medicaid will hasten these closures.

Despite her experience and the ongoing crisis among Native American and Alaska Native people, Swaney hopes for change.

She had a second complicated pregnancy soon after her stillbirth. She went into labor about three months early, and the doctors said her son wouldn’t live to the next morning. But he did, and he was transferred about 525 miles away from Missoula to the nearest advanced neonatal unit, in Salt Lake City.

Her son, Kelly Camel, is now 48. He has severe cerebral palsy and profound deafness. He lives alone but has caregivers to help with cooking and other tasks, said Swaney, 73.

He “has a good sense of humor. He’s kind to other people. We couldn’t ask for a more complete child.”

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Â鶹ŮÓÅ Health News senior correspondent Julie Appleby discussed changes to the Affordable Care Act in 2026 and how enrollees may be affected on WUNC’s Due South on Jan. 7.

• (begins 33:00).
• Read Appleby’s “.”

Â鶹ŮÓÅ Health News South Dakota correspondent Arielle Zionts discussed rural health funding on South Dakota Public Broadcasting on Dec. 22.

• Read Zionts’ “,” co-reported with Sarah Jane Tribble.

Â鶹ŮÓÅ Health News senior correspondent Renuka Rayasam discussed ACA subsidy expiration on WUGA’s The Georgia Health Report on Dec. 19.

• Read Julie Appleby’s “.”

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

Â鶹ŮÓÅ Health News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

Â鶹ŮÓÅ Health News South Dakota correspondent Arielle Zionts contributed to this report.

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The outbreaks are fueled by falling vaccination rates, fading immunity, and delays in public health tracking systems, according to interviews with state and federal health officials. Babies too young to be fully vaccinated are most at risk.

“Pertussis cases increase in a cyclical fashion driven by waning immunity, but the size of the outbreak and the potential for severe outcomes in children who cannot be vaccinated can be mitigated by high coverage and good communication to folks at risk,” said Demetre Daskalakis, a former head of the Centers for Disease Control and Prevention’s immunization program, who resigned in August.

Before the first pertussis vaccine became available in the , whooping cough was one of the most common childhood diseases and a in the United States. Today, children get a series of DTaP shots (full-dose version) starting at 2 months old, and teens and adults receive a Tdap booster (lower-dose version) every 10 years. (Both vaccines target diphtheria and tetanus in addition to pertussis.)

Until recently, had received four doses of the DTaP vaccine by age 2, and case rates were controlled. But vaccine coverage has declined since the covid pandemic and increases in state nonmedical exemptions have widened immunity gaps, which is when the proportion of individuals who are immune falls below the level needed to contain spread.

Texas logged in 2024. By October 2025, the state had . National numbers are just as stark: In the first three months of 2025, the U.S. tallied — four times last year’s pace and 25 times 2023’s. Several states are posting their highest case totals in a decade, and outbreaks from Louisiana to South Dakota to Idaho make clear this surge isn’t regional. It’s everywhere.

Key Factors Behind These Numbers

Texas lawmakers recently passed a law that for parents to claim nonmedical exemptions from school vaccine requirements by allowing them to download exemption forms online. These forms now go straight to schools, not health departments, making the exemptions harder to track.

Dallas County Health and Human Services Director Phil Huang said the full impact of the new exemption rule is not yet known because it began this school year, but he expects it will make school-level vaccination rates fall even more.

He’s already noted a dramatic drop in vaccinations. Normally, during back-to-school season, “our whole front downstairs area is packed,” he said. “We did not see that this year.”

Huang believes fear of immigration enforcement may be keeping at least some families, especially Hispanic families, from getting vaccinated. Dallas County is about 40% Hispanic. “We think that a lot of them are deterred by the ICE activity,” he said, referring to Immigration and Customs Enforcement.

More complications: These vaccines protect against severe disease, but protection against infection fades over time, as is the case with the covid and influenza vaccines.

The U.S. switched in the 1990s from whole-cell pertussis vaccines to “acellular” ones, which cause fewer side effects but do not last as long. Because more adults today than in the past received the acellular vaccine as children, many have lost immunity over time and may unknowingly pass the infection to babies.

Babies Face the Greatest Risk

Whooping cough is especially dangerous for infants under a year old. Some stop breathing during coughing fits. Many need hospital care, about of whom develop pneumonia, and about 1% of whom die.

Because of this high risk, the CDC urges pregnant women to get a . This allows the mother’s antibodies to pass to the baby before birth.

Health officials once promoted “cocooning,” vaccinating all family members and caregivers around the baby, but that strategy was hard to carry out in real life and is . Vaccination of pregnant women and babies at 2 months of age remains the strongest protection.

Better Testing Finds More Cases

Modern is also than in the past. Many clinics now routinely use this lab-based technology to test for several respiratory infections at once, including pertussis. Ten years ago, these panels were uncommon.

CDC experts say this explains part of the rise in case counts. But the large number of infant hospitalizations and the size of state outbreaks show that true transmission has also increased.

A Growing Worry: Antibiotic Resistance

Doctors normally treat pertussis with , such as erythromycin, azithromycin, and clarithromycin. These drugs work best early in the illness and help stop spread. Another drug, trimethoprim-sulfamethoxazole, is an option for some older infants and adults.

But has become common abroad, especially in China, and recent reports show resistance rising in Peru. In the U.S., resistant cases have been rare.

CDC officials warn that resistant strains could spread more easily through international travel. Because treatment options are limited, especially for very young infants, health workers are watching this closely.

Huang said macrolide resistance has not been seen yet in Dallas County. But he is aware of the national concern.

What Happens Now

The resurgence of whooping cough has no single cause. Instead, several problems are occurring at once: falling vaccine coverage, only of pregnant women receiving Tdap, waning immunity, improved testing, and early signs of antibiotic resistance.

Health experts say solutions must match the problem’s complexity.

Across the nation, clinicians are being told to have a higher suspicion for pertussis when they see patients, especially children or caregivers of newborns with a persistent cough or coughing fits followed by vomiting. Babies who stop breathing or turn blue need immediate care.

Obstetricians are encouraged to discuss Tdap during every pregnancy. Pediatricians and family doctors are urged to check booster status for teens and adults.

Several states have issued health advisories over the past two years, including , which has in both 2024 and 2025 urging clinicians to stay vigilant.

Huang said Dallas County is trying to rebuild public health outreach programs that were cut when covid funding ended. But staffing is still limited. “There’s just a lot of different things that are making it more difficult,” he said.

He also noted that Dallas County now receives immunization registry data only once a month, rather than daily, making it harder to track vaccine coverage. “We don’t have that yet. … It’s not real time,” he said.

Protecting the Youngest

As the holiday season approaches, experts urge families with newborns to take extra care:

• Ensure infants and children are up to date with their childhood vaccines and that everyone in the family is up to date with their vaccines for influenza, covid, and RSV, or respiratory syncytial virus.
• Keep sick visitors away.
• Seek care quickly if an infant has a cough or pauses breathing.

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Kopplin, a physician assistant who works with seniors, low-income people, and mental health patients in the rural Black Hills, shared her thoughts at a meeting hosted by state officials.

South Dakota’s leaders did a “good job of diving in” and asking questions to get “deeper at the root of the problem,” she said.

Kopplin later told Â鶹ŮÓÅ Health News how one of her rural patients recently missed two appointments because of a broken-down car and no access to public transportation.

Nationwide, health care workers like Kopplin and thousands of others — from patient advocates to technology executives — flocked to town halls or online portals during the seven weeks state leaders had to craft and submit their applications for the Rural Health Transformation Program to the federal Centers for Medicare & Medicaid Services. That deadline was Nov. 5.

“We will give $50 billion away by the end of the year,” CMS Administrator Mehmet Oz said Nov. 6 at a Milken Institute event in Washington. He said all 50 states had submitted applications.

The program will “allow us to right-size the health care system,” Oz said, adding that innovations from the rural work “will spill over to suburban and urban America as well.”

Among applications and summaries publicly shared by states, themes include workforce development, telehealth, and access to healthy food. In Kansas, leaders want to build a “Food is Medicine” program. Wyoming officials propose a new program called “BearCare,” a state-sponsored health insurance plan that patients could use only after medical emergencies.

But many health policy experts and Democrats are raising alarms that the Republican-backed program will become a “slush fund.” Critics worry it will fail to reach the small-town patients they say need it most, especially as states face nearly a trillion dollars in Medicaid spending reductions over the next decade. Medicaid, a joint federal-state program, serves nearly rural Americans.

“The status quo is tremendous distress in rural communities,” said Heather Howard, a professor of the practice at Princeton University and director of the university’s State Health and Value Strategies program, which is tracking the rural health fund. The new funding won’t be enough to offset the Medicaid losses, she said.

Congressional Republicans added the five-year, $50 billion Rural Health Transformation Program as a last-minute sweetener to President Donald Trump’s massive tax-and-spending legislation. The move helped win support for the One Big Beautiful Bill Act from conservative holdouts who worried that the Medicaid cuts in the bill would harm rural hospitals in their states.

In Montana, which hosted an online public forum before submitting its application, a nonprofit director pitched youth peer support as a way of battling high suicide rates. A registered nurse asked state leaders to “think maybe even bigger” and consider statewide universal health care.

And in Georgia, a technology-focused chain of primary care clinics that serves seniors proposed expanding its operations into that state in its online public comment. A rural grant writer asked for “safe and stable housing.”

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be doled out according to a points-based system. Of , $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that on initiatives and policies that, in part, mirror the Trump administration’s “” objectives.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who a federal watchdog agency to investigate the fairness and implementation of the fund. Taylor Harvey, a Wyden aide, said the Government Accountability Office has confirmed it will investigate.

According to , no less than a quarter of states with an approved application may share the second half of the funding each fiscal year, CMS spokesperson Catherine Howden said. The agency plans to publish summaries of approved state projects, .

A handful of conservative-leaning states — including Texas, Arkansas, Louisiana, and Oklahoma — have already instituted regulatory and legislative initiatives, such as prohibiting “non-nutritious” foods in benefit programs, that in the program application process.

Michael Chameides, a county supervisor in rural New York, said he fears the money could “be used in ways that would hurt certain states or reward certain states.” Chameides is also the communications and policy director with the Rural Democracy Initiative, a national advocacy organization that released last month.

Edwin Park, a research professor at Georgetown University’s Center for Children and Families, said federal lawmakers gave Oz and his agency “really excessive discretion” when awarding the money.

Federal administrators have added rules that aren’t within the statute that created the program, Park said. For example, its application guidelines say states cannot use more than 15% of their funding to pay providers for patient care — payments that are expected to take a hit due to the Medicaid cuts.

Georgetown’s health policy experts and Democrats aren’t the only ones with concerns. and in Ohio worry the money will go to large health systems instead of smaller, independent hospitals that serve people within their rural communities.

CMS’ Oz repeated the idea of getting “big hospitals to adopt smaller institutions” at the Washington gathering after applications were filed. He used similar language at a rural health summit hosted by South Dakota-based Sanford Health. “How do we get big hospitals to adopt smaller hospitals? Not to take them over, but to keep them viable by giving them good telehealth services, specialty support, radiology support,” he said at the October event.

Sanford owns or manages dozens of hospitals and hundreds of clinics and long-term care centers, as well as a health insurance company. The system reported about $81 million in operating income during the first six months of fiscal year 2025, according to .

Last year, Sanford opened a “command center” for its systemwide telehealth initiative. It launched a telehealth expansion in 2021 and offers virtual care for 78 medical specialties, Sanford President and CEO Bill Gassen said.

“We’ve tried to imagine, what if that number doubles?” Gassen said. The startup costs for telehealth are high, he said, and the rural fund could be a unique opportunity “for us to make virtual care available to more patients, to more communities, to more hospitals and health systems across the country.”

Gassen, who is set to chair the American Hospital Association in 2027, said Sanford leaders have met with state and federal officials, including Oz, whom he’s known for years, and Chris Klomp, a top deputy at CMS and a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

The word “telehealth” appears 36 times in the rural health program’s 124-page application guidelines. But Don Robbins Jr., chief executive of a small hospital on the Illinois-Kentucky border, chuckled at the idea of using the funding for that purpose.

Robbins, whose 25-bed Massac Memorial Hospital averages five to seven patients in its beds each day, said his hospital does not regularly offer telehealth. Even if it did, he said, patients living more than a mile outside of town couldn’t use it because they don’t have a good internet connection.

The small hospital reported a $31,314 loss in September, Robbins said. “I think if we get anything out of it,” Robbins said of the rural health program, “we’ll be lucky.”

Kopplin, the physician assistant who attended the South Dakota meeting, is cautiously optimistic about the rural health fund. She views it as a wonderful chance for states to test out ideas and learn from what works and what doesn’t.

But “in a lot of ways this bill is going to be a band-aid approach” for rural health, she said. “It’s not really going to fix the problem.”

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Despite progress in some mostly blue states this year, however, recent setbacks in more conservative legislatures underscore the persistent challenges in strengthening patient protections.

Bills to shield patients from medical debt failed this year in Indiana, Montana, Nevada, South Dakota, and Wyoming in the face of industry opposition. And advocates warn that states need to step up as millions of Americans are expected to lose insurance coverage because of President Donald Trump’s tax and spending law.

“This is an issue that had been top of mind even before the change of administrations in Washington,” said Kate Ende, policy director of Maine-based Consumers for Affordable Health Care. “The pullback at the federal level made it that much more important that we do something.”

This year, Maine joined a growing list of states that have barred medical debt from residents’ credit reports, a key protection that can make it easier for consumers to get a home, a car, or sometimes a job. The with bipartisan support.

An in the U.S. have some form of health care debt.

The federal government was poised to bar medical debt from credit reports under in the waning days of former President Joe Biden’s administration. That would have helped an estimated 15 million people nationwide.

But the Trump administration did not defend the regulations from lawsuits brought by debt collectors and the credit bureaus, who argued that the Consumer Financial Protection Bureau exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

Now, only patients in states that have enacted their own credit reporting rules will benefit from such protections. More than a dozen have such limits, including California, Colorado, Connecticut, Minnesota, New York, and Vermont, which, like Maine, enacted a ban this year.

Still more states have passed in recent years, including caps on how much interest can be charged on such debt and limits on the use of wage garnishments and property liens to collect unpaid medical bills.

In many cases, the medical debt rules won bipartisan support, reflecting the overwhelming popularity of these consumer protections. In Virginia, the state’s conservative Republican governor this year restricting wage garnishment and capping interest rates.

And several GOP lawmakers in California joined Democrats to make it easier for patients to access financial assistance from hospitals for big bills.

“This is the kind of commonsense, pocketbook issue that appeals to Republicans and Democrats,” said Eva Stahl, a vice president at Undue Medical Debt, a nonprofit that buys up and retires patients’ debts and has pushed for expanded patient protections.

But in several statehouses, the drive for more safeguards hit walls.

Bills to ban medical debts from appearing on credit reports failed in and , despite support from some GOP lawmakers. And measures to limit aggressive collections against residents with medical debt were derailed in , , and .

In some states, the measures faced stiff opposition from debt collectors, the credit reporting industry, and banks, who told legislators that without information about medical debts, they might end up offering consumers risky loans.

In Maine, the Consumer Data Industry Association, which represents credit bureaus, that regulating medical debt should be left to the federal government. “Only national, uniform standards can achieve the dual goals of protecting consumers and maintaining accurate credit reports,” warned Zachary Taylor, the group’s government relations director.

In South Dakota, state Rep. Lana Greenfield, a Republican, echoed industry objections in urging her colleagues to vote against a credit reporting ban. “Small-town banks could not receive information on a mega, mega medical bill. And so, they would in good faith perhaps loan money to somebody without knowing what their credit was,” Greenfield said on the House floor.

Under the Biden administration, that medical debt, unlike other debt, was not a good predictor of creditworthiness.

But South Dakota state Rep. Brian Mulder, a Republican who chairs the health committee and authored the legislation, noted the power of the banking industry in South Dakota, where favorable regulations have made the state a magnet for financial institutions.

In Montana, legislation to shield a portion of debtors’ assets from garnishment easily passed a committee. Supporters hoped the measure would be particularly helpful to Native American patients, who are by medical debt.

But when the bill reached the House floor, opponents “showed up en masse,” talking one-on-one with Republican lawmakers an hour before the vote, said Rep. Ed Stafman, a Democrat who authored the bill. “They lassoed just enough votes to narrowly defeat the bill,” he said.

Advocates for patients and legislators who backed some of these measures said they’re optimistic they’ll be able to overcome industry opposition in the future.

And there are signs that legislation to expand patient protections may make headway in other conservative states, including Ohio and Texas. A to force nonprofit hospitals to expand aid to patients facing large bills picked up support from leading conservative organizations.

“These things can sometimes take time,” said Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society. The patients’ group has been pushing for state medical debt protections in recent years, including in Montana and South Dakota.

More concerning, Culp said, is the wave of uninsured patients expected as millions of Americans lose health coverage due to cutbacks in the recently passed GOP tax law. That will almost certainly make the nation’s medical debt problem more dire.

“States are not ready for that,” Culp said.

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Patients begin lining up before dawn at , an annual five-day health clinic in Texas’ Rio Grande Valley. Many residents in this predominantly spanning the Mexican border lack insurance, making the health fair a major source of free medical care in South Texas for more than 25 years.

Until this year. The Trump administration’s plan to strip in federal public health and pandemic funds from Texas helped prompt just before its scheduled July 21 start.

“Some people come every year and rely on it,” said Hidalgo County Health and Human Services Director Dairen Sarmiento Rangel. “Some people even camp out outside of Border Health so they can be the first in line to receive services. This event is very important to our community.”

States and local governments have made painful program cuts in the wake of major reductions in federal health funding that have already taken effect. Now, they’re sizing up the financial hits to come — some not until late next year or beyond — from the “,” the tax and spending law congressional Republicans passed in July that enacts much of President Donald Trump’s domestic agenda.

Texas, for instance, expects to see its federal Medicaid funds reduced by as much as over 10 years due to new barriers for enrollment, such as more frequent eligibility checks, according to a July analysis by Â鶹ŮÓÅ.

Taken together, the reductions amount to a seismic shift in how state health programs are provided and paid for. The administration is, in effect, pushing a significant amount of health costs to states. That will force their leaders to make difficult choices, as many state budgets are already strained by declining tax revenues, a slowdown in federal pandemic spending, and economic uncertainty.

Revenue forecasters have lowered expectations for the coming year, according to a .

“It’s almost inevitable that states will enact a number of cuts to health services because of the fiscal pressure,” said Wesley Tharpe, senior adviser for state tax policy at the left-leaning .

Some are proactively trying to stanch the impact.

Hawaii lawmakers are looking to aid nonprofits that are already contending with federal funding cuts. They’re in grants to health, social service, and other nonprofits hit by federal funding cuts. To get the money, nonprofits must show a termination or drop in funding, or that they have otherwise been harmed by the cuts.

“It is not fair that organizations dedicated to supporting the people of Hawaii are being forced to scale back due to federal funding cuts,” Democratic Gov. Josh Green .

Other states are scaling back projects to contend with cuts. Delaware Gov. Matt Meyer, a Democrat, received notice in March that the Trump administration was in public health funding from the state. The next month, state legislative leaders halted a planned project to upgrade and expand the Capitol complex as a result.

“We recognized that the reckless federal cuts to the social safety nets of thousands of Delawareans called for us to hold back resources to protect our most vulnerable,” said , president pro tempore of the Delaware Senate.

In New Mexico, the state with the , a bipartisan group of lawmakers voted to create a trust fund to boost funding for the program. About 10% of the more than covered by Medicaid and the related Children’s Health Insurance Program could lose their health coverage under the federal spending law, based on .

Some state leaders are warning constituents that the worst may be yet to come.

At an Aug. 18 event at a hospital in the South Bronx section of New York City, New York Gov. Kathy Hochul, a Democrat, stood on stage among health care workers in white coats to skewer Trump’s new law.

“What Republicans in Washington have done through the ‘Big Ugliest Bill’ I’ve ever seen is literally screwing New Yorkers,” she said. The state’s health system is bracing for in annual cuts.

And in California, lawmakers weighed the impact of the coming cuts from the federal law at a general assembly , where some Democratic legislators said state efforts to protect reproductive health services and other programs were in jeopardy.

“We’ve been bracing for this reality: President Trump’s so-called ‘Big, Beautiful Bill’ is now law,” Democratic lawmaker Gregg Hart said at the hearing, calling it a “direct assault on California’s core programs and our values.”

“Sadly, the reality is, the state does not have the capacity to backfill all of these draconian federal funding cuts in the current budget,” Hart said. “We cannot simply write a check and make this go away.”

The sweeping budget law, which passed without any Democratic support, will reduce federal spending on Medicaid by about over the next decade, based on estimates from the . The spending reductions largely come from the imposition of a on people who’ve obtained Medicaid under the Affordable Care Act’s expansion, as well as other new barriers to coverage.

The law will mean more than 7.5 million people will lose Medicaid coverage and become uninsured, according to the Congressional Budget Office, while extending tax cuts for wealthy people who, Democrats say, don’t need them. Republicans and Trump have said the spending package and its accompanying program cuts were necessary to prevent fraud and waste, and to sustain Medicaid, a state-federal program for people with disabilities and lower incomes.

“The One Big Beautiful Bill removes illegal aliens, enforces work requirements, and protects Medicaid for the truly vulnerable,” the White House said in a .

The Medicaid cuts won’t begin until after the midterm elections in November 2026, but other cuts have already hit.

The Trump administration has sought to claw back earmarked to states because of the pandemic, spurring a with a coalition of Democratic-led states. It also in for mental health services in schools, and halted grants from the National Institutes of Health that provided money to more than 90 public universities.

HHS press secretary Emily Hilliard said the agency is prioritizing investments that advance Trump’s mandate to confront chronic disease. She defended some of the cuts and said, erroneously, that the spending law doesn’t cut Medicaid.

“The covid-19 pandemic is over, and HHS will no longer waste billions of taxpayer dollars responding to a crisis that Americans moved on from years ago,” she said.

State leaders say the pandemic funding the administration wants returned was earmarked for other public health measures, such as tracking emerging diseases, outbreak responses, and staffing. State attorneys general in May won a against the administration.

“What we’re seeing now is states anticipating big cuts in Medicaid coming, but they’re also dealing with a whole variety of federal cutbacks in public health programs that are smaller but still quite meaningful,” said , executive vice president for health policy at Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

Part of the challenge for states is simply understanding the changes.

“I think it’s fair to say there is concern, confusion, and uncertainty,” said Kathryn Costanza, a Medicaid expert at the National Conference of State Legislatures.

States are struggling to sort it all out, forming that are , suing to try to block the cuts, and reallocating funding.

In Colorado, lawmakers to let state Medicaid dollars pay for non-abortion care at Planned Parenthood of America clinics after Trump’s law banned federal funding for such care. Whether the ban holds up in court .

The Louisiana Legislature to state universities to make up for cuts to federal research funding, much of which goes to health-related research.

And in South Dakota, the state’s largest food bank has to make up for funding cuts to the U.S. Department of Agriculture.

States must balance their budgets every year, so cuts put many services at risk if state lawmakers are unwilling to raise taxes. The work will begin in earnest in January, when many states begin new legislative sessions.

And the tough choices are likely to continue. Congressional House Republicans are considering legislation that could , including by slashing the generous cost sharing the federal government provides for 20 million adults who enrolled in Medicaid under the ACA’s Medicaid expansion.

Some states will roll back their Medicaid expansions and cut more health programs as a result.

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Wieder is a member of the Confederated Salish and Kootenai Tribes in Montana and can access some health services free of charge through her tribe’s health clinics. But funding is limited, so, like a lot of Native American people, she relied on Medicaid for herself and Oakleigh.

Months before Oakleigh’s 1st birthday, the date when Wieder’s postpartum coverage would come to an end, Wieder completed and returned paperwork to enroll her daughter in Healthy Montana Kids, the state’s version of the Children’s Health Insurance Program. But her paperwork, caught up in the lengthy delays and processing times for applications, did not go through.

“As soon as she turned 1, they cut her off completely,” Wieder said.

It took six months for Wieder to get Oakleigh covered again through Healthy Montana Kids. Before health workers in her tribe stepped in to help her resubmit her application, Wieder repeatedly called the state’s health department. She said she would dial the call center when she arrived at her job in the morning and go about her work while waiting on hold, only for the call to be dropped by the end of the day.

“Never did I talk to anybody,” she said.

Wieder and Oakleigh’s experience is an example of the chaos for eligible Medicaid beneficiaries caused by the process known as the “unwinding,” which led to millions of people in the U.S. losing coverage due to paperwork or other procedural issues. Now, tribal health leaders fear their communities will experience more health coverage disruptions when new federal Medicaid work and eligibility requirements are implemented by the start of 2027.

The tax-and-spending law that President Donald Trump signed this summer exempts Native Americans from the new requirement that some people work or do another qualifying activity a minimum number of hours each month to be eligible for Medicaid, as well as from more frequent eligibility checks. But as Wieder and her daughter’s experience shows, they are not exempt from getting caught up in procedural disenrollments that could reemerge as states implement the new rules.

“We also know from the unwinding that that just doesn’t always play out necessarily correctly in practice,” said Joan Alker, who leads Georgetown University’s Center for Children and Families. “There’s a lot to worry about.”

The new law is projected to increase the number of people who are uninsured .

The lessons of the unwinding suggest that “deep trouble” lies ahead for Native Americans who rely on Medicaid, according to Alker.

Changes to Medicaid

Trump’s new law changes Medicaid rules to require some recipients ages 19 to 64 to log 80 hours of work or other qualifying activities per month. It also requires states to recheck those recipients’ eligibility every six months, instead of annually. Both of these changes will be effective by the .

The Congressional Budget Office that the law would reduce federal Medicaid spending by more than $900 billion over a decade. In addition, more than 4 million people enrolled in health plans through the Affordable Care Act marketplace are projected to become uninsured if Congress allows pandemic-era enhanced premium tax credits to expire at the end of the year.

Wieder said she was lucky that the tribe covered costs and her daughter’s care wasn’t interrupted in the six months she didn’t have health insurance. Citizens of federally recognized tribes in the U.S. can access some free health services through the Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives.

But free care is limited because Congress has historically failed to fully fund the Indian Health Service. Tribal health systems rely heavily on Medicaid to fill that gap. Native Americans are enrolled in Medicaid than the white population and have higher rates of chronic illnesses, die more from preventable diseases, and have less access to care.

Medicaid is to the Indian Health Service and other tribal health facilities and organizations. Accounting for about two-thirds of the outside revenue the Indian Health Service collects, it helps tribal health organizations pay their staff, maintain or expand services, and build infrastructure. Tribal leaders say protecting Medicaid for Indian Country is a responsibility Congress and the federal government must fulfill as part of their trust and treaty obligations to tribes.

Lessons Learned During the Unwinding

The Trump administration prevented states from disenrolling most Medicaid recipients for the duration of the public health emergency starting in 2020. After those eligibility checks resumed in 2023, nearly 27 million people nationwide were disenrolled from Medicaid during the unwinding, according to by the Government Accountability Office published in June. The majority of disenrollments — about 70% — occurred for procedural reasons, according to the federal Centers for Medicare & Medicaid Services.

CMS did not require state agencies to collect race and ethnicity data for their reporting during the unwinding, making it difficult to determine how many Native American and Alaska Native enrollees lost coverage.

The lack of data to show how the unwinding affected the population makes it difficult to identify disparities and create policies to address them, said Latoya Hill, senior policy manager with Â鶹ŮÓÅ’s Racial Equity and Health Policy program. Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health News.

The National Council of Urban Indian Health, which advocates on public health issues for Native Americans living in urban parts of the nation, analyzed the Census Bureau’s 2022 American Community Survey and Â鶹ŮÓÅ data in an effort to understand how disenrollment affected tribes. The council estimated had lost coverage as of May 2024. About 2.7 million Native Americans and Alaska Natives were enrolled in Medicaid in 2022, according to the council.

The National Indian Health Board, a nonprofit that represents and advocates for federally recognized tribes, has been working with federal Medicaid officials to ensure that state agencies are prepared to implement the exemptions.

“We learned a lot of lessons about state capacity during the unwinding,” said Winn Davis, congressional relations director for the National Indian Health Board.

Nevada health officials say they plan to apply lessons learned during the unwinding and launch a public education campaign on the Medicaid changes in the new federal law. “A lot of this will depend on anticipated federal guidance regarding the implementation of those new rules,” said Stacie Weeks, director of the Nevada Health Authority.

Staff at the Fallon Tribal Health Center in Nevada have become authorized representatives for some of their patients. This means that tribal citizens’ Medicaid paperwork is sent to the health center, allowing staff to notify individuals and help them fill it out.

Davis said the unwinding process showed that Native American enrollees are uniquely vulnerable to procedural disenrollment. The new law’s exemption of Native Americans from work requirements and more frequent eligibility checks is the “bare minimum” to ensure unnecessary disenrollments are avoided as part of trust and treaty obligations, Davis said.

Eligibility Checks Are ‘Complex’ and ‘Vulnerable to Error’

The GAO said the process of determining whether individuals are eligible for Medicaid is “complex” and “vulnerable to error” in a .

“The resumption of Medicaid eligibility redeterminations on such a large scale further compounded this complexity,” the report said.

It highlighted weaknesses across state systems. By April 2024, federal Medicaid officials had found nearly all states were out of compliance with redetermination requirements, according to the GAO. Eligible people lost their coverage, the accountability office said, highlighting the need to improve federal oversight.

In Texas, for example, federal Medicaid officials found that 100,000 eligible people had been disenrolled due to, for example, the state system’s failure to process their completed renewal forms or miscalculation of the length of women’s postpartum coverage.

Some states were not conducting ex parte renewals, in which a person’s Medicaid coverage is automatically renewed based on existing information available to the state. That reduces the chance that paperwork is sent to the wrong address, because the recipient doesn’t need to complete or return renewal forms.

But poorly conducted ex parte renewals can lead to procedural disenrollments, too. in Nevada were disenrolled by September 2023 through the ex parte process. The state had been conducting the ex parte renewals at the household level, rather than by individual beneficiary, resulting in the disenrollment of still-eligible children because their parents were no longer eligible. in the state were for procedural reasons — the highest in the nation, according to Â鶹ŮÓÅ.

Another issue the federal agency identified was that some state agencies were not giving enrollees the opportunity to submit their renewal paperwork through all means available, including mail, phone, online, and in person.

State agencies also identified challenges they faced during the unwinding, including an unprecedented volume of eligibility redeterminations, insufficient staffing and training, and a lack of response from enrollees who may not have been aware of the unwinding.

Native Americans and Alaska Natives have unique challenges in maintaining their coverage.

Communities in rural parts of the nation experience issues with receiving and sending mail. Some Native Americans on reservations . Others may not have permanent housing or change addresses frequently. In Alaska, mail service is often disrupted by severe weather. Another issue is the lack of reliable internet service on remote reservations.

Tribal health leaders and patient benefit coordinators said some tribal citizens did not receive their redetermination paperwork or struggled to fill it out and send it back to their state Medicaid agency.

The Aftermath

Although the unwinding is over, many challenges persist.

Tribal health workers in Montana, Oklahoma, and South Dakota said some eligible patients who lost Medicaid during the unwinding had still not been reenrolled as of this spring.

“Even today, we’re still in the trenches of getting individuals that had been disenrolled back onto Medicaid,” said Rachel Arthur, executive director of the Indian Family Health Clinic in Great Falls, Montana, in May.

Arthur said staff at the clinic realized early in the unwinding that their patients were not receiving their redetermination notices in the mail. The clinic is identifying people who fell off Medicaid during the unwinding and helping them fill out applications.

Marlena Farnes, who was a patient benefit coordinator at the Indian Family Health Clinic during the Medicaid unwinding, said she tried for months to help an older patient with a chronic health condition get back on Medicaid. He had completed and returned his paperwork but still received a notice that his coverage had lapsed. After many calls to the state Medicaid office, Farnes said, state officials told her the patient’s application had been lost.

Another patient went to the emergency room multiple times while uninsured, Arthur said.

“I felt like if our patients weren’t helped with follow-up, and that advocacy piece, their applications were not being seen,” Farnes said. She is now the behavioral health director at the clinic.

Montana was one of five states where more than 50% of enrollees lost coverage during the unwinding, . The other states are Idaho, Oklahoma, Texas, and Utah. who lost coverage were disenrolled for procedural reasons.

In Oklahoma, eligibility redeterminations remain challenging to process, said Yvonne Myers, a Medicaid and Affordable Care Act consultant for Citizen Potawatomi Nation Health Services. That’s causing more frequent coverage lapses, she said.

Myers said she thinks Republican claims of “waste, fraud, and abuse” are overstated.

“I challenge some of them to try to go through an eligibility process,” Myers said. “The way they’re going about it is making it for more hoops to jump through, which ultimately will cause people to fall off.”

The unwinding showed that state systems can struggle to respond quickly to changes in Medicaid, leading to preventable erroneous disenrollments. Individuals were often in the dark about their applications and struggled to reach state offices for answers. Tribal leaders and health experts are raising concerns that those issues will continue and worsen as states implement the requirements of the new law.

Georgia, the only state with an active Medicaid work requirement program, has shown that the changes can be difficult for individuals to navigate and costly for a state to implement. More than 100,000 people have applied for Georgia’s Pathways program, but only as of the end of July.

Alker, of Georgetown, said Congress took the wrong lesson from the unwinding in adding more restrictions and red tape.

“It will make unwinding pale in comparison in terms of the number of folks that are going to lose coverage,” Alker said.

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

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