State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a 麻豆女优 Health News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat 鈥� or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price 鈥� both in the cost to taxpayers and coverage losses 鈥� according to state documents obtained by 麻豆女优 Health News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly will lose access to monthly cash assistance for food, including those with children.

In five states alone, for state officials and reviewed by 麻豆女优 Health News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting company Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will . Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company that operates the state’s eligibility system.

Optum 鈥� which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act 鈥� to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, . And in Illinois, will cost at least $12 million.

A Historic Mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules 鈥� .

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements 鈥� about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was as of October.

of adult Medicaid enrollees nationally are already working, according to 麻豆女优. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the .

In Wisconsin, state officials estimate could lose coverage after work requirements take effect. Not covering those people would in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP 鈥� known as CARES 鈥� in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New Hurdles for Vets and Homeless People

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults 鈥� doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year . , initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government 鈥� that is, taxpayers 鈥� to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems 鈥� as D.C. is 鈥斅� I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to 麻豆女优 Health News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” 麻豆女优 Health News found that Deloitte, a global consultancy that generated in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 Million Bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a .

Adding the ability to verify work status would cost up to $7 million, . By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions . Accenture’s analysis said the federal law necessitated . Making employment a condition of Medicaid benefits could cause an estimated 32,000 Iowans to lose coverage, according to a

Cutting 32,000 people from coverage in one year, a fraction of the Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level 鈥� currently .

“There is no benefit to this population,” Lock said.

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that 鈥� priced at $12 million 鈥� is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” , the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time 鈥� supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 鈥� Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

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LISTEN: In this audio portrait of homeless people displaced by the Trump administration’s crackdown on encampments in the nation’s capital, 麻豆女优 Health News senior correspondent Angela Hart tells of residents living outside this winter and their search for medical care and shelter.

January’s extreme cold has put a spotlight on the conditions homeless people face. They get sicker and die younger than housed people, often because health problems go untreated. The Trump administration’s in Washington, D.C., has made it more difficult for health workers to reach that vulnerable population this winter.

麻豆女优 Health News senior correspondent Angela Hart takes WAMU “Health Hub” listeners to Washington’s streets to hear how homeless people are juggling their health and shelter after the Trump administration’s crackdown.

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Scattered visits to free clinics notwithstanding, Guevara hadn’t had a full medical checkup in years. She required dental work. She wanted to start looking for a job. And she was overwhelmed by the maze of paperwork needed simply to get her off the street, much less to make any of the other things happen.

But Guevara had help. The Jamboree Housing Corp., an affordable-housing nonprofit that renovated the former Stanton, California, hotel Guevara now calls home, didn’t just move her in 鈥� it also provided her a fleet of wraparound services. Jamboree counselors helped Guevara navigate the health care system to see a doctor and a dentist, buy a few things for her apartment, and get training to become a caregiver.

“I was years on the street before I got the kind of help I needed so I could help myself,” said Guevara, 68.

Amid the Trump administration’s apparent opposition to using Medicaid funding for such social services, staffers at Jamboree and similar affordable housing providers in California have been worried about losing federal money, particularly as the experimental waivers that provide the primary funding for the program they rely on expire at the end of 2026. But as it turns out, the state had the foresight several years ago to designate certain nonhousing social services, such as mental health care, drug counseling, and job training, as a form of Medicaid spending that will continue to be reimbursed.

Catherine Howden, a spokesperson for the federal Centers for Medicare & Medicaid Services, confirmed that California’s use of the “in lieu of services” classification for these wraparound programs is allowed under federal regulations.

“It is starting to sound positive that we will, at the very least, be able to continue billing for these services after the waiver period,” said Natalie Reider, a senior vice president at Jamboree Housing.

During President Donald Trump’s first term, states were permitted to use Medicaid money for social support services not typically covered by health insurance. But the second Trump administration is , saying that the intervening Biden administration took the supportive services process too far. Howden said in a statement that the policy “distracted the Medicaid program from its core mission: providing excellent health outcomes for vulnerable Americans.”

Through CalAIM, a five-year experimental build-out of the Medicaid system, programs like Jamboree were able to leverage federal funding to offer the kinds of nonhousing social services that experts contend are essential to keeping people permanently housed.

However, these wraparound services are only one component of the CalAIM initiative, which is attempting to take Medicaid, known as Medi-Cal in California, in a more holistic direction across all areas of care. And when CalAIM launched, California officials gave the programs the Medicaid “in lieu of services” designation, known as ILOS, effectively putting them outside the waiver process and ensuring that even when CalAIM sunsets, money for those social initiatives will continue to flow.

“California has tried to future-proof many of the policy changes it has made in Medi-Cal by including them in mechanisms like ILOS that do not require federal waiver approval,” said Larry Levitt, executive vice president for health policy at 麻豆女优, a health information nonprofit that includes 麻豆女优 Health News. “That allows these policy changes to continue, even with a politically hostile federal administration.”

The designation allows these social services to be funded through Medicaid managed-care plans under existing federal laws because they are cost-effective substitutes for a Medicaid service or reduce the likelihood of patients needing other Medicaid-covered health care services, said Glenn Tsang, policy adviser for homelessness and housing at the state’s Department of Health Care Services. The state could not provide an estimate of the annual funding for these wraparound services because they are not distinguished from other payments made to Medicaid managed-care plans.

“We are full steam ahead with these services,” Tsang said, “and they are authorized.”

Although California was the first state to incorporate the designation for such housing and other health-related social support, Tsang said, several other states 鈥� including Arizona, Arkansas, Florida, New York, and North Carolina 鈥� are now using the mechanism in a similar fashion.

Early results suggest such support saves on health care spending. When Jamboree, in Northern California, in the Central Valley, and other permanent supportive housing providers employ a holistic approach that includes social services, they have reported higher rates of formerly homeless people remaining in housing, less frequent use of costly emergency health services, and more residents landing jobs that help them pay rent and stay housed.

At the nonprofit MidPen Housing, which serves 12 counties in and around the San Francisco Bay Area, roughly 40% of the units in the program’s pipeline are earmarked for “extremely low-income” people, a group that includes the homeless, said Danielle McCluskey, senior director of resident services.

CalAIM reimbursements help fund the part of MidPen that focuses on supportive services across a wide range of experiences, from chronic homelessness to mental health issues to those leaving the foster care system. McCluskey described it as one leg of a three-legged stool, the others being real estate development and property management.

“If any of those legs are not getting what they need, if they’re not funded or not staffed or resourced, then that stool is kind of wobbly 鈥� off-kilter,” the director said.

A recent found that people who used at least one of the housing support services 鈥� including navigation into new housing, health care assistance, and a 鈥� saw a 13% reduction in emergency department visits and a 24% reduction in inpatient admissions in the six months that followed.

Documenting those outcomes is critical because the department needs to show federal officials that the services lessen the need for other, often costlier Medicaid-covered care 鈥� the essence of the classification.

Advocates for the inclusion of supportive services argue that the American system ultimately saves money on those investments. As California’s homeless population to more than 187,000 on a given night 鈥� nearly a quarter of the U.S. total 鈥� Jamboree has been allocating more of its resources to permanent supportive housing.

Founded in 1990 in Orange County, Jamboree builds various types of affordable housing using federal, state, and private funding. Reider said about a fifth of the organization’s portfolio is dedicated to permanent supportive housing.

“They’re not going back out to the streets. They’re not going to jail. They’re not going to the hospitals,” Reider said. “Keeping people housed is the No. 1 outcome, and it is the cost-saver, right? We’re using Medicaid dollars, but we’re saving the system money in the long run.”

Guevara, who wound up on the streets after a falling-out with family in 2015, spent years living out of her truck before a shelter worker connected her with Jamboree. There, she was paired with a specialist to help her figure out how to get and see a doctor, and to keep up with scheduling the battery of medical tests she needed after years spent living in temporary shelters.

“I also got a job developer, who helped me get this job with the county so I can pay my rent,” Guevara said of her position as a part-time in-home caregiver. “Now I take care of people kind of the same way people have been taking care of me.”

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But inside, the store is a welcoming oasis. Twinkly string lights adorn racks of donated clothing. Shelves and bins overflow with children’s books, allergy medications, and toiletries. Curtains cordon off one side of the room, where there’s a stage for musicians and a neon sign depicting roller skates for weekly free skate nights.

The space is part free thrift store, part over-the-counter pharmacy, part punk show venue 鈥� and wholly “a radical community center,” said Dan Bingler, who runs the place.

Bingler is a waiter and bartender in the city who founded a mutual-aid organization called the . He said the building owners allow him to use the space as long as he pays the water, electricity, and trash bills.

On Monday evenings, volunteers from other community organizations show up 鈥� some used to set up in the parking lot before Bingler opened the store. They offer free testing for sexually transmitted infections, basic medical care, hot meals, and sterile syringes and other supplies for people who use drugs.

The purpose of the space is simple, Bingler said: “We’re going to make sure we provide for the community.”

Although it’s been open for a few years now, the space has become even more crucial to this community in recent months, with the Trump administration slashing funding for many social service organizations and taking an aggressive approach to homelessness and drug use. In Washington, D.C., the administration has to push people living on the street to . Nationally, it has called for people who use drugs to be . It has 鈥� practices that public health experts say keep people who use drugs safe and alive but that critics say promote illegal drug use.

The community space in New Orleans 鈥� named the Fred Hampton Free Store after the known for bringing together diverse groups to fight for social reforms 鈥� aims to be a haven among this sea of changes.

It doesn’t receive federal funding, state or local grants, or money from foundations, Bingler said. It’s simply neighbors helping neighbors, he said, tearing up and adding, “It’s a really beautiful thing to be able to share all this space.”

All items inside are provided by people or organizations in the community. Bingler said one time a local hotel undergoing renovations donated 50 flat-screen TVs.

On nights the store is open, often more than 100 people visit, Bingler said.

One fall evening, dozens of people browsed for free clothing and over-the-counter medications. Others sat on the grass outside, chatting while keeping an eye on their bicycles or grocery carts full of possessions.

James Beshears stopped by the harm reduction group in the parking lot to get sterile supplies he uses to inject heroin and fentanyl. He said he’d been in treatment for years but relapsed after his doctor moved away and he was referred to a clinic that charged $250 a day. Street drugs were cheaper than treatment, he said.

He wants to stop. But until he can find affordable care, places like the free store keep him going. Without it, he said, he’d have “one foot in the grave.”

Another man in the parking lot was waiting for the arrival of Aquil Bey, a paramedic and former Green Beret well known for helping people overcome obstacles to getting health care. As soon as the man spotted Bey’s black Jeep, he ran up.

“I’ve got stage 4 kidney disease,” the man said, adding that he was scheduled for treatments at a hospital but was struggling to get there.

“Do me a favor,” Bey said as he unloaded folding tables and medical equipment from his car. “When our team gets here, come and see us. Maybe we can get you transportation.”

Bey is the founder of , a volunteer-run organization that provides free basic medical care and referrals for people who are homeless, using drugs, or part of other vulnerable communities. The group has a steady presence at the free store.

That day, Bey and his team connected the man needing kidney disease treatment to reduced-cost transit programs. They also did blood pressure and blood sugar checks for anyone who wanted them, cleaned infected wounds, and called clinics to make appointments for patients without phones.

A man with a leg injury mentioned he was sleeping on the concrete floor of an abandoned naval base. Bey noticed the free store’s furniture section had a mattress. He and another volunteer hauled it out, strapped it to the top of a car, and delivered it to where the man was sleeping.

“We’re just trying to find all these barriers” that people face and “find ways to fix them,” Bey said.

The clinic at the free store helped Stephen Wiltz connect with addiction care. He grew up in the Lower 9th Ward and had been using drugs since he was 10.

Fed up with discrimination from doctors who blamed him for his addiction, Wiltz said, he was reluctant to go to any treatment facility. But after years of knowing the volunteers at the free store, he trusted them to point him in the right direction.

At 56, Wiltz was in sustained recovery for the first time in his life, he said during a phone interview in the fall.

Those volunteers “cared for people who didn’t have nobody to care for them,” he said.

As the sun went down that fall evening at the store, a punk band started setting up for a show across the room from the medical clinic. Lights dimmed and music blared 鈥� a reminder that this was not your everyday clinic or community center.

Bey continued consulting with a patient who had gout.

“I get used to the sound,” Bey said of the rapid drums and loud power chords. “I like it sometimes.”

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Residents share rooms designed to be accessible to those with mobility issues. There are also private bathrooms, which are a big deal for seniors struggling with incontinence.

Unlike the MVP, most homeless shelters aren’t equipped to help seniors, especially those 65 and older. They are the fastest-growing homeless population nationwide, according to , a researcher at the University of Pennsylvania. Not only are people who struggle with chronic homelessness aging, but many seniors are becoming homeless for the first time in their lives.

Getting in and out of bunks, managing medications, and making it to a shared bathroom in time are among the major challenges of shelter life for older adults. Staff at traditional shelters sometimes ask seniors to leave if they’re unable to care for themselves.

The MVP is unusual among shelters because it provides on-site medical care to better serve its residents as they age.

Last spring, Jamie Mangum, who is in her 50s and has lung cancer, tripped and fell in her room. To visit with an emergency medical technician, she needed only to make it downstairs. Her swollen wrist was quickly wrapped, and she returned to her room. She said that wouldn’t have been possible at other shelters she’s stayed in.

“There, I’d have to wait hours as opposed to come in here, be seen,” Mangum said.

Mangum said that in other shelters she’d likely have had to find her own way to an urgent care office or get an ambulance ride. Specialized case managers at the MVP have helped her get treatment for lung cancer as well.

“We have clients that need memory care. Maybe they were living independently before, but they were unable to maintain that and got evicted due to dementia or different things like that,” said Baleigh Dellos, who manages the MVP shelter for , a local nonprofit.

Specialized medical case managers work at the shelter. Primary care doctors and therapists visit weekly. Residents can even receive physical therapy in private spaces on-site.

A Path to Stability

The MVP partnered with the to offer medical care.

The first thing most new residents need help with is medication, said Matt Haroldsen with the Fourth Street Clinic, which provides health services at the shelter.

For people living on the streets, just keeping hold of regular medications is a challenge. “Their medications get jacked when they’re in their camps,” he said.

Diabetes patients without homes often bury their insulin to keep it cold. Haroldsen said they might forget where they buried it, or the vials might get too warm and spoil.

Helping residents at the shelter get those medications can stabilize their conditions, allowing them to focus on other priorities, such as getting an ID and other documents they need to apply for disability, Social Security, and various programs that can help them secure housing.

Nonprofits and local governments have opened similar shelters in Florida, California, and Arizona to meet the needs of older unhoused adults.

Having access to specialized shelters can be the difference between life and death, said , assistant director of the National Health Care for the Homeless Council.

In cold-weather states, denying seniors a bed because of mobility and other health issues can be especially risky. In 2022, a Bozeman, Montana, after he was asked to leave a shelter because of incontinence.

Complex medical needs can pose a danger to other residents that most shelters aren’t prepared to manage.

“A typical shelter doesn’t allow somebody on oxygen to come in because that’s such a fire hazard and risk,” she said.

Synovec said giving seniors better access to health care inside shelters is the best way to help them succeed once they get housing. Health issues are a common reason seniors can’t afford or maintain housing, she said.

A Growing Model

The MVP model is showing promise, both in Utah and elsewhere.

“Over 80% of the people who’ve stayed in our program this past year have moved into stable or permanent housing,” said , vice president of programs for the TaskForce for Ending Homelessness in Fort Lauderdale, Florida. The nonprofit runs a shelter called .

The MVP shelter near Salt Lake City is also marking success. It was able to permanently house 36 seniors as of late last year.

Still, there are more seniors in need of shelter than it can accommodate. Dellos, the shelter’s manager, said the MVP’s waitlist hovers around 200 people. She said the shelter prioritizes people based on medical need, not time spent on the waitlist.

For residents who do get a room, it’s life-changing.

Last spring, 62-year-old Jeff Gregg was playing fetch with his dog, Ruffy, just beyond the lawn in front of the MVP.

An old back injury forced Gregg to hunch over as he threw the ball. It also fueled a decades-long addiction to opioids. That cycle was hard to escape, he said.

“Fighting that, having a job, insurance, then losing the job, not having insurance, going out to the streets and being back in that crap, and I’d be back in the same position,” he said.

Gregg said sobriety took a back seat to more immediate needs like finding food and a bed in a shelter. He said the MVP was the first place where he could relax and focus on recovery.

“I was able to get clean. It took me a couple months, but I just kept plucking away,” he said.

He said the experience paved the way for him to get back surgery. He hopes that with less back pain, he can eventually get a job to help him afford an apartment.

This article is part of a partnership with and .

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“That’s what I’m trying to avoid,” said Ferguson, who still calls Quincy Jackson III her baby. She remembers a boy who dressed himself in three-piece suits, donated his allowance, and graduated high school at 16 with an academic scholarship and plans to join the military or start a business.

Instead, Ferguson watched as her once bright-eyed, handsome son sank into disheveled psychosis, bouncing between family members’ homes, homeless shelters, jails, clinics, emergency rooms, and Ohio’s regional psychiatric hospitals.

Over the past year, The Marshall Project – Cleveland and 麻豆女优 Health News interviewed Jackson, other patients and families, current and former state hospital employees, advocates, lawyers, judges, jail administrators, and national behavioral health experts. All echoed Ferguson, who said the mental health system makes it “easier to criminalize somebody than to get them help.”

State psychiatric hospitals nationwide have largely lost the ability to treat patients before their mental health deteriorates and they are charged with crimes. Driving the problem is a meteoric rise in the share of patients with criminal cases who stay significantly longer, generally by court order.

Patients Wait or Are Turned Away

Across the nation, psychiatric hospitals are short-staffed and consistently turn away patients or leave them waiting with few or no treatment options. Those who do receive beds are often sent there by court order after serious criminal offenses.

In Ohio, the share of state hospital patients with criminal charges jumped from about half in 2002 to .

The surge has coincided with a steep decline in total state psychiatric hospital patients served, down 50% in Ohio in the past decade, from 6,809 to 3,421, according to the . During that time, total patients served nationwide dropped about 17%, from 139,434 to 116,320, with state approaches varying widely, from adding community services and building more beds to closing hospitals.

Ohio Department of Behavioral Health officials declined multiple interview requests for this article.

The decline in capacity at state facilities unfurled as a spate of local hospitals across the country shuttered their psychiatric units, which disproportionately serve patients with Medicaid or who are uninsured. And the financial stability of is likely to deteriorate further after Congress passed President Donald Trump’s One Big Beautiful Bill Act, which slashes nearly $1 trillion from the federal Medicaid budget over the next decade.

The constricted flow of new patients through state hospitals is “absolutely” a crisis and “a huge deal in Ohio and everywhere,” said retired Ohio Supreme Court Justice Evelyn Lundberg Stratton. As co-chair of the state attorney general’s , Lundberg Stratton has spent decades searching for solutions.

“It hurts everybody who has someone who needs to get a hospital bed that’s not in the criminal justice system,” she said.

鈥業t’s Heartbreaking’

Quincy Jackson III’s white socks stuck out of the end of a hospital bed as police officers stood watch.

At 5 feet, 7 inches tall, Jackson has a stocky build and robotic stare. Staff at Blanchard Valley Hospital in Findlay, Ohio, had called for help, alleging Jackson had assaulted a security guard.

“I’m sick; I take medication,” Jackson said to the officers, according to law enforcement body camera footage. His hands were cuffed behind his back as he lay on the bed, a loose hospital gown covering him.

Ferguson called it one of his “episodes” and said her son experienced severe psychosis frequently. In one incident, she said, Jackson “went for a knife” at her home.

From December 2023 through this July, Jackson was arrested or cited in police reports on at least 17 occasions. He was jailed at least five times and treated more than 10 times at hospitals, including three state-run psychiatric facilities. A recent psychiatric evaluation noted that Jackson has been in and out of community and state facilities since 2015.

Jackson is among a glut of people nationwide with severe mental illness who overwhelm community hospitals, courtrooms, and jails, eventually leading to backlogs at state hospitals.

High-Profile Incidents

That dearth of care is often cited by families, law enforcement authorities, and mental health advocates after people struggling with severe mental illness harm others. In the past six months, at least four incidents made national headlines.

In August, a homeless reportedly diagnosed with schizophrenia fatally stabbed a woman on a train. Also in August, police said a with a history of mental health issues killed three people, including a child, at a Target store. In July, a homeless who family members said had needed treatment for decades attacked 11 people at a Walmart store with a knife. In June, police shot and killed a reportedly diagnosed with schizophrenia after authorities said he attacked law enforcement.

Mark Mihok, a longtime municipal judge near Cleveland, told a spring that he had never seen so many people with serious mental illnesses living on the streets and “now punted into the criminal justice system.”

37-Day Wait for a Bed

At Blanchard Valley Hospital, sheriff’s deputies had taken Jackson from jail for a mental health check. But Jackson’s actions raised concerns.

In the body camera video, a nurse said Jackson was “going to be here all weekend. And we’re going to be calling you guys every 10 minutes.”

The officer responded: “Yeah, well, if he keeps acting like that, he’s going to go right back” to the county jail.

Within minutes, Jackson was taken back to jail, yelling at the officers: “Kill me, motherf—–. Yeah, shoot them, shoot them. Pop!”

Statewide, Ohio has about 1,100 beds in its six regional psychiatric hospitals. In May, the median wait time to get a state bed was 37 days.

That’s “a long time to be waiting in jail for a bed without meaningful access to mental health treatment,” said Shanti Silver, a senior research adviser at the national nonprofit Treatment Advocacy Center.

Long waits, often leaving people who need care lingering in jails, have drawn lawsuits in several states, including , , and , where a large 2014 class action case forced systemic changes such as expansion of crisis intervention training and residential treatment beds.

Ohio officials noticed bed shortages as early as 2018. State leaders assembled task forces and . They launched community programs, crisis units, and a statewide emergency hotline.

Yet backlogs at the Ohio hospitals mounted.

Ohio Department of Behavioral Health Director LeeAnne Cornyn, who left the agency in October, wrote in a May emailed statement that the agency “works diligently to ensure a therapeutic environment for our patients, while also protecting patient, staff, and public safety.”

Eric Wandersleben, director of media relations and outreach for the department, declined to respond to detailed questions submitted before publication and, instead, noted that responses could be publicly found in a governor’s working group report .

Elizabeth Tady, a hospital liaison who also spoke to judges and lawyers at the May gathering, said 45 patients were waiting for beds at Northcoast Behavioral Healthcare, the state psychiatric hospital serving the Cleveland region.

“It’s heartbreaking for me and for all of us to know that there are things that need to be done to help the criminal justice system, to help our communities, but we’re stuck,” she said.

Ohio officials added 30 state psychiatric beds by in Columbus and are planning in southwestern Ohio.

Still, Ohio Director of Forensic Services Lisa Gordish told the gathering in Cleveland that adding capacity alone won’t work.

“If you build beds 鈥� and what we’ve seen in other states is that’s what they’ve done 鈥� those beds get filled up, and we continue to have a waitlist,” she said.

This year, Jackson waited 100 days in the and Montgomery County jail for a bed at a state hospital, according to jail records.

Ferguson said she was afraid to leave him there but could not bail him out, in part, she said, because her son cannot survive on his own.

“There’s no place for my son to experience symptoms in the state of Ohio safely,” Ferguson said.

Sick System

Patrick Heltzel got the extended treatment Ferguson has long sought for her son, but he stabbed a 71-year-old man to death before getting it.

The 32-year-old is one of more than receiving treatment in Ohio’s psychiatric hospitals.

“People need long-term care,” Heltzel said in October, calling from inside Heartland Behavioral Healthcare, near Canton, where he has lived for more than a decade after being found not guilty by reason of insanity of aggravated murder. Inpatient care, he said, helps patients figure out what medication regimen will work and deliver the therapy needed “to develop insight.”

As he spoke, the sound of an open room and patients chatting filled the background.

“You have to know, 鈥極K, I have this chronic condition, and this is what I have to do to treat it,’” Heltzel said.

As the ranks of criminally charged patients in Ohio’s hospitals have increased over the past decade, the shift has had an impact on patient care: The hospitals have endangered patients, have become more restrictive, and are understaffed, according to interviews with Heltzel, other patients, and former staff members, as well as documents obtained through public records requests.

Escapes and a Lockdown

Katie Jenkins, executive director of the National Alliance on Mental Illness Greater Cleveland, said the shift from mostly civil patients, who haven’t been charged with a crime, to criminally charged patients has changed the hospitals.

“It’s hard in our state hospitals right now,” she said. Unfortunately, she said, patients who have been in jail bring that culture to the hospitals.

In the first 10 months of 2024, at least nine patients escaped from Ohio’s regional psychiatric hospitals 鈥� compared with three total in the previous four years, according to .

, two female patients at Summit Behavioral Healthcare near Cincinnati escaped after one lunged at a staff member. In another, a man broke a window and climbed out.

Most of the escapes, though, were not violent. Days after a patient at Northcoast during a trip to the dentist in a Cleveland suburb, state officials stopped allowing patients to leave any of the six regional hospitals.

to leaders at the hospitals said officials had seen “similarities across multiple facilities,” raising significant concern about “ensuring patient and public safety.”

For Heltzel, the inability to go on outings or to his mother’s house on the weekends was a setback for his treatment. In 2024, when the lockdown began, he had more freedom than most patients at the psychiatric hospitals, regularly leaving to go to the local gym and attend off-site group therapy.

His mother signed him out each Friday to go home for the weekend, where he drove a car and played with his 2-year-old German shepherd, Violet. On Sundays, Heltzel was part of the “dream team” at church, volunteering to operate the audio and slides.

Federal records reveal that, at Ohio’s larger state-run psychiatric hospitals, including Summit and Northcoast, patients and staff have faced imminent danger.

In 2019 and 2020, federal investigators responded to patient deaths, including two suicides in six months at Northcoast. One hospital employee told federal inspectors, “The facility has been understaffed for a while and it’s getting worse,” according to . “It is very dangerous out here.”

Disability Rights Ohio, which has a federal mandate to monitor the facilities, in October against the department. The advocacy group, alleging abuse and neglect, asked for records of staff’s response to a Northcoast patient who suffocated from a plastic bag over their head. At the end of October, the court docket showed the parties had settled the case.

Retired sheriff’s deputy Louella Reynolds worked as a police officer at Northcoast for about five years before leaving in 2022. She said the increase in criminally charged patients meant the hospitals “absolutely” became less safe. Her hip still hurts from a patient who threw her against a cement wall.

Reynolds said officers should be able to carry weapons, which they don’t, and that more staff are needed to handle the patients. Mandatory overtime was common, she said, and often staff would report to work and not “know when we would get off.”

A Disaster That Wasn’t Averted

Back at Heartland, Heltzel requested conditional release. The judge denied the release request.

Heltzel said it was devastating. He grew up Catholic and said, “I was kind of looking for absolution.”

Now, Heltzel said he is practicing acceptance. “Acceptance is all the more important to practice when you don’t agree with something,” Heltzel said, adding, “I’m a ward of the state.”

He still hopes to be released: “I just do what I can to move forward.”

Heltzel, like Jackson, had been hospitalized before and released.

In early 2013, Heltzel said, he asked his dad to kill him. “And he refused and I did smack him,” he said. Heltzel was sent to Heartland for a short stay 鈥� about 10 days, according to his mother, Jan Dyer. She recalled “begging” the hospital staff to keep him.

Heltzel said he remembers not being ready to leave: “I was still sick, and I was still delusional.” Back at home, he said, he had a “sense of existential dread, like that all this horrible stuff was going to happen.” He stopped taking his medication.

Within weeks, Heltzel killed 71-year-old Milton A. Grumbling III at his home, placing him in a chokehold and stabbing him repeatedly, according to . He beat him with a remote control and then left, taking a Bible from the home, as well as a ring. Delusional with schizophrenia, Heltzel believed that Grumbling had sexually abused him in another life, according to the records.

A family member of the man he killed told the judge in 2023 that Heltzel should “stay in prison,” according to .

In denying his conditional release, judges cited Heltzel’s failure to take medication before killing Grumbling.

Jenkins, who said she worked at a state hospital for nine years before becoming the lead advocate for NAMI Greater Cleveland, said psychiatric medications can take as long as six weeks to become fully effective.

“So clients aren’t even getting stabilized when they’re being hospitalized,” Jenkins said.

鈥楬e’s Not a Throwaway Child’

In a July interview, Jackson said inconsistent care or unmedicated time in jail “worsens my symptoms.” Jackson was on the phone during a stay at a state psychiatric hospital.

Without medicine, “my head hurts, to be honest,” Jackson said, before asking to get off the phone because he was hungry. It was lunchtime. “Can you get the information from my mom?” Jackson said. “She has the records.”

After Jackson hung up the phone, Ferguson explained that “he says the food is excellent, so he does not want to miss it.” And, she added, the hospital staff had not yet seen the explosive side of her son.

In early September, after 45 days at Summit 鈥� his longest stay yet at a state psychiatric hospital 鈥� Jackson returned to the Montgomery County jail facing misdemeanor charges because of with staff at a Dayton behavioral health hospital. In court, Ferguson said, her son struggled to explain to the judge why he was there. On a video call from the jail days later, she saw him playing with his hair and ears.

“That tells me he’s not OK,” Ferguson said.

Before Jackson’s diagnosis more than a decade ago, Ferguson said, her son wasn’t a troublemaker. He had goals and dreams. And he’s still “loved and liked by a lot of people.”

“He’s not a throwaway child,” she said.

 is a nonprofit news team covering Ohio’s criminal justice systems.

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As night falls and temperatures drop, he erects a tent and builds a fire beneath a canopy of pine, hemlock, and cedar trees.

He evades authorities by rotating use of three tents of different colors at three campsites. As day breaks, he dismantles his shelter, rolls up his belongings, and hides them for the next night. “They don’t see you if you’re in the woods,” the 32-year-old said. “But make sure it’s broken down by morning or they’ll find you.”

During the day, he wanders, stopping at a public library to warm up or a soup kitchen to eat. What’s important is to not draw attention to himself for being homeless.

“Police want us out of the way,” he said, dressed in a gray jacket and carrying none of his possessions. “Out of sight, out of mind.”

Ibrahim has been deliberate about blending in since August, when President Donald Trump placed the district’s police under and ordered National Guard soldiers to patrol its streets. The president homeless people to leave immediately. “There will be no 鈥楳R. NICE GUY,’” .

The Trump administration says encampment sweeps have reduced the visibility of homelessness, thereby enhancing the city. “There is no disputing that Washington, DC is a safer, cleaner, and more beautiful city thanks to President Trump’s historic actions to restore the nation’s capital,” White House spokesperson Taylor Rogers said.

While there may appear to be fewer homeless people in the nation’s capital now, they have not disappeared.

In interviews, homeless people said they are in a constant shuffle, hiding in plain sight. During the day, they stay on the move, grabbing meals at soup kitchens and resting on occasion in public libraries, on park benches, or at bus stops. At night, many unsheltered people bed down in business doorways, on park sidewalks, and on church stoops. Some ride the bus all night, while a few shelter in emergency rooms. Others find respite in the woods or flee to suburbs in Virginia or Maryland.

There are about 5,100 homeless people in Washington, D.C., including in temporary shelters, according to an . After Trump ordered the crackdown on public homelessness, people living in makeshift communities scattered and are now living in the shadows. City officials estimated in August that homeless people were living outdoors without tents or other shelter.

As winter draws near, they are exposed to the elements and grow sicker as chronic ailments such as diabetes and heart disease go untreated. Street medicine providers say that, since the National Guard was deployed, they have faced enormous difficulty finding patients. Many caught up in sweeps have had their lifesaving medications thrown away, and they are more likely to miss medical appointments because they are constantly on the move. Street medicine providers say they can’t find their patients to deliver medication or transport them to medical appointments. The constant chaos can suck patients with mental illness and substance use deeper into drug and alcohol addiction, raising the risk of overdose.

Caseworkers report similar disruptions, saying as clients get lost, they break connections essential for obtaining housing documents, particularly IDs and Social Security cards.

District officials and health providers say this cascade will make homelessness worse, threatening public health and public safety and racking up enormous costs for the health care system.

“It was already hard locating people, but the federal presence just made it worse,” said Tobie Smith, a street medicine doctor and the executive director of Street Health D.C.

The Homeless Shuffle

Chris Jones was born and raised in Washington, D.C., but now is homeless, having been pushed out of his tent near the White House in the initial days of the federal homelessness crackdown. He said two of his tents were taken during sweeps. Now, sleeping on a sidewalk outside a church, he doesn’t bother trying to get another one. “Why? What’s the point? It’ll just get thrown away again.”

Jones, 57, has a severe knee injury that prevents him from walking some days and said he was scheduled for a knee replacement in December. He said it’s important to stay where he is 鈥� he relies on a nearby drugstore to refill his medications for bipolar disorder, diabetes, and high blood pressure. When he’s hungry, he goes to a soup kitchen for a meal or tries to get a cheeseburger and a soda from a fast-food joint across the street.

It’s important for him to stay outside the church, he said, so his case manager can find him when a permanent housing slot opens up. If it gets too cold, he said, he will cross the street and sleep in the doorway of a business, which can provide a bit more shelter. He wants to get indoors, but for now, he waits.

Since taking control of Washington’s police force, the Trump administration has on cities and counties across the nation to clear homeless encampments under threat of arrest, citation, or detention. It has ordered or threatened similar National Guard deployments in Los Angeles; ; and other cities with large homeless populations.

Rogers, the White House spokesperson, said the president is maintaining National Guard and federal law enforcement presence in the nation’s capital “to ensure the long-term success of the federal operation.” Since March, city and federal officials have removed more than 130 homeless encampments, she said, though some local homelessness experts say that number could be inflated.

The Supreme Court last year for elected officials and law enforcement to fine or arrest homeless people for living outside. Then, in July of this year, the president issued an executive order calling for a nationwide crackdown on urban camping, including a massive removal of people living outdoors and forced mental health or substance use treatment.

Trump is also spearheading an overhaul of homelessness policy, moving to and services for homeless people. The move would limit the use of a long-standing federal policy known as “” that offers housing without mandating mental health or addiction treatment. The National Alliance to End Homelessness warns the move risks displacing in permanent supportive housing. The Department of Housing and Urban Development paused the plan on Dec. 8 to make revisions, which it “intends” to do, .

City officials say they are complying with the Trump administration’s forceful campaign against homeless people sheltering outside. Pressured by the White House, local officials said they’ve gotten more aggressive in breaking up camps. Advocates for homeless people say some of the sweeps have been conducted at night and others with little or no notice to move. City leaders believe they could be done more compassionately by offering services and shelter.

“We’ve pivoted from the notion of allowing encampments if they didn’t violate public health or safety to a position of, 鈥榃e don’t want you in the streets,’” said Wayne Turnage, deputy mayor for District of Columbia Health and Human Services, who oversees encampment cleanups. “It’s unsafe, it’s unhealthy, and it’s dangerous.” Yet he acknowledges the encampment sweeps can waste city resources as caseworkers and street medicine providers scramble to find their clients and patients.

Advocates say the Trump administration is inciting fear and mistrust between homeless people and those working to help them while wasting taxpayer dollars used to provide care and place people into housing. There are, however, far fewer tents and large-scale encampments visible to tourists and residents.

“People found safety in those communities and service providers could find them. Now there are people with guns and flashing lights dislocating folks experiencing homelessness without notice and just throwing stuff away,” said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

District officials say some people have accepted emergency shelter. But even as the city works to connect people with services and expand shelter capacity, officials acknowledge there isn’t enough permanent housing or temporary beds for everyone.

And there will be fewer places for people living outside to go.

The city, in its fiscal year 2026 budget, concentrated its homelessness funding on families, funding 336 new permanent supportive housing vouchers. Yet it cut funding for temporary housing for both families and individuals and provided no new permanent supportive housing vouchers for individuals. That means fewer housing slots for single adults, who make up most of those wandering the streets. City officials said, however, that they have slotted 260 more permanent housing units for homeless individuals or families into their construction pipeline.

Worsening Health Care

The fallout is inundating local soup kitchens with demand, including Miriam’s Kitchen in Foggy Bottom. The local institution provides hot meals, housing assistance, and warm blankets to people in need.

Caseworkers say it’s becoming increasingly difficult to help clients secure IDs and other documents needed for housing and other social services.

“I’m looking everywhere, but I can’t find people,” said Cyria Knight, a caseworker at Miriam’s Kitchen. “Most of my clients went to Virginia.”

It’s unclear how much of the district’s homeless population has fanned out to neighboring Virginia and Maryland communities. There were an estimated in the region in January, months before Trump’s crackdown. Four of six counties around Washington saw homelessness rise from 2024, while it .

“I’m not seeing my patients for a month or more, and then when I do, their chronic conditions are uncontrolled. They’ve been in and out of the ER, and they’re more likely to be hospitalized,” said Anna Graham, a street medicine nurse practitioner for , a network of clinics in Washington. “It’s just setting us back.”

Graham’s team stations its mobile medical van outside Miriam’s Kitchen at dinnertime to better find patients.

Willie Taylor, 63, was figuring out where to sleep for the night after grabbing dinner from Miriam’s. He saw Graham to receive his medications for advanced lung disease, seizures, chronic pain, and other health disorders.

He has difficulty walking and needs a wheelchair, which is complicated because he doesn’t have a permanent address. Taylor and his medical providers say his previous wheelchairs have been stolen while he slept outdoors at night. He uses a shopping cart to keep him steady, walking around all day, until nightfall.

On a cold November night, Graham helped Taylor figure out his daily medications and checked his vitals. The team handed him a warm coat and hand warmers before sending him back outside.

After walking for about 45 minutes, he found a piece of park pavement where he could build a bed out of tarps and sleeping bags.

“My body can’t take this,” Taylor said, preparing to sleep. “There’s ice on the concrete. I’m in so much pain; it hurts so much worse when it’s cold.”

Homeless people and cost the health care system more than housed people, largely because conditions go untreated on the streets, and when they do seek care, many go to the ER. Among Medicaid enrollees, homeless people have been estimated to incur $18,764 a year in spending, compared with $7,561 for other enrollees.

Over at the So Others Might Eat soup kitchen earlier that day, Tyree Kelley was finishing his breakfast of a sausage sandwich and hard-boiled eggs. He was considering going into a shelter. The streets were becoming too dangerous for someone like him, he said, referring to the police and National Guard presence. He was feeling the loss of an encampment community that would watch his back.

He’s been to the ER at least seven times this year to get care for a broken ankle he sustained falling off an electric scooter. The accident caused him to lose his job and health insurance as a garbageman, he said. His situation has caused him to sink deeper into a depression that began three years ago after his mother died, he said.

Then his father and sister died this year. He began to numb his pain with beer.

“You get so depressed, being out here,” said Kelley, 42. “It gets addictive. You start to not care about even changing your clothes.”

His depression also led him to seek out marijuana. Then he smoked a joint laced with fentanyl. The overdose sent him to the hospital for days.

“I actually died and came back,” he said, crediting other homeless people with administering naloxone and saving his life. “I need to get out of this, but I feel so stuck.”

A few blocks west of the White House sits a vacant plot of land that earlier this year held more than a dozen tents. Workers in the area sense what they don’t always see.

“I was here when this was all cleared. A bulldozer came in, and all their stuff was thrown in a garbage truck,” said Ray Szemborski, who works across the street from the now-empty lot. “People are still homeless. I still see them around underneath the bridge. Sometimes they’re at bus stops, sometimes just walking around. Their tents are gone but they’re still here.”

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At Nov. 7 in the Inland Empire, four Democratic candidates vying to succeed Gov. Gavin Newsom vowed to push back against Republican cuts to health care programs and to improve people’s access to medical care, including mental health services. But while some floated taxes, candidates were light on details about how they would bring down health care costs.

Former U.S. Health and Human Services Secretary Xavier Becerra promised to be California’s next “health care governor,” echoing to lower costs and broaden access when he first got into office. State Superintendent of Public Instruction Tony Thurmond pledged to create a single-payer health care system in which everyone is pooled into one program. Former state Controller Betty Yee said she would “build back better” from federal cuts and create a health care system tailored to California’s diverse communities.

And former Los Angeles Mayor Antonio Villaraigosa vowed to fight to preserve safety net health care pared by the Trump administration and Republicans in Congress, although he acknowledged the challenge given limited state resources.

“I’m not gonna sell you snake oil,” he said. “It is going to be tough to provide that care, but I’m absolutely committed to it.”

The candidates’ assurances come amid recent shifts in state and federal policies that, together with a variety of forces, are driving up the cost of health care and making it harder for people to obtain and maintain coverage. In addition to providers raising prices, other include an aging population, rising chronic conditions, medical advancements, and new technologies, according to analysts. That’s added to a sense of financial precarity for the millions of Californians struggling with the state’s and .

Although the forum was open to up to six candidates, former U.S. Rep. Katie Porter and entrepreneur Stephen Cloobeck declined to participate, citing scheduling or other factors, according to Jon Koriel, an event spokesperson.

Health Care Top Concern

A commissioned by the California Wellness Foundation ahead of the forum found that nearly 80% of likely voters worry about the cost of health care and that 72% think the next governor should prioritize capping out-of-pocket expenses. Access to affordable mental health care and being able to care for aging family members or friends were also top concerns. Perhaps in an early signal, voters last week in Santa Clara County passed to help backfill federal cuts to food and health care safety net programs.

California mirrors much of the nation. Exit polls from the Nov. 4 election show 81% of those who voted for Democrat Abigail Spanberger, winner of the Virginia governor’s race, as the most important issue facing the state. In a national , health care was cited as the top everyday expense Americans want Congress to prioritize. And 65% of voters said an annual health cost increase of $1,000 would have some impact on their 2026 vote, according to a .

Some Californians interviewed on Nov. 4, the day of the state’s special election, expressed disappointment in Newsom’s unmet promises on health care. Newsom, a Democrat who is mulling as he wraps up his second term in January 2027, had campaigned on .

During his tenure he’s steered billions of dollars and engineered rules to help the neediest Californians afford and access health care. The state also expanded state-funded Medicaid coverage, known as Medi-Cal, to all eligible residents, regardless of immigration status. Medicaid provides free or low-cost health insurance to low-income and disabled people.

But this year, facing rising costs and budget deficits, Newsom and the Democratic-controlled legislature walked back some of that expansion by freezing enrollment for adults without legal status starting in 2026 and implementing premiums. They also resurrected an asset test for older adults and people with disabilities. Meanwhile, health care costs and homelessness remain a huge problem, and many Californians . And there’s no sign of a single-payer health care system, which Sacramento lawmakers have repeatedly amid concerns about cost, including one estimate in 2017 of $400 billion annually.

“I remember him coming and speaking to our members and telling them that he was going to fight with them for single payer,” Michael Cusack, a 30-year-old former health care union worker from Oakland, said as he cast his ballot last week. “And I never saw him deliver on that campaign.”

Paying for Health Care

Becerra, Thurmond, and Yee said they would be open to raising taxes to pay for health care programs. Villaraigosa sidestepped the tax question, saying his focus would be to “grow the pie” economically. Yee also suggested offering tax credits to help struggling families pay for health care and caregiving expenses.

During the forum’s lightning round, Becerra, Thurmond, and Yee also raised their hands when asked whether they supported single-payer care. Becerra said after the event that he doesn’t believe the state would receive support from the Trump administration for a single-payer system, but he said he would push for universal access to health care.

Indeed, all the candidates appeared mindful of Washington’s power over health care resources, even as they vowed to stand up to President Donald Trump, who has an especially adversarial relationship with Newsom.

“Let’s recognize that the federal government is our largest partner,” Becerra said. “We must work with them. We will not take a knee, but we must work with them.”

Currently, the biggest threats to health care costs and accessibility come from the federal government. Republicans in Congress have refused to give in to Democrats’ demand to extend premium tax subsidies for health insurance plans purchased on Affordable Care Act exchanges, the main issue that drove the government shutdown. Enrollees in Covered California, the state’s health insurance exchange, have received notices that their premiums will increase next year. On average, monthly premium payments聽for people receiving ACA subsidies聽are across the nation.

Laura Jones, a small-business owner in Oakland, currently pays the minimum possible for her Covered California plan, but she worries she wouldn’t be able to afford a major medical emergency. She thinks about one of her friends who recently suffered a stroke.

“The hospital bills were just so egregious,” Jones said. “How would I pay for that?”

Meanwhile, an impending in federal Medicaid spending reductions under the One Big Beautiful Bill Act and tighter eligibility restrictions are expected to push as many as out of the program. More than a third of Californians are currently enrolled in Medi-Cal.

Oseoba Airewele, 29, of Ventura, a registered Democrat who previously worked as a software engineer, said Medi-Cal became a lifeline after he lost insurance through his job and needed mental health and dental care.

“If I were to lose it, I would be very concerned,” he said. “I’d be in a bad place.”

People with employer-based health coverage also face steep price hikes. Family premiums for employer-based plans averaged almost $27,000 this year, up 6% from 2024, a . Workers typically pay almost $7,000 of that, the report found. That doesn’t include other out-of-pocket expenses.

“Even though I have a job, it’s still really expensive to pay for the copays,” said Rheema Calloway, 35, a San Francisco independent.

Primary in June

Among the other Democratic candidates vying for governor in 2026, Porter has said she to Medicaid and Medicare a top priority, along with expanding and improving health care for all residents. Porter’s campaign suffered a blow after viral videos surfaced of her threatening to walk out of a CBS interview and berating a staff member. Former Assemblyman Ian Calderon has said he would protect . And Cloobeck wants to fast-track .

Republican candidates include Riverside County Sheriff and , a former Fox News contributor and policy adviser to David Cameron when he was Britain’s prime minister. Both have pledged to tackle affordability issues, especially housing costs.

Two other high-profile Democrats 鈥� former Vice President Kamala Harris and U.S. Sen. Alex Padilla 鈥� have said they won’t run. Rick Caruso, a Republican-turned-Democrat and wealthy Los Angeles businessman, has yet to decide whether to run.

The California primary will be held June 2 and the general election on Nov. 3.

麻豆女优 Health News correspondent Christine Mai-Duc and ethnic media editor Ngoc Nguyen contributed to this report.

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Public health experts and local advocates say the outbreak is fueled by a confluence of on-the-ground factors: the sidelining and closing of programs that distributed sterile syringes to people who use drugs, a shortage of medical providers focused on HIV, and the clearing of the city’s largest homeless encampment, which upended care for newly diagnosed people living there.

But those issues may not remain local for long.

The Trump administration is pushing similar tactics nationwide. In a , Trump called for defunding programs that engage in harm reduction 鈥� a broad term that encompasses many public health interventions, including syringe services, aimed at keeping people who use drugs alive. Such efforts are sometimes controversial, with critics saying they enable illegal activity. The executive order also supports forcing homeless people off the street and into treatment. This comes after the administration cut or delayed funding for various addiction and HIV-related programs and federal agencies .

The administration says its approach will increase public safety, but suggest otherwise. Many advocates and researchers warn these efforts could spark more outbreaks like the one in Bangor.

“That feels inevitable,” said Laura Pegram, director of for NASTAD, an association of public health officials who administer HIV and hepatitis programs.

She said people who use drugs face a trifecta of risks: HIV, hepatitis C, and overdose. “Across the country, I think we’ll start to see those three things starting to be on the rise again.”

“That will be incredibly costly,” she added 鈥� in dollars and “in a real human way.”

Outbreaks that start among people who use drugs can easily spread to those who don’t.

An HIV Outbreak

The first HIV case in Bangor’s current outbreak , well before Trump’s return to the presidency.

Puthiery Va, director of , attributed the emergence to the opioid epidemic, housing shortages, and the greater Bangor area’s sparse health care services.

Local advocates highlighted an additional, acute factor: supply shortages at the region’s largest syringe services program and its subsequent closure.

A nonprofit that provided health care and social services to people who use drugs, Health Equity Alliance, or HEAL, distributed sterile needles annually.

Like other such programs nationwide, its goal was to prevent the spread of infectious disease that can occur if people share needles to inject drugs.

However, financial struggles and mismanagement led to severe shortages in recent years. Former HEAL executive director Josh D’Alessio acknowledged such issues, telling 麻豆女优 Health News, “We did run out of syringes” at times or limit how many participants could take. Several of these shortages struck in the fall of 2023, leading HEAL staffers to suggest a link to the first HIV case.

The Future of Harm Reduction

Research suggests a strong connection between past HIV outbreaks among people who use drugs and lack of access to sterile needles, said , an epidemiologist at Tufts University School of Medicine.

A 2015 outbreak in Scott County, Indiana, and one in the a few years later were curbed only after , he said. If such programs had existed sooner in Scott County, more than a hundred infections could have been prevented, .

Va, who leads the Maine Center for Disease Control and Prevention, said she considers the shortage of syringe services in the Bangor area to be a factor in the outbreak but not the primary cause.

Stopka said the best practice during an outbreak “is to amplify access to sterile syringes.”

But Trump’s recent executive order links harm-reduction programs to crime, saying such efforts “only facilitate illegal drug use and its attendant harm.” The order doesn’t name syringe services programs 鈥� which have been supported by both Democrats and Republicans in the past 鈥� but it targets “safe consumption” sites, where people can use drugs under supervision. the attacks will be broader.

A letter from the nation’s leading addiction agency expanding on Trump’s executive order said federal funds to buy syringes or drug pipes. However, that has been true for most of the past few decades. The letter did not address supporting general operating costs for syringe services programs.

Department of Health and Human Services spokesperson Andrew Nixon told 麻豆女优 Health News that the administration is committed to “addressing the addiction and overdose crisis impacting communities across our nation.” But he and spokespeople for the White House did not respond to specific questions about the administration’s stance toward syringe services.

In Bangor, some locals have raised concerns about harm reduction that echo the president’s. At a 鈥� shortly after a syringe services program was newly certified by the state to operate locally 鈥� residents and business owners said they felt unsafe with the growing population of people who were homeless and using drugs. They worried syringe programs were fueling the behavior.

But research suggests syringe services programs in the community and . They new HIV and hepatitis C cases, into addiction treatment fivefold, . They are also of overdose reversal medications, the use of which many communities 鈥� and the Trump administration 鈥� have said they support.

The city ultimately decided the newly certified program, , could not operate in prominent public parks or squares.

In the following months, Needlepoint ran its syringe services only at the city’s largest homeless encampment, where several people had tested positive for HIV, said the group’s executive director, William “Willie” Hurley. That ended in February when the city cleared the encampment.

This summer, Needlepoint secured a private location for its syringe services but shut it down five days later when city officials .

, director of Bangor’s health department, said the city is trying to strike a balance between “making services available and what the community wants.”

“Getting the buy-in of most of the community” is “critical to the future of harm reduction,” she said.

Other cities have seen backlash result in new laws that restrict how syringe services programs operate or shutter them.

Gunderman said she is hoping to avoid that in Bangor.

Clearing Encampments

Trump’s recent executive order also calls for clearing homeless people off the street and involuntarily committing them to treatment facilities.

The administration is enacting this policy in Washington, D.C., where it has and threatened homeless people if they don’t leave the streets.

White House spokesperson Abigail Jackson said people have the option to be taken to a shelter or receive addiction and mental health services.

Similar policies have taken hold nationwide in recent years, even in liberal hubs like and .

Last year in Bangor, as a homeless encampment that grew to nearly 100 residents, business owners and locals called for its clearing.

Some advocates and social service providers warned that doing so could exacerbate the HIV outbreak and overdose crisis. At two City Council meetings in November, that it would be difficult to find people they served after a clearing and that scattering newly diagnosed people HIV clusters elsewhere.

“Plenty of people said you’re going to lose track of these people,” , a board member for the Bangor Area Recovery Network, told 麻豆女优 Health News. “They did it anyway.”

鈥業’m Still Alive’

Two months after clearing the encampment, not knowing the location of more than a third of the people who had lived there.

Clark said it’s not surprising that the city couldn’t connect everyone to housing or treatment. Many people distrust these services, shelters are frequently full, and treatment services are scarce. “Where exactly are these people supposed to go?” she said.

City officials stressed in Council meetings and reports that they were taking a humane approach. They ramped up social services for months leading up to the clearing, connecting people to everything from housing to storage facilities and laundry.

Gunderman, the city health director, said she knows the sweep wasn’t ideal but that neither was crowding folks in an unsanitary encampment. “It was a situation where there weren’t a lot of great answers,” she said.

To help track folks from the encampment and keep them engaged in HIV treatment, the city is now using about to hire two case managers. (The only other local HIV medical case management program .)

“What we know from outreach we’ve been doing already is that we spend a lot of time looking for people,” Gunderman said.

Jason, who has been homeless for most of the past decade and tested positive for HIV this year, has seen that in action.

Members of what he calls his medical team have scoured the streets for hours to find his tent and remind him to take his HIV treatment shots, he said. Some picked up prescriptions and delivered them to him.

“They’ve made sure I’m taken care of,” Jason said. (麻豆女优 Health News agreed to use only his first name to protect his privacy.)

Jason believes he got the virus last year at the homeless encampment while using drugs that someone else prepared. He had tried to avoid the encampment for months. But whenever he set up his tent elsewhere, he said, police officers told him to move.

When he got the diagnosis, he thought of his uncle, who died of AIDS in the 1980s.

“It hurts to talk about,” Jason said, “but I’m still alive.”

After months of treatment, his viral load is . Over the summer, his team helped him find housing.

But Jason is still struggling to find sterile needles regularly. He worries about others facing a shortage.

“That’s how this outbreak has been spreading more and more,” Jason said. “Every time we turn around there’s another case.”

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BRISTOL, R.I. 鈥� At age 82, Roberta Rabinovitz realized she had no place to go. A widow, she had lost both her daughters to cancer, after living with one and then the other, nursing them until their deaths. Then she moved in with her brother in Florida, until he also died.

And so last fall, while recovering from lung cancer, Rabinovitz ended up at her grandson’s home in Burrillville, Rhode Island, where she slept on the couch and struggled to navigate the steep staircase to the shower. That wasn’t sustainable, and with apartment rents out of reach, Rabinovitz joined the growing population of older Americans unsure of where to lay their heads at night.

But Rabinovitz was fortunate. She found a place to live, through what might seem an unlikely source 鈥� a health care nonprofit, the . Around the country, arranging for housing is a relatively new and growing challenge for such PACE groups, which are funded through Medicaid and Medicare. PACE stands for a Program of All-Inclusive Care for the Elderly, and the organizations aim to keep frail, older people in their homes. But a patient can’t stay at home if they don’t have one.

As housing costs rise, organizations responsible for people’s medical care are realizing that to ensure their clients have a place to live, they must venture outside their lanes. Even hospitals 鈥� in Denver, , and 鈥� have started investing in housing, recognizing that health isn’t possible without it.

And among older adults, the need is especially growing. In the U.S., who were homeless in 2024 were 55 or older, with the total older homeless population up 6% from the previous year. a University of Pennsylvania professor who specializes in homelessness and housing policy, older than 60 living in shelters roughly tripled from 2000 to 2020.

“It’s a national scandal, really, that the richest country in the world would have destitute elderly and disabled people,” Culhane said.

Over decades of research, Culhane has documented the plight of people born between 1955 and 1965 who and never got an economic foothold. Many in this group endured intermittent homelessness throughout their lives, and now their troubles are compounded by aging.

But other homeless older adults are new to the experience. Many teeter on the edge of poverty, said , CEO of USAging, a national association representing what are known as . A single incident can tip them into homelessness 鈥� the death of a spouse, job loss, a rent increase, an injury or illness. If cognitive decline starts, an older person may forget to pay their mortgage. Even those with paid-off houses often can’t afford rising property taxes and upkeep.

“No one imagines anybody living on the street at 75 or 80,” Markwood said. “But they are.”

President Donald Trump’s recent budget law, , the public insurance program for those with low incomes or disabilities, will make matters worse for older people with limited incomes, said Yolanda Stevens, program and policy analyst with the . If people lose their health coverage or their local hospital closes, it will be harder for them to maintain their health and pay the rent.

“It’s a perfect storm,” Stevens said. “It’s an unfortunate, devastating storm for our older Americans.”

Adding to the challenges, the Labor Department a job training program intended to keep low-income older people in the workforce.

Those circumstances have sent PACE health plans throughout the country into uncharted waters, prompting them to set up shop , partner with housing providers, or even to build their own.

A 1997 federal law recognized PACE organizations as a provider type for Medicare and Medicaid. Today, some 185 operate in the U.S., each serving a defined geographic area, with a total of more than .

They enroll people 55 and older who are sick enough for nursing home care, and then provide everything their patients need to stay home despite their frailty. They also run centers that function as medical clinics and adult day centers and provide transportation.

These organizations primarily serve impoverished people with complex medical conditions who are eligible for both Medicaid and Medicare. They pool money from both programs and operate within a set budget for each participant.

PACE officials worry that, as federal funding for Medicaid programs shrinks, states will curtail support. But the PACE concept has always had bipartisan support, said Robert Greenwood, a senior vice president at the , because its services are significantly less expensive than nursing home care.

The financing structure gives PACE the flexibility to do what it takes to keep participants living on their own, even if it means buying an air conditioner or taking a patient’s dog to the vet. Taking on the housing crisis is another step toward the same goal.

In the Detroit area, , which serves 2,200 participants, partners with the owners of senior housing. The landlords agree to keep the rent affordable, and PACE provides services to their tenants who are members. Housing providers “like to be full, they like their seniors cared for, and we do all of that,” said Mary Naber, president and CEO of PACE Southeast Michigan.

For participants who become too infirm to live on their own, the Michigan organization has leased a wing in an independent living center, where it provides round-the-clock supportive care. The organization also is partnering with a nonprofit developer to create a cluster of 21 shipping containers converted into little houses in Eastpointe, just outside Detroit. Still in the planning stages, Naber said, the refurbished containers will probably rent for about $1,000 to $1,100 a month.

In San Diego, the cares for chronically homeless people as they move into housing, offering not just health services but the backup needed to keep tenants in their homes, such as guidance on paying bills on time and keeping their apartments clean. St. Paul’s also helps those already in housing but clinging to precarious living arrangements, said Carol Castillon, vice president of its PACE operations, by connecting them with community resources, helping fill out forms for housing assistance, and providing meals and household items to lower expenses.

At PACE Rhode Island, which serves nearly 500 people, about 10 to 15 participants each month become homeless or at risk of homelessness, a rare situation five or six years ago, CEO Joan Kwiatkowski said.

The organization contracts with assisted living facilities, but its participants are sometimes rejected because of prior criminal records, substance use, or health care needs that the facilities feel they can’t handle. And public housing providers often have no openings.

So PACE Rhode Island is planning to buy its own housing, Kwiatkowski said. PACE also has reserved four apartments at an assisted living facility in Bristol for its participants, paying rent when they’re unoccupied. Rabinovitz moved into one recently.

Rabinovitz had worked as a senior credit analyst for a health care company, but now her only income is her Social Security check. She keeps $120 from that check for personal supplies, and the rest goes to rent, which includes meals.

Once a week or so, Rabinovitz rides a PACE van to the organization’s center, where she gets medical care, including dental work, physical therapy, and medication 鈥� always, she said, from “incredibly loving people.” When she’s not feeling well enough to make the trek, PACE sends someone to her. Recently, a technician with a portable X-ray machine scanned her sore hip as she lay in her own bed in her new studio apartment.

“It’s tiny, but I love it,” she said of the apartment, which she’s decorated in purple, her favorite color.

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State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a 麻豆女优 Health News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat 鈥� or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price 鈥� both in the cost to taxpayers and coverage losses 鈥� according to state documents obtained by 麻豆女优 Health News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly will lose access to monthly cash assistance for food, including those with children.

In five states alone, for state officials and reviewed by 麻豆女优 Health News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting company Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will . Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company that operates the state’s eligibility system.

Optum 鈥� which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act 鈥� to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, . And in Illinois, will cost at least $12 million.

A Historic Mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules 鈥� .

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements 鈥� about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was as of October.

of adult Medicaid enrollees nationally are already working, according to 麻豆女优. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the .

In Wisconsin, state officials estimate could lose coverage after work requirements take effect. Not covering those people would in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP 鈥� known as CARES 鈥� in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New Hurdles for Vets and Homeless People

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults 鈥� doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year . , initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government 鈥� that is, taxpayers 鈥� to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems 鈥� as D.C. is 鈥斅� I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to 麻豆女优 Health News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” 麻豆女优 Health News found that Deloitte, a global consultancy that generated in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 Million Bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a .

Adding the ability to verify work status would cost up to $7 million, . By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions . Accenture’s analysis said the federal law necessitated . Making employment a condition of Medicaid benefits could cause an estimated 32,000 Iowans to lose coverage, according to a

Cutting 32,000 people from coverage in one year, a fraction of the Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level 鈥� currently .

“There is no benefit to this population,” Lock said.

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that 鈥� priced at $12 million 鈥� is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” , the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time 鈥� supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 鈥� Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

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LISTEN: In this audio portrait of homeless people displaced by the Trump administration’s crackdown on encampments in the nation’s capital, 麻豆女优 Health News senior correspondent Angela Hart tells of residents living outside this winter and their search for medical care and shelter.

January’s extreme cold has put a spotlight on the conditions homeless people face. They get sicker and die younger than housed people, often because health problems go untreated. The Trump administration’s in Washington, D.C., has made it more difficult for health workers to reach that vulnerable population this winter.

麻豆女优 Health News senior correspondent Angela Hart takes WAMU “Health Hub” listeners to Washington’s streets to hear how homeless people are juggling their health and shelter after the Trump administration’s crackdown.

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Scattered visits to free clinics notwithstanding, Guevara hadn’t had a full medical checkup in years. She required dental work. She wanted to start looking for a job. And she was overwhelmed by the maze of paperwork needed simply to get her off the street, much less to make any of the other things happen.

But Guevara had help. The Jamboree Housing Corp., an affordable-housing nonprofit that renovated the former Stanton, California, hotel Guevara now calls home, didn’t just move her in 鈥� it also provided her a fleet of wraparound services. Jamboree counselors helped Guevara navigate the health care system to see a doctor and a dentist, buy a few things for her apartment, and get training to become a caregiver.

“I was years on the street before I got the kind of help I needed so I could help myself,” said Guevara, 68.

Amid the Trump administration’s apparent opposition to using Medicaid funding for such social services, staffers at Jamboree and similar affordable housing providers in California have been worried about losing federal money, particularly as the experimental waivers that provide the primary funding for the program they rely on expire at the end of 2026. But as it turns out, the state had the foresight several years ago to designate certain nonhousing social services, such as mental health care, drug counseling, and job training, as a form of Medicaid spending that will continue to be reimbursed.

Catherine Howden, a spokesperson for the federal Centers for Medicare & Medicaid Services, confirmed that California’s use of the “in lieu of services” classification for these wraparound programs is allowed under federal regulations.

“It is starting to sound positive that we will, at the very least, be able to continue billing for these services after the waiver period,” said Natalie Reider, a senior vice president at Jamboree Housing.

During President Donald Trump’s first term, states were permitted to use Medicaid money for social support services not typically covered by health insurance. But the second Trump administration is , saying that the intervening Biden administration took the supportive services process too far. Howden said in a statement that the policy “distracted the Medicaid program from its core mission: providing excellent health outcomes for vulnerable Americans.”

Through CalAIM, a five-year experimental build-out of the Medicaid system, programs like Jamboree were able to leverage federal funding to offer the kinds of nonhousing social services that experts contend are essential to keeping people permanently housed.

However, these wraparound services are only one component of the CalAIM initiative, which is attempting to take Medicaid, known as Medi-Cal in California, in a more holistic direction across all areas of care. And when CalAIM launched, California officials gave the programs the Medicaid “in lieu of services” designation, known as ILOS, effectively putting them outside the waiver process and ensuring that even when CalAIM sunsets, money for those social initiatives will continue to flow.

“California has tried to future-proof many of the policy changes it has made in Medi-Cal by including them in mechanisms like ILOS that do not require federal waiver approval,” said Larry Levitt, executive vice president for health policy at 麻豆女优, a health information nonprofit that includes 麻豆女优 Health News. “That allows these policy changes to continue, even with a politically hostile federal administration.”

The designation allows these social services to be funded through Medicaid managed-care plans under existing federal laws because they are cost-effective substitutes for a Medicaid service or reduce the likelihood of patients needing other Medicaid-covered health care services, said Glenn Tsang, policy adviser for homelessness and housing at the state’s Department of Health Care Services. The state could not provide an estimate of the annual funding for these wraparound services because they are not distinguished from other payments made to Medicaid managed-care plans.

“We are full steam ahead with these services,” Tsang said, “and they are authorized.”

Although California was the first state to incorporate the designation for such housing and other health-related social support, Tsang said, several other states 鈥� including Arizona, Arkansas, Florida, New York, and North Carolina 鈥� are now using the mechanism in a similar fashion.

Early results suggest such support saves on health care spending. When Jamboree, in Northern California, in the Central Valley, and other permanent supportive housing providers employ a holistic approach that includes social services, they have reported higher rates of formerly homeless people remaining in housing, less frequent use of costly emergency health services, and more residents landing jobs that help them pay rent and stay housed.

At the nonprofit MidPen Housing, which serves 12 counties in and around the San Francisco Bay Area, roughly 40% of the units in the program’s pipeline are earmarked for “extremely low-income” people, a group that includes the homeless, said Danielle McCluskey, senior director of resident services.

CalAIM reimbursements help fund the part of MidPen that focuses on supportive services across a wide range of experiences, from chronic homelessness to mental health issues to those leaving the foster care system. McCluskey described it as one leg of a three-legged stool, the others being real estate development and property management.

“If any of those legs are not getting what they need, if they’re not funded or not staffed or resourced, then that stool is kind of wobbly 鈥� off-kilter,” the director said.

A recent found that people who used at least one of the housing support services 鈥� including navigation into new housing, health care assistance, and a 鈥� saw a 13% reduction in emergency department visits and a 24% reduction in inpatient admissions in the six months that followed.

Documenting those outcomes is critical because the department needs to show federal officials that the services lessen the need for other, often costlier Medicaid-covered care 鈥� the essence of the classification.

Advocates for the inclusion of supportive services argue that the American system ultimately saves money on those investments. As California’s homeless population to more than 187,000 on a given night 鈥� nearly a quarter of the U.S. total 鈥� Jamboree has been allocating more of its resources to permanent supportive housing.

Founded in 1990 in Orange County, Jamboree builds various types of affordable housing using federal, state, and private funding. Reider said about a fifth of the organization’s portfolio is dedicated to permanent supportive housing.

“They’re not going back out to the streets. They’re not going to jail. They’re not going to the hospitals,” Reider said. “Keeping people housed is the No. 1 outcome, and it is the cost-saver, right? We’re using Medicaid dollars, but we’re saving the system money in the long run.”

Guevara, who wound up on the streets after a falling-out with family in 2015, spent years living out of her truck before a shelter worker connected her with Jamboree. There, she was paired with a specialist to help her figure out how to get and see a doctor, and to keep up with scheduling the battery of medical tests she needed after years spent living in temporary shelters.

“I also got a job developer, who helped me get this job with the county so I can pay my rent,” Guevara said of her position as a part-time in-home caregiver. “Now I take care of people kind of the same way people have been taking care of me.”

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But inside, the store is a welcoming oasis. Twinkly string lights adorn racks of donated clothing. Shelves and bins overflow with children’s books, allergy medications, and toiletries. Curtains cordon off one side of the room, where there’s a stage for musicians and a neon sign depicting roller skates for weekly free skate nights.

The space is part free thrift store, part over-the-counter pharmacy, part punk show venue 鈥� and wholly “a radical community center,” said Dan Bingler, who runs the place.

Bingler is a waiter and bartender in the city who founded a mutual-aid organization called the . He said the building owners allow him to use the space as long as he pays the water, electricity, and trash bills.

On Monday evenings, volunteers from other community organizations show up 鈥� some used to set up in the parking lot before Bingler opened the store. They offer free testing for sexually transmitted infections, basic medical care, hot meals, and sterile syringes and other supplies for people who use drugs.

The purpose of the space is simple, Bingler said: “We’re going to make sure we provide for the community.”

Although it’s been open for a few years now, the space has become even more crucial to this community in recent months, with the Trump administration slashing funding for many social service organizations and taking an aggressive approach to homelessness and drug use. In Washington, D.C., the administration has to push people living on the street to . Nationally, it has called for people who use drugs to be . It has 鈥� practices that public health experts say keep people who use drugs safe and alive but that critics say promote illegal drug use.

The community space in New Orleans 鈥� named the Fred Hampton Free Store after the known for bringing together diverse groups to fight for social reforms 鈥� aims to be a haven among this sea of changes.

It doesn’t receive federal funding, state or local grants, or money from foundations, Bingler said. It’s simply neighbors helping neighbors, he said, tearing up and adding, “It’s a really beautiful thing to be able to share all this space.”

All items inside are provided by people or organizations in the community. Bingler said one time a local hotel undergoing renovations donated 50 flat-screen TVs.

On nights the store is open, often more than 100 people visit, Bingler said.

One fall evening, dozens of people browsed for free clothing and over-the-counter medications. Others sat on the grass outside, chatting while keeping an eye on their bicycles or grocery carts full of possessions.

James Beshears stopped by the harm reduction group in the parking lot to get sterile supplies he uses to inject heroin and fentanyl. He said he’d been in treatment for years but relapsed after his doctor moved away and he was referred to a clinic that charged $250 a day. Street drugs were cheaper than treatment, he said.

He wants to stop. But until he can find affordable care, places like the free store keep him going. Without it, he said, he’d have “one foot in the grave.”

Another man in the parking lot was waiting for the arrival of Aquil Bey, a paramedic and former Green Beret well known for helping people overcome obstacles to getting health care. As soon as the man spotted Bey’s black Jeep, he ran up.

“I’ve got stage 4 kidney disease,” the man said, adding that he was scheduled for treatments at a hospital but was struggling to get there.

“Do me a favor,” Bey said as he unloaded folding tables and medical equipment from his car. “When our team gets here, come and see us. Maybe we can get you transportation.”

Bey is the founder of , a volunteer-run organization that provides free basic medical care and referrals for people who are homeless, using drugs, or part of other vulnerable communities. The group has a steady presence at the free store.

That day, Bey and his team connected the man needing kidney disease treatment to reduced-cost transit programs. They also did blood pressure and blood sugar checks for anyone who wanted them, cleaned infected wounds, and called clinics to make appointments for patients without phones.

A man with a leg injury mentioned he was sleeping on the concrete floor of an abandoned naval base. Bey noticed the free store’s furniture section had a mattress. He and another volunteer hauled it out, strapped it to the top of a car, and delivered it to where the man was sleeping.

“We’re just trying to find all these barriers” that people face and “find ways to fix them,” Bey said.

The clinic at the free store helped Stephen Wiltz connect with addiction care. He grew up in the Lower 9th Ward and had been using drugs since he was 10.

Fed up with discrimination from doctors who blamed him for his addiction, Wiltz said, he was reluctant to go to any treatment facility. But after years of knowing the volunteers at the free store, he trusted them to point him in the right direction.

At 56, Wiltz was in sustained recovery for the first time in his life, he said during a phone interview in the fall.

Those volunteers “cared for people who didn’t have nobody to care for them,” he said.

As the sun went down that fall evening at the store, a punk band started setting up for a show across the room from the medical clinic. Lights dimmed and music blared 鈥� a reminder that this was not your everyday clinic or community center.

Bey continued consulting with a patient who had gout.

“I get used to the sound,” Bey said of the rapid drums and loud power chords. “I like it sometimes.”

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Residents share rooms designed to be accessible to those with mobility issues. There are also private bathrooms, which are a big deal for seniors struggling with incontinence.

Unlike the MVP, most homeless shelters aren’t equipped to help seniors, especially those 65 and older. They are the fastest-growing homeless population nationwide, according to , a researcher at the University of Pennsylvania. Not only are people who struggle with chronic homelessness aging, but many seniors are becoming homeless for the first time in their lives.

Getting in and out of bunks, managing medications, and making it to a shared bathroom in time are among the major challenges of shelter life for older adults. Staff at traditional shelters sometimes ask seniors to leave if they’re unable to care for themselves.

The MVP is unusual among shelters because it provides on-site medical care to better serve its residents as they age.

Last spring, Jamie Mangum, who is in her 50s and has lung cancer, tripped and fell in her room. To visit with an emergency medical technician, she needed only to make it downstairs. Her swollen wrist was quickly wrapped, and she returned to her room. She said that wouldn’t have been possible at other shelters she’s stayed in.

“There, I’d have to wait hours as opposed to come in here, be seen,” Mangum said.

Mangum said that in other shelters she’d likely have had to find her own way to an urgent care office or get an ambulance ride. Specialized case managers at the MVP have helped her get treatment for lung cancer as well.

“We have clients that need memory care. Maybe they were living independently before, but they were unable to maintain that and got evicted due to dementia or different things like that,” said Baleigh Dellos, who manages the MVP shelter for , a local nonprofit.

Specialized medical case managers work at the shelter. Primary care doctors and therapists visit weekly. Residents can even receive physical therapy in private spaces on-site.

A Path to Stability

The MVP partnered with the to offer medical care.

The first thing most new residents need help with is medication, said Matt Haroldsen with the Fourth Street Clinic, which provides health services at the shelter.

For people living on the streets, just keeping hold of regular medications is a challenge. “Their medications get jacked when they’re in their camps,” he said.

Diabetes patients without homes often bury their insulin to keep it cold. Haroldsen said they might forget where they buried it, or the vials might get too warm and spoil.

Helping residents at the shelter get those medications can stabilize their conditions, allowing them to focus on other priorities, such as getting an ID and other documents they need to apply for disability, Social Security, and various programs that can help them secure housing.

Nonprofits and local governments have opened similar shelters in Florida, California, and Arizona to meet the needs of older unhoused adults.

Having access to specialized shelters can be the difference between life and death, said , assistant director of the National Health Care for the Homeless Council.

In cold-weather states, denying seniors a bed because of mobility and other health issues can be especially risky. In 2022, a Bozeman, Montana, after he was asked to leave a shelter because of incontinence.

Complex medical needs can pose a danger to other residents that most shelters aren’t prepared to manage.

“A typical shelter doesn’t allow somebody on oxygen to come in because that’s such a fire hazard and risk,” she said.

Synovec said giving seniors better access to health care inside shelters is the best way to help them succeed once they get housing. Health issues are a common reason seniors can’t afford or maintain housing, she said.

A Growing Model

The MVP model is showing promise, both in Utah and elsewhere.

“Over 80% of the people who’ve stayed in our program this past year have moved into stable or permanent housing,” said , vice president of programs for the TaskForce for Ending Homelessness in Fort Lauderdale, Florida. The nonprofit runs a shelter called .

The MVP shelter near Salt Lake City is also marking success. It was able to permanently house 36 seniors as of late last year.

Still, there are more seniors in need of shelter than it can accommodate. Dellos, the shelter’s manager, said the MVP’s waitlist hovers around 200 people. She said the shelter prioritizes people based on medical need, not time spent on the waitlist.

For residents who do get a room, it’s life-changing.

Last spring, 62-year-old Jeff Gregg was playing fetch with his dog, Ruffy, just beyond the lawn in front of the MVP.

An old back injury forced Gregg to hunch over as he threw the ball. It also fueled a decades-long addiction to opioids. That cycle was hard to escape, he said.

“Fighting that, having a job, insurance, then losing the job, not having insurance, going out to the streets and being back in that crap, and I’d be back in the same position,” he said.

Gregg said sobriety took a back seat to more immediate needs like finding food and a bed in a shelter. He said the MVP was the first place where he could relax and focus on recovery.

“I was able to get clean. It took me a couple months, but I just kept plucking away,” he said.

He said the experience paved the way for him to get back surgery. He hopes that with less back pain, he can eventually get a job to help him afford an apartment.

This article is part of a partnership with and .

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“That’s what I’m trying to avoid,” said Ferguson, who still calls Quincy Jackson III her baby. She remembers a boy who dressed himself in three-piece suits, donated his allowance, and graduated high school at 16 with an academic scholarship and plans to join the military or start a business.

Instead, Ferguson watched as her once bright-eyed, handsome son sank into disheveled psychosis, bouncing between family members’ homes, homeless shelters, jails, clinics, emergency rooms, and Ohio’s regional psychiatric hospitals.

Over the past year, The Marshall Project – Cleveland and 麻豆女优 Health News interviewed Jackson, other patients and families, current and former state hospital employees, advocates, lawyers, judges, jail administrators, and national behavioral health experts. All echoed Ferguson, who said the mental health system makes it “easier to criminalize somebody than to get them help.”

State psychiatric hospitals nationwide have largely lost the ability to treat patients before their mental health deteriorates and they are charged with crimes. Driving the problem is a meteoric rise in the share of patients with criminal cases who stay significantly longer, generally by court order.

Patients Wait or Are Turned Away

Across the nation, psychiatric hospitals are short-staffed and consistently turn away patients or leave them waiting with few or no treatment options. Those who do receive beds are often sent there by court order after serious criminal offenses.

In Ohio, the share of state hospital patients with criminal charges jumped from about half in 2002 to .

The surge has coincided with a steep decline in total state psychiatric hospital patients served, down 50% in Ohio in the past decade, from 6,809 to 3,421, according to the . During that time, total patients served nationwide dropped about 17%, from 139,434 to 116,320, with state approaches varying widely, from adding community services and building more beds to closing hospitals.

Ohio Department of Behavioral Health officials declined multiple interview requests for this article.

The decline in capacity at state facilities unfurled as a spate of local hospitals across the country shuttered their psychiatric units, which disproportionately serve patients with Medicaid or who are uninsured. And the financial stability of is likely to deteriorate further after Congress passed President Donald Trump’s One Big Beautiful Bill Act, which slashes nearly $1 trillion from the federal Medicaid budget over the next decade.

The constricted flow of new patients through state hospitals is “absolutely” a crisis and “a huge deal in Ohio and everywhere,” said retired Ohio Supreme Court Justice Evelyn Lundberg Stratton. As co-chair of the state attorney general’s , Lundberg Stratton has spent decades searching for solutions.

“It hurts everybody who has someone who needs to get a hospital bed that’s not in the criminal justice system,” she said.

鈥業t’s Heartbreaking’

Quincy Jackson III’s white socks stuck out of the end of a hospital bed as police officers stood watch.

At 5 feet, 7 inches tall, Jackson has a stocky build and robotic stare. Staff at Blanchard Valley Hospital in Findlay, Ohio, had called for help, alleging Jackson had assaulted a security guard.

“I’m sick; I take medication,” Jackson said to the officers, according to law enforcement body camera footage. His hands were cuffed behind his back as he lay on the bed, a loose hospital gown covering him.

Ferguson called it one of his “episodes” and said her son experienced severe psychosis frequently. In one incident, she said, Jackson “went for a knife” at her home.

From December 2023 through this July, Jackson was arrested or cited in police reports on at least 17 occasions. He was jailed at least five times and treated more than 10 times at hospitals, including three state-run psychiatric facilities. A recent psychiatric evaluation noted that Jackson has been in and out of community and state facilities since 2015.

Jackson is among a glut of people nationwide with severe mental illness who overwhelm community hospitals, courtrooms, and jails, eventually leading to backlogs at state hospitals.

High-Profile Incidents

That dearth of care is often cited by families, law enforcement authorities, and mental health advocates after people struggling with severe mental illness harm others. In the past six months, at least four incidents made national headlines.

In August, a homeless reportedly diagnosed with schizophrenia fatally stabbed a woman on a train. Also in August, police said a with a history of mental health issues killed three people, including a child, at a Target store. In July, a homeless who family members said had needed treatment for decades attacked 11 people at a Walmart store with a knife. In June, police shot and killed a reportedly diagnosed with schizophrenia after authorities said he attacked law enforcement.

Mark Mihok, a longtime municipal judge near Cleveland, told a spring that he had never seen so many people with serious mental illnesses living on the streets and “now punted into the criminal justice system.”

37-Day Wait for a Bed

At Blanchard Valley Hospital, sheriff’s deputies had taken Jackson from jail for a mental health check. But Jackson’s actions raised concerns.

In the body camera video, a nurse said Jackson was “going to be here all weekend. And we’re going to be calling you guys every 10 minutes.”

The officer responded: “Yeah, well, if he keeps acting like that, he’s going to go right back” to the county jail.

Within minutes, Jackson was taken back to jail, yelling at the officers: “Kill me, motherf—–. Yeah, shoot them, shoot them. Pop!”

Statewide, Ohio has about 1,100 beds in its six regional psychiatric hospitals. In May, the median wait time to get a state bed was 37 days.

That’s “a long time to be waiting in jail for a bed without meaningful access to mental health treatment,” said Shanti Silver, a senior research adviser at the national nonprofit Treatment Advocacy Center.

Long waits, often leaving people who need care lingering in jails, have drawn lawsuits in several states, including , , and , where a large 2014 class action case forced systemic changes such as expansion of crisis intervention training and residential treatment beds.

Ohio officials noticed bed shortages as early as 2018. State leaders assembled task forces and . They launched community programs, crisis units, and a statewide emergency hotline.

Yet backlogs at the Ohio hospitals mounted.

Ohio Department of Behavioral Health Director LeeAnne Cornyn, who left the agency in October, wrote in a May emailed statement that the agency “works diligently to ensure a therapeutic environment for our patients, while also protecting patient, staff, and public safety.”

Eric Wandersleben, director of media relations and outreach for the department, declined to respond to detailed questions submitted before publication and, instead, noted that responses could be publicly found in a governor’s working group report .

Elizabeth Tady, a hospital liaison who also spoke to judges and lawyers at the May gathering, said 45 patients were waiting for beds at Northcoast Behavioral Healthcare, the state psychiatric hospital serving the Cleveland region.

“It’s heartbreaking for me and for all of us to know that there are things that need to be done to help the criminal justice system, to help our communities, but we’re stuck,” she said.

Ohio officials added 30 state psychiatric beds by in Columbus and are planning in southwestern Ohio.

Still, Ohio Director of Forensic Services Lisa Gordish told the gathering in Cleveland that adding capacity alone won’t work.

“If you build beds 鈥� and what we’ve seen in other states is that’s what they’ve done 鈥� those beds get filled up, and we continue to have a waitlist,” she said.

This year, Jackson waited 100 days in the and Montgomery County jail for a bed at a state hospital, according to jail records.

Ferguson said she was afraid to leave him there but could not bail him out, in part, she said, because her son cannot survive on his own.

“There’s no place for my son to experience symptoms in the state of Ohio safely,” Ferguson said.

Sick System

Patrick Heltzel got the extended treatment Ferguson has long sought for her son, but he stabbed a 71-year-old man to death before getting it.

The 32-year-old is one of more than receiving treatment in Ohio’s psychiatric hospitals.

“People need long-term care,” Heltzel said in October, calling from inside Heartland Behavioral Healthcare, near Canton, where he has lived for more than a decade after being found not guilty by reason of insanity of aggravated murder. Inpatient care, he said, helps patients figure out what medication regimen will work and deliver the therapy needed “to develop insight.”

As he spoke, the sound of an open room and patients chatting filled the background.

“You have to know, 鈥極K, I have this chronic condition, and this is what I have to do to treat it,’” Heltzel said.

As the ranks of criminally charged patients in Ohio’s hospitals have increased over the past decade, the shift has had an impact on patient care: The hospitals have endangered patients, have become more restrictive, and are understaffed, according to interviews with Heltzel, other patients, and former staff members, as well as documents obtained through public records requests.

Escapes and a Lockdown

Katie Jenkins, executive director of the National Alliance on Mental Illness Greater Cleveland, said the shift from mostly civil patients, who haven’t been charged with a crime, to criminally charged patients has changed the hospitals.

“It’s hard in our state hospitals right now,” she said. Unfortunately, she said, patients who have been in jail bring that culture to the hospitals.

In the first 10 months of 2024, at least nine patients escaped from Ohio’s regional psychiatric hospitals 鈥� compared with three total in the previous four years, according to .

, two female patients at Summit Behavioral Healthcare near Cincinnati escaped after one lunged at a staff member. In another, a man broke a window and climbed out.

Most of the escapes, though, were not violent. Days after a patient at Northcoast during a trip to the dentist in a Cleveland suburb, state officials stopped allowing patients to leave any of the six regional hospitals.

to leaders at the hospitals said officials had seen “similarities across multiple facilities,” raising significant concern about “ensuring patient and public safety.”

For Heltzel, the inability to go on outings or to his mother’s house on the weekends was a setback for his treatment. In 2024, when the lockdown began, he had more freedom than most patients at the psychiatric hospitals, regularly leaving to go to the local gym and attend off-site group therapy.

His mother signed him out each Friday to go home for the weekend, where he drove a car and played with his 2-year-old German shepherd, Violet. On Sundays, Heltzel was part of the “dream team” at church, volunteering to operate the audio and slides.

Federal records reveal that, at Ohio’s larger state-run psychiatric hospitals, including Summit and Northcoast, patients and staff have faced imminent danger.

In 2019 and 2020, federal investigators responded to patient deaths, including two suicides in six months at Northcoast. One hospital employee told federal inspectors, “The facility has been understaffed for a while and it’s getting worse,” according to . “It is very dangerous out here.”

Disability Rights Ohio, which has a federal mandate to monitor the facilities, in October against the department. The advocacy group, alleging abuse and neglect, asked for records of staff’s response to a Northcoast patient who suffocated from a plastic bag over their head. At the end of October, the court docket showed the parties had settled the case.

Retired sheriff’s deputy Louella Reynolds worked as a police officer at Northcoast for about five years before leaving in 2022. She said the increase in criminally charged patients meant the hospitals “absolutely” became less safe. Her hip still hurts from a patient who threw her against a cement wall.

Reynolds said officers should be able to carry weapons, which they don’t, and that more staff are needed to handle the patients. Mandatory overtime was common, she said, and often staff would report to work and not “know when we would get off.”

A Disaster That Wasn’t Averted

Back at Heartland, Heltzel requested conditional release. The judge denied the release request.

Heltzel said it was devastating. He grew up Catholic and said, “I was kind of looking for absolution.”

Now, Heltzel said he is practicing acceptance. “Acceptance is all the more important to practice when you don’t agree with something,” Heltzel said, adding, “I’m a ward of the state.”

He still hopes to be released: “I just do what I can to move forward.”

Heltzel, like Jackson, had been hospitalized before and released.

In early 2013, Heltzel said, he asked his dad to kill him. “And he refused and I did smack him,” he said. Heltzel was sent to Heartland for a short stay 鈥� about 10 days, according to his mother, Jan Dyer. She recalled “begging” the hospital staff to keep him.

Heltzel said he remembers not being ready to leave: “I was still sick, and I was still delusional.” Back at home, he said, he had a “sense of existential dread, like that all this horrible stuff was going to happen.” He stopped taking his medication.

Within weeks, Heltzel killed 71-year-old Milton A. Grumbling III at his home, placing him in a chokehold and stabbing him repeatedly, according to . He beat him with a remote control and then left, taking a Bible from the home, as well as a ring. Delusional with schizophrenia, Heltzel believed that Grumbling had sexually abused him in another life, according to the records.

A family member of the man he killed told the judge in 2023 that Heltzel should “stay in prison,” according to .

In denying his conditional release, judges cited Heltzel’s failure to take medication before killing Grumbling.

Jenkins, who said she worked at a state hospital for nine years before becoming the lead advocate for NAMI Greater Cleveland, said psychiatric medications can take as long as six weeks to become fully effective.

“So clients aren’t even getting stabilized when they’re being hospitalized,” Jenkins said.

鈥楬e’s Not a Throwaway Child’

In a July interview, Jackson said inconsistent care or unmedicated time in jail “worsens my symptoms.” Jackson was on the phone during a stay at a state psychiatric hospital.

Without medicine, “my head hurts, to be honest,” Jackson said, before asking to get off the phone because he was hungry. It was lunchtime. “Can you get the information from my mom?” Jackson said. “She has the records.”

After Jackson hung up the phone, Ferguson explained that “he says the food is excellent, so he does not want to miss it.” And, she added, the hospital staff had not yet seen the explosive side of her son.

In early September, after 45 days at Summit 鈥� his longest stay yet at a state psychiatric hospital 鈥� Jackson returned to the Montgomery County jail facing misdemeanor charges because of with staff at a Dayton behavioral health hospital. In court, Ferguson said, her son struggled to explain to the judge why he was there. On a video call from the jail days later, she saw him playing with his hair and ears.

“That tells me he’s not OK,” Ferguson said.

Before Jackson’s diagnosis more than a decade ago, Ferguson said, her son wasn’t a troublemaker. He had goals and dreams. And he’s still “loved and liked by a lot of people.”

“He’s not a throwaway child,” she said.

 is a nonprofit news team covering Ohio’s criminal justice systems.

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As night falls and temperatures drop, he erects a tent and builds a fire beneath a canopy of pine, hemlock, and cedar trees.

He evades authorities by rotating use of three tents of different colors at three campsites. As day breaks, he dismantles his shelter, rolls up his belongings, and hides them for the next night. “They don’t see you if you’re in the woods,” the 32-year-old said. “But make sure it’s broken down by morning or they’ll find you.”

During the day, he wanders, stopping at a public library to warm up or a soup kitchen to eat. What’s important is to not draw attention to himself for being homeless.

“Police want us out of the way,” he said, dressed in a gray jacket and carrying none of his possessions. “Out of sight, out of mind.”

Ibrahim has been deliberate about blending in since August, when President Donald Trump placed the district’s police under and ordered National Guard soldiers to patrol its streets. The president homeless people to leave immediately. “There will be no 鈥楳R. NICE GUY,’” .

The Trump administration says encampment sweeps have reduced the visibility of homelessness, thereby enhancing the city. “There is no disputing that Washington, DC is a safer, cleaner, and more beautiful city thanks to President Trump’s historic actions to restore the nation’s capital,” White House spokesperson Taylor Rogers said.

While there may appear to be fewer homeless people in the nation’s capital now, they have not disappeared.

In interviews, homeless people said they are in a constant shuffle, hiding in plain sight. During the day, they stay on the move, grabbing meals at soup kitchens and resting on occasion in public libraries, on park benches, or at bus stops. At night, many unsheltered people bed down in business doorways, on park sidewalks, and on church stoops. Some ride the bus all night, while a few shelter in emergency rooms. Others find respite in the woods or flee to suburbs in Virginia or Maryland.

There are about 5,100 homeless people in Washington, D.C., including in temporary shelters, according to an . After Trump ordered the crackdown on public homelessness, people living in makeshift communities scattered and are now living in the shadows. City officials estimated in August that homeless people were living outdoors without tents or other shelter.

As winter draws near, they are exposed to the elements and grow sicker as chronic ailments such as diabetes and heart disease go untreated. Street medicine providers say that, since the National Guard was deployed, they have faced enormous difficulty finding patients. Many caught up in sweeps have had their lifesaving medications thrown away, and they are more likely to miss medical appointments because they are constantly on the move. Street medicine providers say they can’t find their patients to deliver medication or transport them to medical appointments. The constant chaos can suck patients with mental illness and substance use deeper into drug and alcohol addiction, raising the risk of overdose.

Caseworkers report similar disruptions, saying as clients get lost, they break connections essential for obtaining housing documents, particularly IDs and Social Security cards.

District officials and health providers say this cascade will make homelessness worse, threatening public health and public safety and racking up enormous costs for the health care system.

“It was already hard locating people, but the federal presence just made it worse,” said Tobie Smith, a street medicine doctor and the executive director of Street Health D.C.

The Homeless Shuffle

Chris Jones was born and raised in Washington, D.C., but now is homeless, having been pushed out of his tent near the White House in the initial days of the federal homelessness crackdown. He said two of his tents were taken during sweeps. Now, sleeping on a sidewalk outside a church, he doesn’t bother trying to get another one. “Why? What’s the point? It’ll just get thrown away again.”

Jones, 57, has a severe knee injury that prevents him from walking some days and said he was scheduled for a knee replacement in December. He said it’s important to stay where he is 鈥� he relies on a nearby drugstore to refill his medications for bipolar disorder, diabetes, and high blood pressure. When he’s hungry, he goes to a soup kitchen for a meal or tries to get a cheeseburger and a soda from a fast-food joint across the street.

It’s important for him to stay outside the church, he said, so his case manager can find him when a permanent housing slot opens up. If it gets too cold, he said, he will cross the street and sleep in the doorway of a business, which can provide a bit more shelter. He wants to get indoors, but for now, he waits.

Since taking control of Washington’s police force, the Trump administration has on cities and counties across the nation to clear homeless encampments under threat of arrest, citation, or detention. It has ordered or threatened similar National Guard deployments in Los Angeles; ; and other cities with large homeless populations.

Rogers, the White House spokesperson, said the president is maintaining National Guard and federal law enforcement presence in the nation’s capital “to ensure the long-term success of the federal operation.” Since March, city and federal officials have removed more than 130 homeless encampments, she said, though some local homelessness experts say that number could be inflated.

The Supreme Court last year for elected officials and law enforcement to fine or arrest homeless people for living outside. Then, in July of this year, the president issued an executive order calling for a nationwide crackdown on urban camping, including a massive removal of people living outdoors and forced mental health or substance use treatment.

Trump is also spearheading an overhaul of homelessness policy, moving to and services for homeless people. The move would limit the use of a long-standing federal policy known as “” that offers housing without mandating mental health or addiction treatment. The National Alliance to End Homelessness warns the move risks displacing in permanent supportive housing. The Department of Housing and Urban Development paused the plan on Dec. 8 to make revisions, which it “intends” to do, .

City officials say they are complying with the Trump administration’s forceful campaign against homeless people sheltering outside. Pressured by the White House, local officials said they’ve gotten more aggressive in breaking up camps. Advocates for homeless people say some of the sweeps have been conducted at night and others with little or no notice to move. City leaders believe they could be done more compassionately by offering services and shelter.

“We’ve pivoted from the notion of allowing encampments if they didn’t violate public health or safety to a position of, 鈥榃e don’t want you in the streets,’” said Wayne Turnage, deputy mayor for District of Columbia Health and Human Services, who oversees encampment cleanups. “It’s unsafe, it’s unhealthy, and it’s dangerous.” Yet he acknowledges the encampment sweeps can waste city resources as caseworkers and street medicine providers scramble to find their clients and patients.

Advocates say the Trump administration is inciting fear and mistrust between homeless people and those working to help them while wasting taxpayer dollars used to provide care and place people into housing. There are, however, far fewer tents and large-scale encampments visible to tourists and residents.

“People found safety in those communities and service providers could find them. Now there are people with guns and flashing lights dislocating folks experiencing homelessness without notice and just throwing stuff away,” said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

District officials say some people have accepted emergency shelter. But even as the city works to connect people with services and expand shelter capacity, officials acknowledge there isn’t enough permanent housing or temporary beds for everyone.

And there will be fewer places for people living outside to go.

The city, in its fiscal year 2026 budget, concentrated its homelessness funding on families, funding 336 new permanent supportive housing vouchers. Yet it cut funding for temporary housing for both families and individuals and provided no new permanent supportive housing vouchers for individuals. That means fewer housing slots for single adults, who make up most of those wandering the streets. City officials said, however, that they have slotted 260 more permanent housing units for homeless individuals or families into their construction pipeline.

Worsening Health Care

The fallout is inundating local soup kitchens with demand, including Miriam’s Kitchen in Foggy Bottom. The local institution provides hot meals, housing assistance, and warm blankets to people in need.

Caseworkers say it’s becoming increasingly difficult to help clients secure IDs and other documents needed for housing and other social services.

“I’m looking everywhere, but I can’t find people,” said Cyria Knight, a caseworker at Miriam’s Kitchen. “Most of my clients went to Virginia.”

It’s unclear how much of the district’s homeless population has fanned out to neighboring Virginia and Maryland communities. There were an estimated in the region in January, months before Trump’s crackdown. Four of six counties around Washington saw homelessness rise from 2024, while it .

“I’m not seeing my patients for a month or more, and then when I do, their chronic conditions are uncontrolled. They’ve been in and out of the ER, and they’re more likely to be hospitalized,” said Anna Graham, a street medicine nurse practitioner for , a network of clinics in Washington. “It’s just setting us back.”

Graham’s team stations its mobile medical van outside Miriam’s Kitchen at dinnertime to better find patients.

Willie Taylor, 63, was figuring out where to sleep for the night after grabbing dinner from Miriam’s. He saw Graham to receive his medications for advanced lung disease, seizures, chronic pain, and other health disorders.

He has difficulty walking and needs a wheelchair, which is complicated because he doesn’t have a permanent address. Taylor and his medical providers say his previous wheelchairs have been stolen while he slept outdoors at night. He uses a shopping cart to keep him steady, walking around all day, until nightfall.

On a cold November night, Graham helped Taylor figure out his daily medications and checked his vitals. The team handed him a warm coat and hand warmers before sending him back outside.

After walking for about 45 minutes, he found a piece of park pavement where he could build a bed out of tarps and sleeping bags.

“My body can’t take this,” Taylor said, preparing to sleep. “There’s ice on the concrete. I’m in so much pain; it hurts so much worse when it’s cold.”

Homeless people and cost the health care system more than housed people, largely because conditions go untreated on the streets, and when they do seek care, many go to the ER. Among Medicaid enrollees, homeless people have been estimated to incur $18,764 a year in spending, compared with $7,561 for other enrollees.

Over at the So Others Might Eat soup kitchen earlier that day, Tyree Kelley was finishing his breakfast of a sausage sandwich and hard-boiled eggs. He was considering going into a shelter. The streets were becoming too dangerous for someone like him, he said, referring to the police and National Guard presence. He was feeling the loss of an encampment community that would watch his back.

He’s been to the ER at least seven times this year to get care for a broken ankle he sustained falling off an electric scooter. The accident caused him to lose his job and health insurance as a garbageman, he said. His situation has caused him to sink deeper into a depression that began three years ago after his mother died, he said.

Then his father and sister died this year. He began to numb his pain with beer.

“You get so depressed, being out here,” said Kelley, 42. “It gets addictive. You start to not care about even changing your clothes.”

His depression also led him to seek out marijuana. Then he smoked a joint laced with fentanyl. The overdose sent him to the hospital for days.

“I actually died and came back,” he said, crediting other homeless people with administering naloxone and saving his life. “I need to get out of this, but I feel so stuck.”

A few blocks west of the White House sits a vacant plot of land that earlier this year held more than a dozen tents. Workers in the area sense what they don’t always see.

“I was here when this was all cleared. A bulldozer came in, and all their stuff was thrown in a garbage truck,” said Ray Szemborski, who works across the street from the now-empty lot. “People are still homeless. I still see them around underneath the bridge. Sometimes they’re at bus stops, sometimes just walking around. Their tents are gone but they’re still here.”

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At Nov. 7 in the Inland Empire, four Democratic candidates vying to succeed Gov. Gavin Newsom vowed to push back against Republican cuts to health care programs and to improve people’s access to medical care, including mental health services. But while some floated taxes, candidates were light on details about how they would bring down health care costs.

Former U.S. Health and Human Services Secretary Xavier Becerra promised to be California’s next “health care governor,” echoing to lower costs and broaden access when he first got into office. State Superintendent of Public Instruction Tony Thurmond pledged to create a single-payer health care system in which everyone is pooled into one program. Former state Controller Betty Yee said she would “build back better” from federal cuts and create a health care system tailored to California’s diverse communities.

And former Los Angeles Mayor Antonio Villaraigosa vowed to fight to preserve safety net health care pared by the Trump administration and Republicans in Congress, although he acknowledged the challenge given limited state resources.

“I’m not gonna sell you snake oil,” he said. “It is going to be tough to provide that care, but I’m absolutely committed to it.”

The candidates’ assurances come amid recent shifts in state and federal policies that, together with a variety of forces, are driving up the cost of health care and making it harder for people to obtain and maintain coverage. In addition to providers raising prices, other include an aging population, rising chronic conditions, medical advancements, and new technologies, according to analysts. That’s added to a sense of financial precarity for the millions of Californians struggling with the state’s and .

Although the forum was open to up to six candidates, former U.S. Rep. Katie Porter and entrepreneur Stephen Cloobeck declined to participate, citing scheduling or other factors, according to Jon Koriel, an event spokesperson.

Health Care Top Concern

A commissioned by the California Wellness Foundation ahead of the forum found that nearly 80% of likely voters worry about the cost of health care and that 72% think the next governor should prioritize capping out-of-pocket expenses. Access to affordable mental health care and being able to care for aging family members or friends were also top concerns. Perhaps in an early signal, voters last week in Santa Clara County passed to help backfill federal cuts to food and health care safety net programs.

California mirrors much of the nation. Exit polls from the Nov. 4 election show 81% of those who voted for Democrat Abigail Spanberger, winner of the Virginia governor’s race, as the most important issue facing the state. In a national , health care was cited as the top everyday expense Americans want Congress to prioritize. And 65% of voters said an annual health cost increase of $1,000 would have some impact on their 2026 vote, according to a .

Some Californians interviewed on Nov. 4, the day of the state’s special election, expressed disappointment in Newsom’s unmet promises on health care. Newsom, a Democrat who is mulling as he wraps up his second term in January 2027, had campaigned on .

During his tenure he’s steered billions of dollars and engineered rules to help the neediest Californians afford and access health care. The state also expanded state-funded Medicaid coverage, known as Medi-Cal, to all eligible residents, regardless of immigration status. Medicaid provides free or low-cost health insurance to low-income and disabled people.

But this year, facing rising costs and budget deficits, Newsom and the Democratic-controlled legislature walked back some of that expansion by freezing enrollment for adults without legal status starting in 2026 and implementing premiums. They also resurrected an asset test for older adults and people with disabilities. Meanwhile, health care costs and homelessness remain a huge problem, and many Californians . And there’s no sign of a single-payer health care system, which Sacramento lawmakers have repeatedly amid concerns about cost, including one estimate in 2017 of $400 billion annually.

“I remember him coming and speaking to our members and telling them that he was going to fight with them for single payer,” Michael Cusack, a 30-year-old former health care union worker from Oakland, said as he cast his ballot last week. “And I never saw him deliver on that campaign.”

Paying for Health Care

Becerra, Thurmond, and Yee said they would be open to raising taxes to pay for health care programs. Villaraigosa sidestepped the tax question, saying his focus would be to “grow the pie” economically. Yee also suggested offering tax credits to help struggling families pay for health care and caregiving expenses.

During the forum’s lightning round, Becerra, Thurmond, and Yee also raised their hands when asked whether they supported single-payer care. Becerra said after the event that he doesn’t believe the state would receive support from the Trump administration for a single-payer system, but he said he would push for universal access to health care.

Indeed, all the candidates appeared mindful of Washington’s power over health care resources, even as they vowed to stand up to President Donald Trump, who has an especially adversarial relationship with Newsom.

“Let’s recognize that the federal government is our largest partner,” Becerra said. “We must work with them. We will not take a knee, but we must work with them.”

Currently, the biggest threats to health care costs and accessibility come from the federal government. Republicans in Congress have refused to give in to Democrats’ demand to extend premium tax subsidies for health insurance plans purchased on Affordable Care Act exchanges, the main issue that drove the government shutdown. Enrollees in Covered California, the state’s health insurance exchange, have received notices that their premiums will increase next year. On average, monthly premium payments聽for people receiving ACA subsidies聽are across the nation.

Laura Jones, a small-business owner in Oakland, currently pays the minimum possible for her Covered California plan, but she worries she wouldn’t be able to afford a major medical emergency. She thinks about one of her friends who recently suffered a stroke.

“The hospital bills were just so egregious,” Jones said. “How would I pay for that?”

Meanwhile, an impending in federal Medicaid spending reductions under the One Big Beautiful Bill Act and tighter eligibility restrictions are expected to push as many as out of the program. More than a third of Californians are currently enrolled in Medi-Cal.

Oseoba Airewele, 29, of Ventura, a registered Democrat who previously worked as a software engineer, said Medi-Cal became a lifeline after he lost insurance through his job and needed mental health and dental care.

“If I were to lose it, I would be very concerned,” he said. “I’d be in a bad place.”

People with employer-based health coverage also face steep price hikes. Family premiums for employer-based plans averaged almost $27,000 this year, up 6% from 2024, a . Workers typically pay almost $7,000 of that, the report found. That doesn’t include other out-of-pocket expenses.

“Even though I have a job, it’s still really expensive to pay for the copays,” said Rheema Calloway, 35, a San Francisco independent.

Primary in June

Among the other Democratic candidates vying for governor in 2026, Porter has said she to Medicaid and Medicare a top priority, along with expanding and improving health care for all residents. Porter’s campaign suffered a blow after viral videos surfaced of her threatening to walk out of a CBS interview and berating a staff member. Former Assemblyman Ian Calderon has said he would protect . And Cloobeck wants to fast-track .

Republican candidates include Riverside County Sheriff and , a former Fox News contributor and policy adviser to David Cameron when he was Britain’s prime minister. Both have pledged to tackle affordability issues, especially housing costs.

Two other high-profile Democrats 鈥� former Vice President Kamala Harris and U.S. Sen. Alex Padilla 鈥� have said they won’t run. Rick Caruso, a Republican-turned-Democrat and wealthy Los Angeles businessman, has yet to decide whether to run.

The California primary will be held June 2 and the general election on Nov. 3.

麻豆女优 Health News correspondent Christine Mai-Duc and ethnic media editor Ngoc Nguyen contributed to this report.

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Public health experts and local advocates say the outbreak is fueled by a confluence of on-the-ground factors: the sidelining and closing of programs that distributed sterile syringes to people who use drugs, a shortage of medical providers focused on HIV, and the clearing of the city’s largest homeless encampment, which upended care for newly diagnosed people living there.

But those issues may not remain local for long.

The Trump administration is pushing similar tactics nationwide. In a , Trump called for defunding programs that engage in harm reduction 鈥� a broad term that encompasses many public health interventions, including syringe services, aimed at keeping people who use drugs alive. Such efforts are sometimes controversial, with critics saying they enable illegal activity. The executive order also supports forcing homeless people off the street and into treatment. This comes after the administration cut or delayed funding for various addiction and HIV-related programs and federal agencies .

The administration says its approach will increase public safety, but suggest otherwise. Many advocates and researchers warn these efforts could spark more outbreaks like the one in Bangor.

“That feels inevitable,” said Laura Pegram, director of for NASTAD, an association of public health officials who administer HIV and hepatitis programs.

She said people who use drugs face a trifecta of risks: HIV, hepatitis C, and overdose. “Across the country, I think we’ll start to see those three things starting to be on the rise again.”

“That will be incredibly costly,” she added 鈥� in dollars and “in a real human way.”

Outbreaks that start among people who use drugs can easily spread to those who don’t.

An HIV Outbreak

The first HIV case in Bangor’s current outbreak , well before Trump’s return to the presidency.

Puthiery Va, director of , attributed the emergence to the opioid epidemic, housing shortages, and the greater Bangor area’s sparse health care services.

Local advocates highlighted an additional, acute factor: supply shortages at the region’s largest syringe services program and its subsequent closure.

A nonprofit that provided health care and social services to people who use drugs, Health Equity Alliance, or HEAL, distributed sterile needles annually.

Like other such programs nationwide, its goal was to prevent the spread of infectious disease that can occur if people share needles to inject drugs.

However, financial struggles and mismanagement led to severe shortages in recent years. Former HEAL executive director Josh D’Alessio acknowledged such issues, telling 麻豆女优 Health News, “We did run out of syringes” at times or limit how many participants could take. Several of these shortages struck in the fall of 2023, leading HEAL staffers to suggest a link to the first HIV case.

The Future of Harm Reduction

Research suggests a strong connection between past HIV outbreaks among people who use drugs and lack of access to sterile needles, said , an epidemiologist at Tufts University School of Medicine.

A 2015 outbreak in Scott County, Indiana, and one in the a few years later were curbed only after , he said. If such programs had existed sooner in Scott County, more than a hundred infections could have been prevented, .

Va, who leads the Maine Center for Disease Control and Prevention, said she considers the shortage of syringe services in the Bangor area to be a factor in the outbreak but not the primary cause.

Stopka said the best practice during an outbreak “is to amplify access to sterile syringes.”

But Trump’s recent executive order links harm-reduction programs to crime, saying such efforts “only facilitate illegal drug use and its attendant harm.” The order doesn’t name syringe services programs 鈥� which have been supported by both Democrats and Republicans in the past 鈥� but it targets “safe consumption” sites, where people can use drugs under supervision. the attacks will be broader.

A letter from the nation’s leading addiction agency expanding on Trump’s executive order said federal funds to buy syringes or drug pipes. However, that has been true for most of the past few decades. The letter did not address supporting general operating costs for syringe services programs.

Department of Health and Human Services spokesperson Andrew Nixon told 麻豆女优 Health News that the administration is committed to “addressing the addiction and overdose crisis impacting communities across our nation.” But he and spokespeople for the White House did not respond to specific questions about the administration’s stance toward syringe services.

In Bangor, some locals have raised concerns about harm reduction that echo the president’s. At a 鈥� shortly after a syringe services program was newly certified by the state to operate locally 鈥� residents and business owners said they felt unsafe with the growing population of people who were homeless and using drugs. They worried syringe programs were fueling the behavior.

But research suggests syringe services programs in the community and . They new HIV and hepatitis C cases, into addiction treatment fivefold, . They are also of overdose reversal medications, the use of which many communities 鈥� and the Trump administration 鈥� have said they support.

The city ultimately decided the newly certified program, , could not operate in prominent public parks or squares.

In the following months, Needlepoint ran its syringe services only at the city’s largest homeless encampment, where several people had tested positive for HIV, said the group’s executive director, William “Willie” Hurley. That ended in February when the city cleared the encampment.

This summer, Needlepoint secured a private location for its syringe services but shut it down five days later when city officials .

, director of Bangor’s health department, said the city is trying to strike a balance between “making services available and what the community wants.”

“Getting the buy-in of most of the community” is “critical to the future of harm reduction,” she said.

Other cities have seen backlash result in new laws that restrict how syringe services programs operate or shutter them.

Gunderman said she is hoping to avoid that in Bangor.

Clearing Encampments

Trump’s recent executive order also calls for clearing homeless people off the street and involuntarily committing them to treatment facilities.

The administration is enacting this policy in Washington, D.C., where it has and threatened homeless people if they don’t leave the streets.

White House spokesperson Abigail Jackson said people have the option to be taken to a shelter or receive addiction and mental health services.

Similar policies have taken hold nationwide in recent years, even in liberal hubs like and .

Last year in Bangor, as a homeless encampment that grew to nearly 100 residents, business owners and locals called for its clearing.

Some advocates and social service providers warned that doing so could exacerbate the HIV outbreak and overdose crisis. At two City Council meetings in November, that it would be difficult to find people they served after a clearing and that scattering newly diagnosed people HIV clusters elsewhere.

“Plenty of people said you’re going to lose track of these people,” , a board member for the Bangor Area Recovery Network, told 麻豆女优 Health News. “They did it anyway.”

鈥業’m Still Alive’

Two months after clearing the encampment, not knowing the location of more than a third of the people who had lived there.

Clark said it’s not surprising that the city couldn’t connect everyone to housing or treatment. Many people distrust these services, shelters are frequently full, and treatment services are scarce. “Where exactly are these people supposed to go?” she said.

City officials stressed in Council meetings and reports that they were taking a humane approach. They ramped up social services for months leading up to the clearing, connecting people to everything from housing to storage facilities and laundry.

Gunderman, the city health director, said she knows the sweep wasn’t ideal but that neither was crowding folks in an unsanitary encampment. “It was a situation where there weren’t a lot of great answers,” she said.

To help track folks from the encampment and keep them engaged in HIV treatment, the city is now using about to hire two case managers. (The only other local HIV medical case management program .)

“What we know from outreach we’ve been doing already is that we spend a lot of time looking for people,” Gunderman said.

Jason, who has been homeless for most of the past decade and tested positive for HIV this year, has seen that in action.

Members of what he calls his medical team have scoured the streets for hours to find his tent and remind him to take his HIV treatment shots, he said. Some picked up prescriptions and delivered them to him.

“They’ve made sure I’m taken care of,” Jason said. (麻豆女优 Health News agreed to use only his first name to protect his privacy.)

Jason believes he got the virus last year at the homeless encampment while using drugs that someone else prepared. He had tried to avoid the encampment for months. But whenever he set up his tent elsewhere, he said, police officers told him to move.

When he got the diagnosis, he thought of his uncle, who died of AIDS in the 1980s.

“It hurts to talk about,” Jason said, “but I’m still alive.”

After months of treatment, his viral load is . Over the summer, his team helped him find housing.

But Jason is still struggling to find sterile needles regularly. He worries about others facing a shortage.

“That’s how this outbreak has been spreading more and more,” Jason said. “Every time we turn around there’s another case.”

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BRISTOL, R.I. 鈥� At age 82, Roberta Rabinovitz realized she had no place to go. A widow, she had lost both her daughters to cancer, after living with one and then the other, nursing them until their deaths. Then she moved in with her brother in Florida, until he also died.

And so last fall, while recovering from lung cancer, Rabinovitz ended up at her grandson’s home in Burrillville, Rhode Island, where she slept on the couch and struggled to navigate the steep staircase to the shower. That wasn’t sustainable, and with apartment rents out of reach, Rabinovitz joined the growing population of older Americans unsure of where to lay their heads at night.

But Rabinovitz was fortunate. She found a place to live, through what might seem an unlikely source 鈥� a health care nonprofit, the . Around the country, arranging for housing is a relatively new and growing challenge for such PACE groups, which are funded through Medicaid and Medicare. PACE stands for a Program of All-Inclusive Care for the Elderly, and the organizations aim to keep frail, older people in their homes. But a patient can’t stay at home if they don’t have one.

As housing costs rise, organizations responsible for people’s medical care are realizing that to ensure their clients have a place to live, they must venture outside their lanes. Even hospitals 鈥� in Denver, , and 鈥� have started investing in housing, recognizing that health isn’t possible without it.

And among older adults, the need is especially growing. In the U.S., who were homeless in 2024 were 55 or older, with the total older homeless population up 6% from the previous year. a University of Pennsylvania professor who specializes in homelessness and housing policy, older than 60 living in shelters roughly tripled from 2000 to 2020.

“It’s a national scandal, really, that the richest country in the world would have destitute elderly and disabled people,” Culhane said.

Over decades of research, Culhane has documented the plight of people born between 1955 and 1965 who and never got an economic foothold. Many in this group endured intermittent homelessness throughout their lives, and now their troubles are compounded by aging.

But other homeless older adults are new to the experience. Many teeter on the edge of poverty, said , CEO of USAging, a national association representing what are known as . A single incident can tip them into homelessness 鈥� the death of a spouse, job loss, a rent increase, an injury or illness. If cognitive decline starts, an older person may forget to pay their mortgage. Even those with paid-off houses often can’t afford rising property taxes and upkeep.

“No one imagines anybody living on the street at 75 or 80,” Markwood said. “But they are.”

President Donald Trump’s recent budget law, , the public insurance program for those with low incomes or disabilities, will make matters worse for older people with limited incomes, said Yolanda Stevens, program and policy analyst with the . If people lose their health coverage or their local hospital closes, it will be harder for them to maintain their health and pay the rent.

“It’s a perfect storm,” Stevens said. “It’s an unfortunate, devastating storm for our older Americans.”

Adding to the challenges, the Labor Department a job training program intended to keep low-income older people in the workforce.

Those circumstances have sent PACE health plans throughout the country into uncharted waters, prompting them to set up shop , partner with housing providers, or even to build their own.

A 1997 federal law recognized PACE organizations as a provider type for Medicare and Medicaid. Today, some 185 operate in the U.S., each serving a defined geographic area, with a total of more than .

They enroll people 55 and older who are sick enough for nursing home care, and then provide everything their patients need to stay home despite their frailty. They also run centers that function as medical clinics and adult day centers and provide transportation.

These organizations primarily serve impoverished people with complex medical conditions who are eligible for both Medicaid and Medicare. They pool money from both programs and operate within a set budget for each participant.

PACE officials worry that, as federal funding for Medicaid programs shrinks, states will curtail support. But the PACE concept has always had bipartisan support, said Robert Greenwood, a senior vice president at the , because its services are significantly less expensive than nursing home care.

The financing structure gives PACE the flexibility to do what it takes to keep participants living on their own, even if it means buying an air conditioner or taking a patient’s dog to the vet. Taking on the housing crisis is another step toward the same goal.

In the Detroit area, , which serves 2,200 participants, partners with the owners of senior housing. The landlords agree to keep the rent affordable, and PACE provides services to their tenants who are members. Housing providers “like to be full, they like their seniors cared for, and we do all of that,” said Mary Naber, president and CEO of PACE Southeast Michigan.

For participants who become too infirm to live on their own, the Michigan organization has leased a wing in an independent living center, where it provides round-the-clock supportive care. The organization also is partnering with a nonprofit developer to create a cluster of 21 shipping containers converted into little houses in Eastpointe, just outside Detroit. Still in the planning stages, Naber said, the refurbished containers will probably rent for about $1,000 to $1,100 a month.

In San Diego, the cares for chronically homeless people as they move into housing, offering not just health services but the backup needed to keep tenants in their homes, such as guidance on paying bills on time and keeping their apartments clean. St. Paul’s also helps those already in housing but clinging to precarious living arrangements, said Carol Castillon, vice president of its PACE operations, by connecting them with community resources, helping fill out forms for housing assistance, and providing meals and household items to lower expenses.

At PACE Rhode Island, which serves nearly 500 people, about 10 to 15 participants each month become homeless or at risk of homelessness, a rare situation five or six years ago, CEO Joan Kwiatkowski said.

The organization contracts with assisted living facilities, but its participants are sometimes rejected because of prior criminal records, substance use, or health care needs that the facilities feel they can’t handle. And public housing providers often have no openings.

So PACE Rhode Island is planning to buy its own housing, Kwiatkowski said. PACE also has reserved four apartments at an assisted living facility in Bristol for its participants, paying rent when they’re unoccupied. Rabinovitz moved into one recently.

Rabinovitz had worked as a senior credit analyst for a health care company, but now her only income is her Social Security check. She keeps $120 from that check for personal supplies, and the rest goes to rent, which includes meals.

Once a week or so, Rabinovitz rides a PACE van to the organization’s center, where she gets medical care, including dental work, physical therapy, and medication 鈥� always, she said, from “incredibly loving people.” When she’s not feeling well enough to make the trek, PACE sends someone to her. Recently, a technician with a portable X-ray machine scanned her sore hip as she lay in her own bed in her new studio apartment.

“It’s tiny, but I love it,” she said of the apartment, which she’s decorated in purple, her favorite color.

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