She spoke at rallies. With other members of the advocacy organization Compassion & Choices, she visited legislators’ offices. In 2024, as the state Assembly was debating the aid in dying bill, she helped unfurl a banner in the chamber gallery that read, “Stop the Suffering.”

Her activism was becoming difficult. Netherland, who is 59 and works for a nonprofit, was diagnosed with breast cancer in 2019. “I did a full year of aggressive treatment,” she said. “Chemotherapy. A mastectomy. Radiation treatment every weekday for five weeks. Six months of two oral medications.”

She recovered and felt well until the cancer returned a few years later. Although metastatic breast cancer is incurable, drugs are keeping her disease at bay for now. Netherland feels fortunate but also fatigued, and she contends with brain fog, gastrointestinal symptoms, and joint pain.

“My energy is really limited,” she said.

As she emailed and called legislators, Netherland feared she might die before the aid in dying bill 鈥� first introduced in New York in 2016 鈥� could become law.

鈥楢 Breakthrough Moment’

On June 9, 2025, after the Assembly approved the bill, Netherland was in the state Senate chamber, watching the aye votes mount, and seeing it pass.  an amended version in February; it is scheduled to take effect Aug. 5.

A similar law is  in September in Illinois, which would become the (plus the District of Columbia) where medical aid in dying is legal.

“A breakthrough moment,” said Kevin Díaz, president of Compassion & Choices, which has spearheaded the long campaign for such laws. After almost 30 years 鈥� Oregon’s law, the first in the country, was enacted in 1997 鈥� the addition of two populous states means that almost a third of Americans will live in one where medical aid in dying is legally available. “It shows that there’s broad support for this model,” Díaz said.

Polls consistently back that claim. A  last spring found that almost two-thirds of respondents didn’t consider the practice “morally wrong,” either because they thought it was acceptable or not a moral issue. Support crossed many political and religious lines: A narrow majority of Republicans and 76% of Democrats both found “physician-assisted death” (also sometimes called “physician-assisted suicide”) permissible; so did most Catholics, Jews, and nonevangelical white Protestants.

In New York,  that 54% of respondents supported aid in dying, including majorities of men and women, of all age groups, and of city, suburban, and upstate residents. A plurality of Latinos supported it; Black respondents narrowly opposed it.

Passing these laws has grown somewhat easier, said Thaddeus Pope, a bioethicist and professor at Mitchell Hamline School of Law in St. Paul, Minnesota, who tracks such policies. “You can say, 鈥榃e have 10 years in California, 18 years in Washington, and 29 years in Oregon, and nothing bad has happened.’ It becomes more accepted.”

鈥榊ou Need A, B, and C’

Yet legalizing medical aid in dying, or MAID, has been and remains a long, contentious process. Catholic leadership and many disability organizations staunchly oppose it. (Pope Leo XIV personally  not to sign the bill.)

The American Medical Association says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer” and poses “serious societal risks,” although a number of state medical organizations have opted to remain neutral or, as in New York, to .

The Patients’ Rights Action Fund, through a sister organization, has lawsuits pending or on appeal in California, Delaware, and Colorado, arguing that aid in dying laws discriminate against people with disabilities by steering them toward physician-assisted suicide instead of treatment.

“This is a litigation strategy we’ve developed to ultimately get to the Supreme Court,” said Matt Vallière, the group’s executive director, who declined to say whether it would sue to block the Illinois and New York laws.

Even when aid in dying laws succeed, using them can prove challenging. In every state (except Montana, where it became legal through a court decision, so there is no statute governing eligibility), aid in dying is available only to people with incurable illnesses who are expected to die within six months.

It typically involves oral and written requests to two doctors, with mandated waiting periods between requests. Patients must have the mental capacity to make the decision, which disqualifies those with dementia, and they must ingest the medication without assistance. (An amendment Hochul insisted on adds a psychologist or psychiatrist to the process.)

All but two states require patients to be residents. Oregon and Vermont scrapped their residency requirements  brought by Compassion & Choices. ( a .)

Moreover, any doctor, hospital, or healthcare system can legally decline to provide aid in dying, and religiously affiliated institutions often opt out. Those that participate can add their own requirements.

“The state can say 鈥榊ou need A, B, and C,’ and Columbia-Presbyterian can say, 鈥榃e also want D, E, and F,’” said Pope, the Minnesota bioethicist.

Hotly Debated, Seldom Used

Perhaps these restrictions, or a lack of public awareness, help explain why, despite the headlines and fervent debates, the number of people who actually use the law is tiny in every state 鈥� usually 1% or fewer of the deaths recorded annually. The support for giving patients this kind of autonomy at the end of life remains widespread, but the desire to personally exercise it apparently is not.

Still, after studies showed that many patients seeking MAID were dying , the trend has been to loosen restrictions. California cut its 15-day waiting period to 48 hours; New Mexico allows physician assistants and advanced-practice nurses to write prescriptions along with doctors.

“Most states have now amended their laws two or three times,” Pope said. “We have liberalized.” Telehealth can also facilitate access to participating doctors.

Compassion & Choices is planning legal challenges to end residency requirements in additional states, Díaz said. It is also considering how to “make inroads in jurisdictions with a much different cultural and political environment,” he added, mentioning Florida and other Southern states.

Medical aid in dying represents a shift in power, Díaz said. “The person who has to bear the burden of the suffering should have the ability to decide when it’s enough,” he added.

Anne Gurnett Bander, 72, a retired research scientist in Carmel, New York, cared for her husband for four years as ALS 鈥� the relentlessly disabling neurological disorder also known as Lou Gehrig’s disease 鈥� rendered him bedridden and dependent on feeding and breathing tubes. “By the time he died, the only thing he could do was nod his head,” she recalled.

So being diagnosed with ALS herself last year was “my worst possible nightmare,” Gurnett Bander said. She was planning to fly to Switzerland, where the nonprofit organization Dignitas provides medical aid in dying, when she learned about the New York bill and began speaking publicly in support of it, her voice faltering as her illness advanced.

Gurnett Bander and Netherland say they’re not certain they’ll use lethal drugs to end their lives as their symptoms intensify. Not infrequently, patients complete the necessary steps, secure the prescribed medication, decide they don’t need it after all, and die of their diseases. But both women insist that the choice should be theirs.

“It can offer so much peace of mind,” Netherland said. “I thought, 鈥楶eople should have this option.’ Now, they will.”

The New Old Age is produced through a partnership with .

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Hundreds of detainees across at least 33 states allege in federal suits that immigration detention facilities are failing to provide adequate medical care, an investigation by 麻豆女优 Health News and The Associated Press found. Detainees say they didn’t get medications on time 鈥� or at all 鈥� for conditions including high blood pressure, diabetes, depression, epilepsy, Parkinson’s, and HIV. Requests for help went unanswered for weeks. Blood sugars rose. Infections festered. Cancers remained untreated. Detainees collapsed and had seizures.

U.S. jails and immigration detention centers have to meet the medical needs of the people in their charge. But the system is sagging under an influx of detentions since President Donald Trump returned to office: More than 75,000 immigrants were being detained by U.S. Immigration and Customs Enforcement , up from around 40,000 a year earlier.

麻豆女优 Health News and AP analyzed thousands of court cases filed since Trump’s second inauguration that use a legal route known as habeas corpus to argue people are being held illegally by ICE. The records offer a rare window into how those detained say, often under penalty of perjury, ICE is handling their medical needs. Reporters also interviewed more than 50 detainees, family members, and lawyers.

The investigation revealed that medical neglect is alleged across the sprawling detention system, including in offices not designed to house people, county jails, and quickly staged sites with nicknames such as “Alligator Alcatraz.”

ICE custody is deadlier than it has been in two decades, researchers wrote in April. The Department of Homeland Security reported 51 people had died in detention since the start of Trump’s second administration 鈥� with suicides .

麻豆女优 Health News and AP asked DHS to respond to the findings six days before publication, but it did not provide comment. The department’s acting chief medical officer, Sean Conley, has “it is both policy and longstanding practice for aliens to receive timely and appropriate medical care from the moment they enter ICE custody” and that the agency recruits healthcare professionals to maintain high standards. “This is better, more responsive healthcare than many aliens have ever received in their entire lives,” he has said.

Individual facilities and private prison companies contracting with DHS that responded to requests for comment said they follow ICE standards and detainees receive medical care when it is required. Some said they were unfamiliar with the allegations outlined in court documents; others blamed some detainees for lapses in their medical care.

“I have never seen such disregard or medical neglect like this anywhere,” Vardan Gukasian, a political dissident and former paramedic who spent years behind bars in Armenia, wrote in in March to contest his detention in Henderson, Nevada, as it stretched to 13 months despite health problems.

Madeleine Skains, a spokesperson for the city of Henderson, said medical care is always available at the facility and that the court had not ordered changes to his care.

Last June, as Gukasian experienced the symptoms of uncontrolled high blood pressure 鈥� dizziness, a nosebleed, and a headache 鈥� his cellmate banged on their door for help.

“When it did not arrive, the rest of the block banged on their doors,” he wrote. Gukasian was hospitalized that day.

鈥楤razen Indifference to Really Obvious Problems’

The administration’s mass deportation effort has swept up during routine immigration check-ins, at traffic stops, at their homes, and in hospitals.

About have no criminal conviction. Their immigration proceedings are civil, not criminal.

“I couldn’t understand why they treated me so harshly,” said a father of six in Georgia. He said he was injured while shackled in custody when the vehicle transporting him to an Atlanta facility jolted, throwing him out of his seat and into a metal armrest. His wound became infected with E. coli, he said, because he had to sleep on a dirty concrete floor amid leaking toilets.

Like other detainees interviewed, he spoke on the condition of anonymity; they said they fear for their safety, for the safety of their families, or that speaking out would jeopardize their immigration cases. The AP and 麻豆女优 Health News are not naming anyone identified in court documents without their consent.

Staffers at Stewart Detention Center in rural Lumpkin, Georgia, didn’t adequately respond to that man’s request for medical help, , until he passed out and was taken to a hospital about an hour away. There, he said, a doctor told him he’d narrowly escaped amputation of his left leg. Medical staff found no records of a case matching this description, according to Brian Todd, a spokesperson for CoreCivic, which runs the facility.

The 48-year-old, who moved to the U.S. from Guatemala more than two decades ago, was released in October and is now a legal permanent resident. But he is unsure if he’ll be able to return to his job in construction because, he said, he can no longer lift heavy things due to his injury.

Some detainees or their lawyers said even basic care was denied: gauze to protect an open foot wound, prenatal care for a high-risk pregnancy, a pillow to ease the pain of sleeping with advanced stomach cancer, sanitary pads for postpartum bleeding.

“I would like to believe the government has the best interest of those it holds in detention for whatever period of time,” Judge Benita Pearson, a federal judge in Ohio, said during a hearing in October concerning a 70-year-old who alleged the government lost her glasses during her arrest. “If one is unable to see due to the loss of glasses when detained, that should be fixed.”

, who worked for ICE and now serves as a special adviser to the American Bar Association, said case law requires the government to treat people in immigration detention with the same care it affords those in traditional jails awaiting trial. But administrators are granted discretion and medical care standards vary.

Detainees are frequently moved across the country, often without warning, interrupting treatment. A woman from El Salvador said she missed a week of HIV medication when she was transferred from Colorado to a county jail in Wyoming.

A Russian man wrote that, while detained in Texas, he saw a gastroenterologist about his painful gallstones and scheduled an appointment with a surgeon. “Unfortunately, I never got to see him, due to my being moved around various detention centers.”

Advocates say that even obvious disabilities, like legal blindness, are ignored.

A detainee who lost one eye and had severe glaucoma in the other required twice-daily drops to maintain what vision remained. But, he said, some days the drops never came.

“Now I can only see a little bit straight in front. It now often looks like I’m seeing through gauze,” the man wrote in a court declaration. “This makes me very afraid that one of these times I am going to open my eyes and not be able to see anything at all.”

He wrote that he was scared he wouldn’t be able to see his infant son grow up.

“It’s just sort of brazen indifference to really obvious problems, things you would have thought absurd a decade ago 鈥� like the fact that you can’t see,” the man’s attorney, Brian Hoffman, said. “Before, you could attempt to work with folks on the government side and maybe shame them into doing the right thing. Now, it’s sort of like anything you want done you have to go to court and sue over.”

Even court orders aren’t always enough. One California judge ordered the government to take a man showing signs of prostate cancer to a specialist for diagnosis and treatment. Records show they did not take him.

Lawyers representing ICE told the judge that officials missed the appointment because of an “internal scheduling error.” CoreCivic, which runs that facility, said it was unable to comment on active litigation.

A Surge in Cases

When immigrants file habeas corpus petitions, they exercise a right to challenge unlawful imprisonment that dates to .

More than 40,000 such petitions have been filed during Trump’s second term, fueled by decisions last year to deny bond to many people held on immigration charges. Judges are split on whether that’s legal; the question appears headed to the Supreme Court.

Many habeas claims , but judges typically cite reasons unrelated to the medical neglect described in the petitions, such as detainees’ being held too long before being deported.

The more than 300 medical neglect claims found in this investigation represent a fraction of the problem. The details of habeas corpus cases are often hidden due to a federal rule barring the public from viewing such documents online. 麻豆女优 Health News and AP obtained some documents from courthouses and received records on 4,400 cases from , a project of the nonprofit Immigration Justice Transparency Initiative. But tens of thousands more remain largely inaccessible.

Some judges have written that the habeas process is not how to raise allegations of medical neglect and have declined to release detainees over those claims. Not every detainee who believes they experienced medical neglect files a habeas petition or cites their medical issues if they do.

Jose-Antonio Segismundo’s petition made no mention of being unable to see an oncologist for the cancer in his abdomen while detained for more than seven months at the Florida detention facility known as Alligator Alcatraz and Folkston D Ray ICE Processing Center in Georgia. Medical records in his court filings show he was arrested about five weeks before his scheduled appointment with a cancer specialist.

His wife, Maria Jose Gonzalez, said he didn’t receive any treatment even though she sent his medical records and explained his condition to officials at Folkston. When his stomach pain erupted, often suddenly and intensely, she said, they gave him Tylenol.

Geo Group, which runs Folkston, follows ICE standards and provides healthcare and access to off-site medical specialists when needed, spokesperson Christopher Ferreira said.

This spring, Segismundo, 48, was deported to Mexico, a country he left nearly 30 years ago, Gonzalez said. Now, she said, he will have to restart his search for care in the Oaxacan village where he grew up.

Watching Loved Ones Deteriorate

Detainees receiving inadequate healthcare have little recourse. The Department of Homeland Security last year gutted the Office of the Immigration Detention Ombudsman. In early May, it shut the office entirely, arguing that Congress didn’t fund it.

Previously, ombudsman staffers could help facilitate medical care or look into complaints of neglect, according to Matt Boles, an immigration attorney in Georgia. Now, he said, there’s no one to call.

Meanwhile, detainees’ families said they feel helpless, making desperate calls to facilities, the government, and their legislators while watching their loved ones deteriorate.

Riya Khan saw her mother get sicker at the California City Detention Facility, which is owned by CoreCivic. When she visited a week after her mother arrived at the facility in the Mojave Desert, Riya said, the 64-year-old woman stumbled into her seat. She was shaking and her breathing was labored.

Masuma Khan came to the U.S. from Bangladesh in 1997. She has no criminal history, her records say, and was detained in October when she showed up for her regular ICE check-in.

For the month she was detained, according to her daughter, she only intermittently received her medications for conditions including high blood pressure, hypothyroidism, and prediabetes. CoreCivic treats chronic conditions in line with applicable medical standards, Todd said.

“Nothing matters more to CoreCivic than the health, safety and well-being of the people in our care,” Todd said.

Khan said she got her asthma medication for the first time two days before she was released and that her eye drops for glaucoma never arrived. Staffers told Khan she needed to buy some of her medications from the commissary but it didn’t stock them, her daughter said.

Before ICE detained Masuma Khan, she made friends with everyone, her daughter said. She had worked for years at Lucky Boy, an iconic Pasadena fast-food restaurant, and in her free time fed birds and left out fruit for bees that visited her apartment’s balcony.

Now she’s too scared to go outside. She still must regularly check in with ICE, and she’s terrified each time.

Previous Next

A Stroke on a Video Call

Previously, detainees with serious medical needs would likely have been released on humanitarian parole, in part to avoid the cost of their care, Vermont attorney Andrew Pelcher said.

In fiscal year 2023 鈥� before the detained population soared 鈥� ICE spent more than $390 million on healthcare for detained noncitizens, according to its to Congress. In May, Todd Lyons, then acting director of ICE, said at a conference that the agency had already spent “almost half a billion dollars” on detainee healthcare this year.

Now, under “mandatory detention,” people are staying locked up with serious 鈥� and expensive 鈥� conditions.

A Romanian citizen underwent several heart surgeries, including an emergency triple bypass in April 2025, before he was arrested in July. As part of his recovery, the 52-year-old was required to take 16 daily medications. While at an ICE field office in Baltimore, his court filings allege, he went two days without any medication before officials moved him to a facility in New Jersey.

He was hospitalized three times while detained, complaining of chest pains 鈥� in part, medical records and court documents say, because despite “countless requests,” the detention center did not provide all his medications. Hospital discharge papers cited by his lawyer show he received only eight of the 16 medications after his second release from the hospital.

“Can you please talk to the ICE facility to make sure they give him his medications?” his treatment providers wrote in medical records included in his court filings. “He was admitted last week for chest pain and today he was readmitted again for chest pain secondary to non compliance for medications.”

Several weeks later in August, he had a stroke while on a video call with his daughter, according to court filings. “He was struggling to breathe, and was pointing at his chest where he was again experiencing pain, and suddenly stopped speaking.” His daughter screamed for help through the video monitor, according to his petition. “Eventually an officer came in to assist him and cut the feed.”

The man lost his ability to speak for four days, the document says. He was returned to detention, where he remained until a federal judge ordered his release in November.

Impossible Choices

Cassandra Amador waits for the phone to ring every morning, desperate to ask her husband the question that’s woken her up every night for months: “Did you get your medicine?”

Her husband, Pedro Javier Amador Gutierrez, 36, has high blood pressure and depends on the state-run facility in Florida nicknamed “Deportation Depot” to administer the prescriptions that have kept him alive for years. Many mornings, he tells his wife he did not get them.

When she talks to him, she said, he sounds weaker and more scared every day, not like the upbeat man who would take her kids out for ice cream.

“You can hear in his voice how he feels,” she said.

Now, she said, he’s considering returning to Cuba, which he fled because of political persecution, out of fear that he will die in detention without his medicines. Amador and her children would go with him, she said, even though she was born in New Jersey, has never been to Cuba, and doesn’t speak much Spanish.

But he’s already collapsed twice at the Baker Correctional Institution in Sanderson, Florida, his wife said. She’s terrified that the next time, he won’t get up.

Methodology

麻豆女优 Health News and The Associated Press sifted through thousands of immigration habeas corpus claims to find allegations of medical neglect from people detained by U.S. Immigration and Customs Enforcement during the second Trump administration.

Without a comprehensive, publicly available dataset of medical complaints by those in ICE custody, we used immigration habeas corpus claims to identify detainees’ healthcare-related allegations raised in federal court. Although the intended purpose of habeas corpus is to challenge the legality of a petitioner’s detention 鈥� rather than conditions of their confinement 鈥� these filings sometimes include detainees’ claims of inadequate healthcare.

But habeas corpus filings are not always publicly available. Federal rules restrict how members of the public can access habeas petitions filed by people in immigration detention. For most of these cases, court websites publish only court orders and dockets describing other filings. The initial petitions are available only through in-person visits to federal courthouses across the country. Habeas Dockets, a project of the nonprofit Immigration Justice Transparency Initiative, coordinates a nationwide network of volunteers to gather these petitions and make them available online.

麻豆女优 Health News and AP analyzed the dockets of roughly 33,000 cases filed by detainees from Jan. 20, 2025, through March 2026. The vast majority of cases had only basic procedural information, like dates of court filings and rulings. Only about 4,400 included the original petitions.

We also gathered a few dozen case files from courthouses, lawyers, and the Massachusetts federal district court website, which posts most petitions under a unique standing order.

We ran keyword and semantic searches of court records, including petitions, motions, and orders, for terms and phrases potentially related to medical neglect, such as surgery, medications, inadequate medical care, and treatment for chronic conditions such as diabetes and high blood pressure.

We found about 500 cases potentially alleging medical neglect. At least two reporters reviewed each case manually, yielding more than 300 cases containing specific allegations in sworn filings of delayed, denied, or deficient healthcare.

To be conservative, we excluded dozens of cases that alleged inadequate medical care but lacked specifics, for example a petitioner writing, “I have been sick and don’t get proper treatment,” or a judge noting a petitioner “complains that ICE is ignoring his medical problems.” We also excluded cases in which petitioners claimed only that they were denied special diets, exercise, or other accommodations that they said were key to managing their health conditions, such as a petitioner writing, “I suffer from Parkinson’s and cannot properly exercise,” or claiming that the food provided was unfit for a person with diabetes.

The cases we analyzed were neither randomly selected nor representative of immigration habeas filings nationwide. The claims were not independently verified. Many filings are not publicly available, and not all detainees raise medical concerns in court, so our account of cases represents a limited window into the landscape of claims, rather than a comprehensive picture.

Associated Press journalists Garance Burke, Valerie Gonzalez, and Tim Sullivan as well as 麻豆女优 Health News correspondent Kate Wells contributed to this report.

This report is a collaboration between The Associated Press and 麻豆女优 Health News.

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“Did we hike this morning?” she asked.

“Yes, we hiked,” said her husband, Steve Francks. “And you did really well.”

But 15 seconds later, she asked the same question: “Did we hike today?”

Anderson, 65, a retired finance executive, doesn’t remember any of it. She can recall what happened that afternoon only because her husband started recording her on his cellphone.

“I was just on this nonstop loop,” she said.

Almost immediately, Francks knew something was wrong. “Jan was out of it,” he said.

He took her to an emergency room in Sedona, where staff initially thought she might be having a stroke. Because the facility wasn’t fully equipped to evaluate or treat stroke patients, Francks said, she was airlifted to a Phoenix-area hospital, where she was admitted.

It turned out she wasn’t having a stroke. Her medical team eventually determined she was probably experiencing , a rare, temporary, and benign memory disorder.

The good news was that her symptoms didn’t last long, and she has suffered no long-term effects from the episode. It took about 24 hours before she was able to start forming new memories, and she was discharged the next day. Anderson and Francks, who split their time between Sedona and Edmonds, Washington, returned to the Pacific Northwest a few weeks later.

Then the bill came.

The Medical Service

The sudden confusion associated with transient global amnesia can also be a sign of a more common neurological condition, so it’s important to rule out other possible causes — such as a stroke, for which timely emergency care can spell the difference between life and death.

Anderson’s records show her care at Abrazo Health’s Arrowhead Campus in Glendale, Arizona, included an electrocardiogram, which can detect underlying cardiac abnormalities, and imaging, which would rule out any vessel blockages that might cause a stroke. She also underwent various lab tests commonly used to diagnose a stroke.

The Bill

$59,181: $35,302 for diagnostic/therapeutic imaging, $8,147 for laboratory services, $8,146 for a special care unit, $5,532 for EKG services, and $2,054 for pharmacy. Anderson’s first bill from Abrazo Health said she owed $15,312.43, citing an insurance adjustment of $43,868.57, even though her insurer had not covered any of the charges.

Anderson said her insurer covered separate charges for the ER and helicopter transfer.

The Billing Problem: Communication Breakdown

The federal No Surprises Act bans out-of-network bills for most emergency services, even if those services are received at an out-of-network facility and are not preapproved by the insurer.

That means the cost of Anderson’s hospital care should have been covered as though it were in-network. At the time, she was insured by Molina Healthcare, through a plan purchased on the federal Affordable Care Act marketplace.

But for a year, Molina declined to pay for her care in Glendale, at one point arguing that her hospital stay required authorization when, or even before, she was admitted.

“I can’t get anyone to resolve it,” Anderson said. “It’s almost $60,000 hanging over my head.”

The first problem arose about two weeks after she was discharged, when Abrazo Health sent Anderson a bill indicating she was a self-pay patient.

The hospital didn’t request her insurance information at any point during her stay, Francks said. He assumed, at the time, that his wife’s financial paperwork had been transferred from the ER in Sedona. It had not.

She called the Glendale hospital and corrected the error.

Then, in late June, Anderson received notice from the hospital indicating she was not a Molina member.

“Your insurance company notified our office that the patient was not a covered member for the services provided by Abrazo Arrowhead Campus on the above referenced service date(s),” the notice said. It showed the total charges for her stay exceeded $59,000.

But when Anderson called Molina to confirm her coverage, she said, the insurance company assured her the claim was being processed.

That didn’t mean Molina was willing to cover her hospital bill.

Anderson spent months trying to resolve the balance. She filed complaints with members of Congress, the Arizona Department of Insurance and Financial Institutions, and the Office of the Insurance Commissioner in Washington state.

In an October letter to Washington’s insurance commissioner, an appeal and grievance specialist for Molina wrote that the claim was denied because “inpatient stays require prior authorization, or notification at the time of admission. No notification of admission or prior authorization was received from the hospital, so the claim was denied.”

It continued: “Molina covers out of network emergency services but since this was an inpatient admission authorization is required.”

Nicole Broadhurst, who focuses on medical billing issues as CEO of a , said this dispute appears to rest between the insurer and the medical provider.

She said that Anderson’s insurance information should have been transferred between the first ER and the Glendale hospital. Since it wasn’t, Broadhurst said, Anderson shouldn’t be held liable for her hospital bill. (Broadhurst was not involved in efforts to resolve Anderson’s billing dispute.)

Unfortunately, Broadhurst said, these situations are “not uncommon, even though we have the No Surprises Act.”

The Resolution

Anderson said she was told by Abrazo Health for months that it was working with Molina to resolve the bill. She said she was also told that even if Molina did not cover the full cost of her hospital care, she would not be liable for the balance — but she never received that assurance in writing.

Meanwhile, Molina continued to uphold its decision to deny payment.

After 麻豆女优 Health News contacted the insurer and the hospital with questions about her case, Molina told Anderson it had launched an internal review of her claim, and a revenue director with Abrazo Health told her the company was “treating this as a high-priority matter,” she recalled.

Anderson said the revenue director for the health system assured her that if Molina continued to deny payment, “the balance will be written off on the hospital’s end,” she said. “I will not be responsible for any balance” — not even the $15,312.43 the hospital initially billed her after the hospitalization.

Linda Nofer, a spokesperson for Abrazo Health, would not answer questions about Anderson’s bill. In a statement, she said the hospital system is “committed to working closely with our patients to resolve billing questions and concerns.”

Molina spokesperson Caroline Zubieta would not discuss or respond to questions about Anderson’s case on the record.

The Takeaway

The flurry of insurance paperwork and medical bills patients receive after a hospital stay can be overwhelming — and may sometimes appear contradictory.

Broadhurst said it’s important for patients to focus on the “patient responsibility” portion of an insurance document called an explanation of benefits.

Patients should not pay a bill if their explanation of benefits indicates they aren’t responsible for the amount charged.

In this case, Anderson had received a bill from the hospital saying she owed money. And her explanation of benefits from Molina confirmed she’d racked up more than $59,000 in hospital charges.

But that document also indicated her patient liability was “$0.00.” Anderson said the hospital was not pressuring her to pay the $15,312.43 bill or any of the charges tied to her account, but she was worried she would eventually owe a large sum because the charges remained unresolved for more than a year.

“The question I kept asking them was, ‘How much am I going to owe?’” said Anderson, who is now insured by Medicare. “It could be anywhere from that $15,000 adjusted amount to the full balance of $59,000.”

Broadhurst said she tells patients facing similar situations to “send the hospital a copy of the EOB and ask them to correct the account to $0 patient responsibility.”

“Even if no one is actively trying to collect, I’d still push for written closure so it doesn’t keep hanging over them,” she said.

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

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Clinicians and patient advocates say the incoming changes will deliver a twofold blow: They expect the work requirements to kick more patients off Medicaid, meaning fewer can afford care, while the health department’s budget problems make it harder for doctors to serve those who keep the coverage.

It’s a tumultuous time for state health departments. Additional federal changes are forcing states to perform more checks on who qualifies for food assistance, better monitor doctors’ compliance with Medicaid rules, and set up new programs to access a share of $50 billion in federal funds meant to improve rural health services.

“Our concern is, is the department ready?” said Jean Branscum, CEO of the Montana Medical Association. “Does the capacity exist for all this to be done right and ensure that patients don’t pay the price?”

Already, some Montanans struggle to access the government health coverage amid state backlogs. Meanwhile, clinicians struggle with staffing, attributing the issue to low Medicaid payments. Those problems reflect a national challenge to connect people to care through strained public assistance programs.

The Montana Department of Public Health and Human Services didn’t respond to a list of questions, instead directing 麻豆女优 Health News to the latest information on the state’s website detailing Medicaid changes, at .

Health policy analysts have said Montana’s challenges offer an early glimpse at what states must navigate to comply with congressional Republicans’ One Big Beautiful Bill Act. Signed by Trump last year, the federal tax and spending law requires millions of Medicaid enrollees to prove they’re working or attending school for 80 hours each month, unless they’re eligible for an exemption. States also will be required to evaluate enrollees’ eligibility every six months instead of annually, which will take more time and money. Some states already don’t have enough staff to quickly process Medicaid applications or answer enrollees’ phone calls.

On July 1, Montana is scheduled to become the second state, after Nebraska, to implement Medicaid work requirements. That’s six months ahead of the Jan. 1 federal deadline to do so for the 42 states, along with the District of Columbia, that expanded Medicaid to cover more low-income people. Montana health officials say they’ve had time to plan for that shift. The state mandated work rules in 2019 but hadn’t gained federal approval to move ahead until now.

More states are likely to face a budget crunch soon, said Joan Alker, a Georgetown University researcher focused on health coverage.

The One Big Beautiful Bill Act is expected to reduce federal Medicaid spending 鈥� the biggest pool of federal cash states receive 鈥� by nearly $1 trillion over 10 years. The law also left states with a bigger share of the cost to run food assistance programs, while creating tax breaks that could lower states’ bottom lines.

“States are the ones that are gonna have to do the dirty work of implementing cuts,” Alker said.

Withholding Medicaid Provider Rate Increases

On top of federal changes, Montana lawmakers underfunded the health department in its two-year budget in 2025, the result of cuts and an underestimate of Medicaid enrollment. The state also overestimated how much the federal government would contribute toward Montana’s Medicaid costs this year.

That resulted in a $183 million shortfall in state and federal funds, requiring the health department to borrow from next year’s budget. To partially offset those costs, the department wants to withhold a 3% Medicaid provider rate increase approved by the legislature and governor last year. State officials have said they’re trying save money without unraveling services.

Health organizations have pushed against the plan, saying that Montana’s Medicaid payments already don’t cover the cost of care and that health businesses can’t afford wages that attract workers.

Matt Bugni, head of the statewide nonprofit Aware, which provides behavioral health and disability services, said the organization was counting on incoming increases to keep existing employees amid a staff shortage. Bugni said Aware has more than 70 group-home beds it’s been unable to fill, because it’s down roughly 15% of its workforce.

“There are waiting lists,” he said. “We just can’t staff it.”

Montana health organizations said they’re still recovering from 2017 budget cuts that buckled services. The largely disappeared, more than half of Montana’s public assistance offices , and mental health crisis centers closed.

“We still are struggling,” said Sierra Riesberg, head of the Montana Behavioral Health Alliance, a nonprofit advocacy group.

In 2023, Montana Gov. Greg Gianforte, a Republican, signed into law a investment to repair the state’s behavioral health and disability services. He also created an initiative to use Medicaid funding to fill in gaps in addiction treatment programs.

But Riesberg said that, despite improvements, some beds created through those initiatives remain empty because low Medicaid reimbursement rates make it hard to recruit staff.

The stalled increases would especially hit community-based services such as mental health treatment and developmental disability services. They wouldn’t affect physician services or federally funded health centers that offer care based on what patients can afford. But Lander Cooney, an executive vice president at One Health, which has rural clinics in rural Montana and Wyoming, said low reimbursement rates can hurt their patients who need care elsewhere, as more healthcare providers decide they can’t afford to accept Medicaid.

Montana’s Legislative Finance Committee recommended the state’s leadership find a way to cut costs without stalling the increases. Gianforte will have the final say. He must make that decision before the state begins its new budget year on July 1, the same day Medicaid work requirements begin.

Medicaid enrollees will have three months to show they’re working before the state begins dropping people for noncompliance in October. That gives the state time “to work out the bugs,” said state Rep. Ed Buttrey, a Republican who is also president of the Montana Hospital Association.

鈥楥ompletely in the Dark’

The work requirements won’t apply to everyone. There are exemptions for people who are severely sick, children, adults older than 64, and Native Americans, among others. Even so, most people will have to submit proof that For some, how to do that remains murky.

Health officials don’t have clear-cut definitions for medical conditions on the exemption list. They’re also awaiting federal guidance on what documents someone needs to prove a hardship that temporarily prevents them from working. “Providers are completely in the dark as to how we reduce the administrative burden,” said Shawna Yates, a family medicine doctor in Butte and president of the Montana Medical Association’s executive committee.

Health officials have said implementing work requirements early means figuring out some details as they go.

Montana’s Medicaid enrollment is at its lowest point in roughly a decade, , a consulting firm that has studied the state’s Medicaid program for years. Enrollment plummeted amid states’ scramble to determine whether tens of millions of people still qualified for Medicaid when the federal government lifted a pandemic-era disenrollment freeze in 2023.

Many primarily because of rather than ineligibility. National health advocates worry similar administrative problems will arise with implementing work requirements.

In Montana, the state’s Medicaid data signals continued red flags, according to a by the nonprofit Montana Budget and Policy Center. That includes long waits to access public assistance and low renewal rates due to paperwork issues.

Julie Anderson, a mental health and addiction counselor in Livingston, Montana, helps people navigate public aid at a food bank. She said she recently spent three hours on hold on the state’s public assistance helpline, trying to help a patient with limited cellphone minutes troubleshoot a Medicaid application. Anderson said she had to hang up to help other people before anyone answered.

“It’s already a cumbersome system,” she said. Once the new requirements go in place, Anderson added, “it’s going to be a nightmare.”

The health department has worked for months to expand its public assistance team. As of early March, Montana had filled 39 of 59 new positions state officials projected are needed for the intensified Medicaid eligibility checks.

“The problem with that is that it takes a lot of training to get caseworkers up to speed,” said Kim Winchell, who helps people enroll in health coverage at Glacier Community Health Center in Cut Bank.

State officials said they’ll try to automatically confirm through existing data whether people are exempt or meet the rules. When that doesn’t work, applicants will have 30 days to provide proof of eligibility.

Charlie Brereton, director of the Montana health department, told lawmakers in May that the agency considered a public service campaign to get the word out. But he said the state’s budget problems curtailed that idea.

Brereton said the state could reevaluate that option, “depending on how implementation goes.”

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The 59-year-old retired teacher, who recently moved from Ohio to Michigan, now pays $341 a month for a pair of plans, one that covers routine and urgent care and another that pays fixed amounts for hospital stays. Neither meets federal standards for comprehensive coverage.

Though she practices yoga and is healthy, Miller said she still feels “vulnerable.” If she lands in the hospital, her plan pays a flat $2,000, a fraction of the of an average hospital stay.

“I don’t gamble. But I may as well,” she said. “This is gambling.”

Congress’ decision late last year not to extend enhanced marketplace tax credits has boosted the appeal of alternatives to comprehensive insurance 鈥� plans like Miller’s, which have lower premiums but don’t meet ACA standards for coverage or consumer protections. Unlike plans sold on the exchanges, these options 鈥� some sold by major insurers, others by small companies or nonprofits 鈥� can deny claims with few or no legal rights for consumers to appeal. The plans are not required to cover “essential health benefits,” such as preventive care, and can impose annual or lifetime caps on benefits.

There is debate over whether these options help or harm patients. Consumer advocates dismiss them as “junk insurance,” while proponents say restricting alternatives to pricey marketplace plans risks driving up the number of uninsured. Some states, including Kansas and Florida, and the federal government itself have eased regulations on such plans or created incentives to join them, while other states, including California and Massachusetts, have tried to deter enrollment in alternative insurance. Those regulatory guardrails, however, are now being stress-tested as premiums blow out household budgets.

Alternative insurance takes many forms, including short-term policies, which were designed to bridge temporary gaps in coverage and often exclude preexisting conditions, and fixed-indemnity plans, which pay a flat rate per service regardless of how high costs go and are intended for supplemental use. Arrangements in which people pool their money to cover one another’s bills, including faith-based “healthcare sharing ministries,” also provide a cheaper alternative to the marketplace options. Because they are not considered insurance under federal or state law, they are not legally bound to pay for even .

Enrollment data for alternative plans is mostly confidential, but several indicators point to shifts in the market. Recent estimates suggest marketplace enrollment from 2025, and a of people on the exchanges last year found that 5% switched to private, nonmarketplace individual coverage, including plans that don’t comply with the ACA. Covered California, the state’s marketplace, plans to survey former enrollees to find out where they went.

Insurance industry insiders also report that, amid the expiration of subsidies, alternative plans are making a marketing push. Colorado insurance broker Samantha Albritton said that before ACA open enrollment, she saw more marketing from fixed-indemnity plans than in previous years. One healthcare sharing plan, Zion HealthShare, had more than 75,000 members in February 鈥� a 50% increase since last June, it said in a statement.

Critics of these alternative plans say the major issues occur when people use them as primary insurance and don’t realize the coverage is inadequate until they need it most. “Humans have bodies that can fail them,” said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.

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7B Care Clinic has been operating in Sandpoint since 2001 and was previously called Life Choices Pregnancy Center and Sandpoint Crisis Pregnancy Center. It is of a nationwide network of Christian evangelical centers called Care Net. 7B, one of about 1,200 pregnancy centers affiliated with Care Net, offers pregnancy tests, limited ultrasounds, parenting and life skills classes, community support groups, and other free resources, such as children’s clothing. Donations from people, businesses, and more than 40 churches keep 7B’s operations running, Executive Director Janine Shepard said.

Such centers are known as crisis pregnancy centers or pregnancy resource centers. They offer limited resources and medical services to pregnant women and aim to dissuade them from having abortions. Healthcare groups including the have said many crisis pregnancy centers use unethical and deceptive practices to bring women into their organizations.

Traffic at 7B has picked up since the local hospital and its OB-GYNs moved out of state three years ago. The closure left a hole in reproductive health services in this town of more than 10,000 on the shores of Lake Pend Oreille and surrounding rural areas.

“We are seeing a lot more people,” Shepard said.

By December 2024, more than two years after the U.S. Supreme Court overturned nationwide abortion rights in its Dobbs decision, Idaho had of its OB-GYNs. 7B is expanding, with the goal of bringing obstetric care back to Sandpoint. The organization plans to add to its current building once it’s paid off, Shepard said, and it’s in talks with a hospital about 30 miles away in Washington state to bring in an OB-GYN once a week to provide prenatal care.

If obstetric care existed now in Sandpoint, Shepard said, “we wouldn’t even be considering” the expanded services. “But there’s such a need. And our community suffers because of it.”

As rural communities face the and , crisis pregnancy centers are growing in influence. Some states have approved legislation granting the organizations greater protections from oversight and regulation, and clinics have seen a massive and in recent years.

In a town with limited maternity care, 7B has been providing important resources to struggling low-income women. But critics say the religious nonprofit, which is not medically licensed and isn’t required to meet regulatory standards for medical facilities, has an agenda that makes it an inappropriate place for pregnant patients to seek medical care.

Jen Jackson Quintano, a Sandpoint resident and the founder of the Pro-Voice Project, a nonprofit that advocates for abortion rights in Idaho, said crisis pregnancy centers mislead patients by drawing them in with the offer of free pregnancy-related services before delivering their anti-abortion pitch.

“We all need clarity on what those services are: ministry-first, rather than comprehensive medicine,” Quintano said.

Shepard said there are misconceptions about the organization, and she invites people to take a tour of 7B to learn what it does. She said her staff talk to pregnant women about abortion, adoption, and parenting as options and hope they feel supported enough to make a “life-affirming” decision.

7B reflects a trend of crisis pregnancy centers seeking to expand their operations in maternal care deserts and regions with gaps in women’s healthcare, said Andrea Swartzendruber, an associate professor of epidemiology and biostatistics at the University of Georgia College of Public Health. Swartzendruber has studied crisis pregnancy centers in the U.S. since 2018.

“Crisis pregnancy centers have, for years and years, capitalized on gaps in access to healthcare,” she said. “In no way, shape, or form do crisis pregnancy centers have the infrastructure or ability or training to bridge those gaps.”

According to Swartzendruber’s research, more than 2,600 crisis pregnancy centers operated in the U.S. as of 2024, more than three times the number of . Many centers have been found to engage in with clients, including putting misleading information on their websites making them appear to be legitimate medical clinics with the goal of attracting women who are seeking abortions.

The organizations are also seeing support from the Trump administration. On May 10 鈥� Mother’s Day 鈥� the Department of Health and Human Services sharing resources and information for new and expectant mothers. It includes a map to find pregnancy centers and cites services the centers provide, such as pregnancy tests, ultrasounds, and medical referrals.

鈥楾he Perfect Place for This’

Sandpoint is a small mountain town in a deeply conservative and Christian part of a state with a strict abortion law put into place after the Supreme Court overturned Roe v. Wade.

Amelia Huntsberger, one of the OB-GYNs who left Sandpoint three years ago, said the town is “the perfect place for this,” referring to the expansion of the 7B Care Clinic.

In underresourced areas, the benefits that crisis pregnancy centers may bring are welcome.

Lori Sabin, a licensed midwife in Bonners Ferry, about 30 miles north of Sandpoint, said that 7B is a helpful resource to the community, especially for people who struggle to get healthcare because of a lack of health insurance or who face challenges in traveling for care.

“The nicest thing about 7B is all their services are free,” Sabin said, adding that the classes and free baby items are particularly helpful for young first-time mothers. “They can point them in the right direction. They tell them where the midwives are; they tell them where the OBs are.”

Huntsberger, who practiced in Sandpoint for more than a decade and now lives in Oregon, also acknowledged the benefits she saw 7B bring for patients, including the parenting classes and support groups. But she has concerns about its resemblance to a medical facility that provides healthcare.

Lisa Battisfore, founder of Reproductive Transparency Now, a Chicago-based organization that provides education and outreach about crisis pregnancy centers, acknowledged that the limited services they provide can be helpful but said the bad outweighs the good.

“If someone needs diapers or someone needs formula and a crisis pregnancy center is willing to give that to them, it’s difficult to say that that in isolation is a bad thing, but you have to look at the bigger picture,” Battisfore said.

Crisis pregnancy centers are largely unregulated and are protected by First Amendment rights to free speech and religious exercise. The Supreme Court crisis pregnancy centers to go to court to block a state attorney general’s subpoena for donor funding information. Critics say lack of oversight allows centers to spread misinformation about abortion and abortion pill “reversal,” a procedure the American College of Obstetricians and Gynecologists has called “.”

Crisis pregnancy centers have against states trying to increase regulation and oversight. Those protections have allowed some of the organizations to blur the line between anti-abortion activism and medical care.

“They seem to be really good at walking on both sides of that line when it suits them best, and that does not suit pregnant people best,” Battisfore said.

She referenced a recent case in Texas in which a woman was hospitalized for an ectopic pregnancy days after she received an ultrasound and a clean bill of health from a crisis pregnancy center. An OB-GYN who works with the Abundant Life Pregnancy Resource Center “there is nothing to fix” when asked about the error. There have been at crisis pregnancy centers.

What’s Next for Sandpoint

angered a lot of locals when it closed its labor and delivery unit three years ago. Residents lamented that women needed to travel farther to give birth and mourned the loss of the OB-GYNs. Since then, the hospital has been working to rebuild trust with the community.

This year, the hospital created a women’s health committee that includes hospital board members, staff, and others. Hospital CEO John Hennessy and Chief Medical Officer Stacey Good, a physician, said their priority is to hear from the community and increase awareness about the women’s healthcare that’s still available.

Women can still receive a range of services, including prenatal care from a nurse practitioner who travels to Bonner General from Coeur d’Alene once a week and other clinicians who can provide more basic gynecological care. A position for a gynecologist at the hospital has been open since May 2023, and Hennessy said filling it remains a priority.

Sandpoint resident Makayla Sundquist, a licensed counselor, grew up in town. She got married last year and has been thinking about starting a family with her husband. She wondered if she would feel safe knowing she’d need to travel at least an hour to the nearest hospital with labor and delivery services.

But she also has doubts about 7B as a potential option for local care. She was skeptical that an anti-abortion, faith-based organization would provide accurate information on the options available to her.

“It is something that I do think about and do have fear about,” Sundquist said. “I wish that wasn’t my reality.”

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The workers, Nathan Jones and Trent Umberger, died in the September 2024 crash, as did a passenger in the Jeep. Tests found that the driver, Patrick Sneddon, then 59, had oxycodone and six times Colorado’s presumed impairment threshold for THC 鈥� the psychoactive compound in cannabis 鈥� in his blood. He pleaded guilty and is serving on three counts of vehicular homicide and other charges.

“Our four children are completely crushed without their Dad,” wrote Kristine Umberger, the wife of Trent, in a victim impact statement for the local district attorney. “We have lost our ability to live life like we used to.”

Federal highway safety officials have long tracked the role of alcohol in fatal crashes, but they don’t track deaths that involve a driver under the influence of drugs or a combination of drugs and alcohol.

That discrepancy is partly due to the challenges of proving impairment, since some drugs remain detectable for weeks after use. Sneddon’s attorney, Jennifer Gregory, said a driver can be presumed impaired under Colorado law if their blood contains 5 nanograms of THC or higher per liter. But that “permissible inference” threshold is different from a legal limit 鈥� such as the 0.08% blood alcohol content limit 鈥� and the level set by Colorado is not supported by published scientific studies, Gregory said.

Such information could prove useful as the nation struggles with , the on marijuana, and more than 40 states have legalized or decriminalized some forms of cannabis and .

“Impaired driving is a top public safety issue that extends beyond alcohol,” said Sean Rushton, a spokesperson for the federal highway safety agency, which is tackling the issue collaboratively, with resources to ensure a “comprehensive and coordinated approach.”

But President Donald Trump’s cuts to the federal workforce since he returned to office in 2025, along with dwindling federal investments, mean that efforts to expand and improve the tracking of impaired-driving deaths nationwide have slowed.

The gap in data can be significant. In Mesa County, Colorado, where Jones and Umberger were killed, the coroner’s office tracks various forms of impaired-driving fatalities. From 2017 through 2024, a third of traffic deaths involved alcohol alone, according to data from the county coroner’s office.

When drugs are factored in, nearly half of Mesa County’s traffic deaths over the same period involved a driver intoxicated with alcohol, drugs, or a combination, according to the coroner’s reports.

“If you want to solve a problem, you need to understand the problem,” National Transportation Safety Board researcher Jana Price said. “If you only know that alcohol is present, then it limits your ability to fully understand what might have been impairing a person or a population of people. It trickles into the countermeasures that we use as a society to address the problem.”

Identifying a Hidden Issue

NTSB researchers that, across four geographical samples of roughly 26,000 drivers, about half of those arrested for impaired driving and more than a quarter of drivers killed in crashes tested positive for more than one substance, such as cocaine, sedatives, and antidepressants. The analysis also found that only four states and the District of Columbia drug-tested more than 60% of fatally injured drivers in 2020.

Those findings led the NTSB, an independent federal agency that investigates major incidents, to make a series of recommendations to the and states to establish a comprehensive, nationwide dataset on impaired driving.

But hurdles remain to creating such a system. Fatality and injury reports submitted to the NHTSA database often feature missing or erroneous data, according to a .

Varying state laws around testing arrestees and decedents for drugs make getting uniform data difficult, according to , a former employee of NHTSA’s impaired-driving division, as does a lack of proven metrics like blood alcohol content to measure drug impairment, not just the presence of a drug.

“It’s a slow process, which is incredibly difficult when you know that each day that passes is risking a lack of safety for however many people facing the potential of a drug-impaired-driving crash,” Cash said. “But some progress is better than no progress.”

Acknowledging how long those efforts will take, the NTSB also recommended that NHTSA build an interim surveillance system that would use data from trauma centers to create a national sample of crash-involved impaired drivers.

The agency made some headway, reporting in 2023 that it was conducting its own study with the help of 11 trauma centers and medical examiner offices. It also helped California establish a 19-month statewide surveillance system, which NHTSA will use to evaluate the feasibility of a nationally representative system.

Such programs are useful for public awareness and for improving the ability of police to understand drugged driving patterns that can help them tailor enforcement, said , a University of California-Davis associate professor who researches toxicology and was involved in the California program. But some trauma centers, especially in rural areas, often lack the research infrastructure necessary for round-the-clock drug testing and participation.

Still, it’s possible, and he said the benefit is apparent in the findings from California’s surveillance system.

“If you go out there and tell people that 44% of drivers who ended up in the ER from a car accident had at least one potentially impairing substance in their blood at the time of the accident, that gets people’s attention,” Chenoweth said.

Shrinking Research Teams

Since NHTSA’s update to the NTSB three years ago, however, the agency has yet to follow up on the recommendation. Staff cuts and departures at NHTSA last year paint a poor outlook for change.

From 2021 to 2024, the agency . At the end of Trump’s first year in office, NHTSA had dropped to about 550 people due to government-wide cuts and people leaving on their own.

Cash, who now works for the nonprofit Governors Highway Safety Association, was one of five employees who left NHTSA’s last year. That leaves just two staff members in the division, she said.

Ian O’Dowd, a former employee in NHTSA’s , said he was part of a team of 16 people who studied, in part, impaired driving. Only three or four team members are still with the agency, he said.

“At some point, it becomes unwieldy for a handful of people to be managing all of the research work going on,” O’Dowd said.

NHTSA communications director Sean Rushton said the agency has “both the financial and personnel resources necessary to support its programs with multiple offices carrying out this work collaboratively, ensuring a comprehensive and coordinated approach.”

The 2021 infrastructure law, passed under the Biden administration, increased funding for NHTSA’s state highway safety program from about $667 million in 2021 to nearly $953 million this year.

The law included $750 million to modernize crash-data programs, but as of January over $475 million was unused. The funds expired in September unless they were obligated through a signed agreement.

A report by the U.S. Government Accountability Office found that nearly a quarter of entities awarded grants in 2022 had not received a signed agreement when surveyed between December 2024 and March 2025. It also found that over 1 in 5 grantees reported that obtaining timely replies from Department of Transportation staff was moderately or very challenging.

With the Biden-era infrastructure law expiring later this year, Congress could extend the unused crash-data fund or implement a new approach to impaired driving.

In mid-April, House Transportation and Infrastructure Committee Chairman Sam Graves (R-Mo.) said proposed legislation 鈥� less than half of the current bill’s $1.2 trillion 鈥� with a more “traditional” focus on roads and bridges.

The bill has amid negotiations for more funding, leaving future support uncertain.

“Certainly, we are always hoping that there will be an increase in the amount of money available to do this work,” Cash said. “Whether or not that will happen this year, I don’t know.”

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Sign-ups were already down in January by about from last year’s . For this year, enrollees then faced premiums that increased, on average, . On top of that, subsidies that help people purchase coverage shrank or vanished.

Now experts are watching how many of the approximately 23 million people who enrolled will fail to pay their share of premiums.

While available data on premium payments is mainly from January, a few states that run their own ACA markets have released information for later months. The sharpest drop in people paying premiums, based on limited data, is , which saw a 28% drop in April compared with the same period a year ago, according to an analysis by Charles Gaba, a healthcare policy analyst and blogger who specializes in the ACA.

The news website NOTUS that it had internal Centers for Medicare & Medicaid Services data showing that roughly 21% of people using the federal ACA marketplace 鈥� 鈥� failed to pay their share of January premiums, which, if correct, is far higher than at the same time last year.

CMS did not answer questions from 麻豆女优 Health News about the enrollment data.

In looking at the early numbers analysts released, “we can’t yet quantify how much worse it will be than in previous years, but it will absolutely be worse because of the sticker shock,” said Ellen Montz, a managing director with the Manatt Health consultancy, who helped oversee the ACA during her tenure with the Biden administration.

The initial results come amid rising public concern about affordability, that are often .

A 麻豆女优 analysis , for instance, found that the average ACA plan deductible saw the steepest increase in history 鈥� growing by 37%, or over $1,000, from $2,759 in 2025 to $3,786 in 2026 as enhanced premium tax credits expired.

Those rising costs pose a political challenge for President Donald Trump and the broader GOP, which has opposed enhanced subsidies to help people purchase Obamacare coverage. Republican lawmakers also passed a spending package last year 鈥� enacted as the One Big Beautiful Bill Act 鈥� that included provisions expected to reduce ACA enrollment and fueling higher premiums this year.

The enrollment reductions “are real people with real consequences,” Montz said. “The Affordable Care Act is a political lightning rod, but it’s a critical component of the coverage landscape.”

Following the Numbers

Right now, the drop-off rate aligns with what some policy experts predicted, partly because Congress did not extend generous benefits that expired at the end of last year. Those enhanced subsidies had been in place since 2021.

“Overall, the individual market does appear to be trending toward a significant contraction in 2026, and may well resemble” drops projected by the , said a , an analysis arm of the HMA Co.

Based on its analysis, drawn from data provided by 75 insurers, Wakely estimates that average ACA enrollment will end up being 17% to 26% lower this year than last.

So far, the Wakely report says, an average 86% of enrollees made their first payment in January.

Failure to pay premiums varied by state. Those with the lowest drop-off rates had enacted additional help 鈥� such as backfilling part or all of the reduced subsidy amounts with state money 鈥� or experienced lower premium increases. States that run their own exchanges had higher payment rates (92%) than those served by the federal marketplace (82% to 84%).

Gaba’s initial analysis of data includes more recent numbers from nine of the 20 states that run their own Obamacare marketplaces.

“Georgia could be fairly representative” of other states that did not enact additional protections, Gaba said. For example, payment failure rates, year over year, were 11.6% as of April in New Jersey, and, as of February, 15.7% in Washington state and 8.5% in California.

Only one state in his sample 鈥� New Mexico 鈥� saw an increase in the percentage of people making premium payments, according to the latest available monthly data. Unlike most, it to fully make up for the lower federal subsidy amounts.

Enrollment figures for the ACA are never static. Traditionally, more people sign up 鈥� either through auto reenrollment or by taking initiative to shop 鈥� than actually pay premiums, so the numbers tend to be higher at the start of the year.

People drop out over the course of a year for many reasons, such as finding other coverage through a job or by marrying someone with insurance.

Cost, of course, is a factor. This year, because premiums went up and subsidies went down, many people faced what they previously paid toward their coverage.

And the Trump administration ended a special enrollment program that let low-income people enroll year-round.

drops should not be seen solely in the context of rising costs. Paragon Health Institute, a free-market think tank that has become influential among conservatives on Capitol Hill, has long argued that record enrollment numbers in recent years were fueled by fraudulent sign-ups, perhaps in the millions.

, , and policy experts took issue with the methodology Paragon used to estimate improper enrollments, saying they likely were vastly overestimated.

In a , the organization’s president, Brian Blase, doubled down on the fraud findings. Using data that detailed how many people failed to make premium payments each year, on average, from 2014 to 2019 鈥� the year before covid emerged and two years before enhanced subsidies kicked in 鈥� he offered this prediction for 2026: About 19 million people would be enrolled by year’s end. Even at that, the note says, the “market would be 90% higher than the pre-COVID average.”

For other experts, however, the biggest explanation for falling enrollment is cost.

Some people had never experienced the ACA before the enhanced tax credits kicked in, so they faced extra sticker shock.

“In economic theory, no matter whether one is left, right, or center, it’s a simple fact that when you raise prices of something, fewer people will buy it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

The Long View

The expectation of a lower enrollment trend holding up is one of the key factors likely to translate into higher cost estimates as insurers draw up 2027 rates.

For one thing, though it is still unclear how many people will stay enrolled, it is also unknown whether those enrollees will submit more medical claims than insurers projected. It’s generally thought that younger or healthier people are more likely to drop coverage when faced with growing premiums.

Secondly, there has been a sharp shift by consumers to purchase bronze-level plans, which have smaller monthly premiums but higher deductibles 鈥� the amount people must pay out-of-pocket for most treatment, except preventive care, before insurers pitch in. The found that sign-ups for bronze plans jumped from 30% to 40% of total plan selections 鈥� growing from 7.3 million in 2025 to 9.2 million people this year. Will they pay? Or will hospitals and doctors be on the hook for uncollected copays or deductibles, and then raise prices to compensate?

Insurers base their premiums, in part, on such analyses.

Another troubling factor for actuaries is the late posting of a key regulation that sets the next year’s rules for ACA health plans. The initial 2027 proposal from the Trump administration came out in mid-February and included aggressive new ideas 鈥� such as sharply increasing deductibles for certain types of ACA plans or allowing insurers to offer plans with no set networks of medical providers. It was , well into the time when insurers are calculating premiums for the following year. Many of the proposed changes, with some modifications, were approved, such as allowing for higher annual deductibles in some types of coverage.

“This is definitely a challenging year to be an actuary,” said Louise Norris, a health policy analyst for healthinsurance.org, a consumer information and referral website affiliated with Trove Group, an insurance agency.

“We know for sure that the individual market has gotten smaller and almost certainly sicker, as the people dropping coverage are more likely to be healthy.”

While they “aren’t waving huge red flags” yet, insurers are closely watching trends, said Michelle Anderson, a director at Wakely and co-author of the recent report.

Anderson does not expect an average 26% premium increase like the one seen this year.

Still, Anderson expects the ongoing uncertainty and predicted decline in enrollment, which will vary by state and insurer, to play a role in setting next year’s premium rates.

“It would not surprise me if there were some double-digit increases,” Anderson said.

麻豆女优 Health News reporter Rachel Spears contributed to this article.

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The certified professional midwife pressed the button on a handheld Doppler ultrasound machine she placed on Collins’ belly. “That’s her heartbeat,” she said to Collins’ 3-year-old daughter, who sat beside her mom as a whooshing sound filled the room. “I think Mommy’s baby’s right here.”

The midwife is not licensed as a nurse. In Georgia, that makes what she’s doing illegal. 麻豆女优 Health News agreed not to identify her by name.

Georgia is one of seven states where delivering babies can earn non-nurse midwives, at minimum, a cease-and-desist letter requiring them to end their careers. In North Carolina, it’s a . In New York, .

Meanwhile, demand for their services is increasing. Intended home births rose by 42% nationally from 2020 to 2024, according to the National Center for Health Statistics, and those births are often overseen by certified professional midwives. In Georgia, they rose by 72%. Midwives who assist with home births typically see clients from prenatal appointments through after childbirth, providing more postpartum checkups than most new mothers receive.

Home births make up nationwide. In the eight states where they were most common in 2024 鈥� Hawai鈥榠, Idaho, Montana, Pennsylvania, Utah, Vermont, Wisconsin, and Wyoming鈥� they made up 3-5% of births.

As that number rises, midwifery advocates said, regulating the practice with licenses would allow home births to be safer. Free birth 鈥� without the help of a skilled professional before or after labor 鈥� can be .

“People are going to keep having their babies at home, and they deserve a trained provider,” said Missi Burgess, president of the Georgia chapter of the National Association of Certified Professional Midwives.

For decades, professional midwives have been advocating for laws to legalize and regulate their profession. More lawmakers have supported those efforts in the past 15 years, with 36 states and Washington, D.C., allowing them to get licensed to deliver babies. Last year, a wave of state lawmakers 鈥� in Georgia, Mississippi, Nebraska, New York, North Carolina, Ohio, and West Virginia 鈥� tried to add their states to the list, although none of their bills has become law.

Certified professional midwives deliver babies in homes or birth centers. Rather than attend nursing school 鈥� which many can’t afford 鈥� they earn a nationally recognized certificate by attending at least 55 births and demonstrating their knowledge. Nurse-midwives more often deliver babies in hospitals or clinics than in patients’ homes.

Some hospitals and doctors oppose midwife licensing proposals without certain guardrails. The American College of Obstetricians and Gynecologists showing that infants are twice as likely to die during planned births at home or in birth centers as in hospitals, while acknowledging that the data remains limited. It doesn’t account for several factors, including who assisted in the birth.

Still, prominent stories of home births with midwives gone wrong contribute to the skepticism around licensing laws. In 2023, The Washington Post of a licensed midwife who pleaded guilty to felonies in Virginia after an infant death and assisted with home births in Maryland in which two more babies died.

In Mississippi, a bill that would have regulated and licensed professional midwives died after a state senator blocked a vote in the committee he chaired. Democratic Sen. Hob Bryan he didn’t “wish to encourage that activity.”

But midwives said they have a sympathetic ear now in the Trump administration, with its Make America Healthy Again movement. Cassaundra Jah, executive director of the , said she has been on calls with midwifery groups pushing for the Department of Health and Human Services to provide legal protections for them, and some midwives have been in contact with the agency.

HHS spokesperson Emily Hilliard declined to comment on policy proposals but told 麻豆女优 Health News that the administration “regularly meets with a wide range of stakeholders to hear input from the American public.”

Hospitals Want Guardrails

Advocates for the license say allowing certified professional midwives to provide care would help address a shortage of maternity care providers.

“Some midwives are leaving our state,” Rep. , a chiropractor who sponsored the Georgia bill, said during a hearing on the measure last year. “They’re being forced to quit. And now we have a shortage of these providers to take care of our pregnant moms.”

A by the March of Dimes found that 35% of counties in the U.S. have no birthing facility or obstetric provider. Georgia has the 13th-highest maternal mortality rate in the nation, according to the .

After the U.S. Supreme Court’s reversal of Roe v. Wade in 2022 eliminated federal protection for abortion, six-week abortion bans prompted more providers to leave states such as Georgia and Texas. Idaho lost by December 2024, two years after its abortion ban took effect. Doctors who left states with such laws cited fear of prosecution and an inability to provide the standard of care.

Of the 13 states with the fewest maternity care providers per capita, nine had a full or six-week abortion ban as of 2024, .

Licensing midwives won’t solve the larger maternity care shortage, but it’s a first step, said , a professor of midwifery and the principal investigator at the Birth Place Lab at the University of British Columbia. Certified professional midwives currently attend only about 1.4% of births in the U.S., according to federal data.

The would have granted certified professional midwives licenses through a state board, allowed them to administer lifesaving medications, and required their services to be covered by private insurance and Medicaid. They would not have needed a physician to supervise them. Without that mandate, giving birth outside of a hospital could be an option for more people.

But the Georgia Department of Public Health and the Georgia Hospital Association opposed the licensing bill, primarily because they wanted more regulations than the midwives were willing to accept 鈥� including physician supervision.

Anna Adams, a spokesperson for the hospital association, suggested establishing transfer agreements that required all women planning to have a home birth to register at the hospital first. When a laboring woman is transferred to a hospital, which happens in about , “we have no prior knowledge of this patient,” Adams said. “It’s a tricky situation to inherit when you’re trying to save the mother and the baby without any background.”

Georgia midwives said they planned to bring the licensing proposal back next year.

In early April, three midwives for restricting their ability to practice, arguing that the rules violate the state constitution.

“Every pregnant person should be able to choose where they give birth and with whom,” said Jamarah Amani, a plaintiff in the lawsuit and co-founder of the .

Black women are three times as likely to die during or after childbirth as white pregnant patients. In January, a prominent Black nurse-midwife in South Carolina died after unexpected complications from childbirth.

Today, midwives and their clients are predominantly white, but the home birth rate among Black women rose 42% nationally from 2019 to 2024, according to the Centers for Disease Control and Prevention.

“Ultimately the system has failed us as a people,” said Tina Braimah, a Black nurse-midwife who attended home births for a decade. She then opened a in North Carolina, allowing her to see more clients from a variety of backgrounds. “When the system consistently fails you, you look for other options.”

Becoming Part of the System

Many maternal health researchers say mothers fare better when midwives are a key part of the health system. In 2018, researchers at the Birth Place Lab published a study of all 50 states showing that integrating midwives was associated with better outcomes for moms and babies, including lower rates of infant deaths. Integration involves collaboration among all kinds of midwives and doctors so that patients can easily transfer to or from a hospital. It also involves giving all midwives the authority to practice the full range of their skills, including prescribing lifesaving medication.

A by the National Academies of Sciences, Engineering, and Medicine states that data from other countries suggests home births can be as safe as hospital births for low-risk women who are part of an integrated, regulated system.

Washington state has one of the highest rates of in the U.S., according to the . Its home birth rate is consistently higher than the national rate, while its remains lower than the national average.

One in 5 women report being mistreated during maternity care, according to a . Pregnant patients tend to be more satisfied when midwives lead their care, whether at a hospital, a birth center, or home.

Hannah Haynes gave birth to her first three children in a hospital near her home in Jefferson, Georgia. During the third labor, which was induced, she received a catheter that led to a urinary tract infection and then sepsis, a life-threatening condition. She was separated from her newborn for four days while receiving treatment.

“Something has to change,” Haynes said.

Haynes regrets electing to get induced when it wasn’t medically necessary. She gave birth to her fourth child at home, with the help of a certified professional midwife she trusted. She’s pregnant with her fifth and plans to use the same midwife. She said she won’t deliver at a hospital again.

“I was a little nervous,” Haynes said, because she had heard rumors that midwives didn’t know what they were doing. But after meeting the midwife, “I just felt so confident in her.”

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North Carolina, in late April, became the latest member of a growing group of Republican-led states to require their public health agencies to flag recipients of Medicaid to the U.S. Department of Homeland Security if their legal status is in question.

It’s a trend health policy researchers expect to spread among GOP-controlled states eager to join Trump in the federal crackdown on Medicaid fraud and illegal immigration. Already, at least four states 鈥� , , , and 鈥� have passed similar laws, and lawmakers in others, such as and , are weighing measures. In those six states, Republicans hold a power trifecta 鈥� both chambers of the legislature and the governor’s office.

“This is an issue that is very much on the political radar right now,” said , a health policy researcher at Harvard Law School.

More than 75 million people , the federal and state-run public health program for people with disabilities and low incomes, or its related Children’s Health Insurance Program, which provides low-cost coverage for people under 19. Immigrants without legal status are ineligible for Medicaid benefits, but a swath of noncitizens qualify, such as green-card holders, asylees, and refugees. A quarter of children in the U.S., most of them citizens, live with an immigrant.

Yet the new reporting laws add a layer of risk for immigrants seeking healthcare in the U.S., where the the use of to help identify and deport people.

Some of the state laws apply only to health agencies, such as in North Carolina. But the bill headed to Tennessee Gov. Bill Lee’s desk , requiring all state agencies to report people suspected of being in the U.S. without legal status. All seven state measures go beyond what’s federally required, which is to cooperate with enforcement officers by providing personal information of recipients when asked.

In Louisiana, families with mixed immigration statuses have reported that the state’s new law, enacted last year, for their kids with U.S. citizenship.

“I expect this law will lead to more families asking whether it is safe to seek healthcare, whether information can be shared with immigration authorities, and whether enrolling a child or seeking treatment could expose them to enforcement consequences,” said , a North Carolina immigration attorney.

North Carolina Republican lawmakers inserted their mandate for the state’s health department as part of a in Medicaid funds, which the legislature cut when it failed to pass a budget last year.

Starting in October, state employees will ask non-U.S. citizens receiving Medicaid for proof of their immigration standing and report those without “satisfactory” legal status to federal authorities. “This bill is designed not only to fund our critical needs today, but to begin looking at fraud, abuse issues we know exist within the system,” Republican state Rep. Donny Lambeth said during a House debate on the bill.

Immigrants than people born in the U.S., according to an analysis by the Cato Institute, a libertarian think tank, which also found noncitizens are much less likely to than citizens. State health agencies are already required to verify whether applicants’ immigration statuses .

Several Republican leaders responsible for the bill did not respond to requests for comment. North Carolina Department of Health and Human Services spokesperson Hannah Jones said the agency is still trying to understand the impact of the new law.

, about half of adults who “likely” lack legal status said someone in their family has avoided seeking medical care because they were concerned their information could draw the attention of immigration enforcement.

, a North Carolina discrimination attorney, said immigrants “in process,” or those waiting for legal authorization, generally already fear using government assistance for themselves.

“What I’ve learned from handling thousands of cases over the years is that most of the individuals who are in process pay for their own medical treatment out-of-pocket,” Rosa said.

Such policies essentially force children who are U.S. citizens to go without health coverage or hospital care, said , a researcher at Georgetown University’s Center for Children and Families.

“When you do policies that target an immigrant, you may think that you are just targeting this one person in the family, but it’s a really imprecise bomb that takes out the whole household,” Cuello said.

The use of states’ public health agencies to find immigrants who lack legal status is not the only strategy states have deployed. Some have passed laws looking to hospitals to collect and report such information. A 2023 Florida law that requires hospital staff to ask about patients’ immigration status has made noncitizens hesitant to seek care, separated families, and caused psychological distress, by the University of South Florida. Texas Gov. Greg Abbott, a Republican, issued an executive order similar to Florida’s law in 2024.

Democratic states have pushed back against Trump administration policies that mine private medical information to target immigrants, with 21 signing on to a filed last year that attempts to prevent DHS from . recipients’ identities could be shared, but medical information could not. Litigation is ongoing.

DHS did not respond to a request for comment on the record.

After he signed the bill into law, North Carolina’s Democratic governor, Josh Stein, urging Republican lawmakers to protect Medicaid coverage for nearly 27,000 pregnant women and children who are lawfully present in the country. He did not respond to questions about the provision that requires the state to report immigrants without legal status.

Polanco-Galdamez said such laws have further eroded trust in healthcare systems among underserved families.

“At the end of the day, public health systems function best when people feel safe seeking medical care,” Polanco-Galdamez said. “Policies that blur the line between healthcare access and immigration enforcement risk pushing vulnerable families further into the shadows.”

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