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

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

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

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

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

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

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

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

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

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

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

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

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

An Influx of Money That’s Out of Reach

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

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

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

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

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

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

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

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

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

that helps primary care doctors in rural and other underserved areas prevent end-stage renal failure.

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

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

Exploring the Option of Home Dialysis

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

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

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

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

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

“It’s just unreal,” she said.

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

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

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

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

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

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

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

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It started building over the summer, fed by news of across Southern California, Trump administration plans to with Immigration and Customs Enforcement, and the passage of state and federal restrictions on immigrant Medicaid eligibility. Then in November, the federal government released a new that, if enacted, could block certain immigrants from obtaining permanent legal residency if they or family members have used public benefits, including Medicaid.

Many of González’ clients and their children, often U.S. citizens, still qualify for California’s Medicaid program, known as Medi-Cal, which provides health coverage to over 14 million residents with low incomes or disabilities. But increasingly, they don’t want to enroll or renew their coverage, she said.

“Many people don’t want to apply,” she said. “There are people who say they don’t even want to go outside and water their plants.”

An analysis by Â鶹ŮÓÅ Health News found that, from June to December, the latest month for which figures are available, almost 100,000 immigrants without legal status left Medi-Cal, representing about a quarter of all disenrollments in that time frame, even though this group makes up only about 11% of Medi-Cal enrollees.

It marks a reversal in a steady rise in enrollment among immigrants without legal status in California. Until July, sign-ups among this group had risen every month since the state opened Medi-Cal to all low-income residents regardless of immigration status in January 2024.

Tessa Outhyse, a spokesperson for the California Department of Health Care Services, which oversees Medi-Cal, said the enrollment declines can be mostly attributed to the fact that the government restarted eligibility checks that were suspended during the covid-19 pandemic. Indeed, overall Medi-Cal enrollment peaked in May 2023, and has since declined by about 1.6 million.

But two researchers, Leonardo Cuello at Georgetown University’s Center for Children and Families and Susan Babey at the UCLA Center for Health Policy Research, pointed out that California and most other states had fully resumed eligibility checks . In other words, that wouldn’t explain why enrollment has fallen precipitously in the last 12 months or so.

What has changed, Cuello said, is that the federal government passed the One Big Beautiful Bill Act, and executive orders added more changes that are propelling disenrollment.

Surveys Offer Clues

found immigrant adults nationally, especially parents, to be increasingly avoiding government programs that help pay for food, housing, or health care, to avoid drawing attention to their or a family member’s immigration status. That included lawfully present residents and naturalized citizens. Parental avoidance of these programs is particularly concerning, Cuello said, because about 1 in 4 children in the U.S. have an immigrant parent, even though most of those children were born in the U.S.

Cuello suspects that may help explain a nationwide enrollment drop of almost 3% in Medicaid and the Children’s Health Insurance Program during the first 10 months of last year, including a 5.6% drop in enrollment among California children, according to .

During the first Trump administration, the president broadened public charge criteria to allow consideration of Medicaid use and food and housing assistance. That led many citizen children and other household members to they were eligible for. Some the programs even after several courts blocked implementation and Democratic President Joe Biden rescinded the rule.

“It caused a high level of confusion,” said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, which represents about 70 health centers in the Los Angeles area. “Community health center staff are still working to undo the effects of the first rule.”

Projected Savings

Currently, only people reliant on cash assistance programs or long-term, government-funded institutionalized care may be considered a public charge risk when applying for a visa to enter the country or to become a legal permanent resident. But under the Trump administration’s proposed rule, Medicaid and other noncash programs could be used to determine whether an immigrant is likely to become dependent on the government. Immigration officers would also have more discretion to label people a public charge.

The Department of Homeland Security’s proposal says the changes are needed because the existing rules hamper the agency’s ability to make decisions about an immigrant’s risk of becoming reliant on government resources. A public comment period for the proposal ended in December.

DHS did not respond to a request about when it plans to make a final decision on the rule. The change would “align with long-standing policy that aliens in the United States should be self-reliant and government benefits should not incentivize immigration,” the proposal states.

The agency projected the change could save federal and state governments almost $9 billion annually from people disenrolling from or forgoing enrollment in public benefit programs.

A of the proposed rule estimated it could result in 1.3 to 4 million people disenrolling from Medicaid or CHIP, including as many as 1.8 million citizen children.

“It’s clearly being weaponized to create fear and anxiety,” said Benyamin Chao, supervising health and public benefits policy manager at the California Immigrant Policy Center. He called the proposal part of an “assault on lawfully present immigrants and U.S. citizens who are family members, and just the general community.”

Public charge fears are expected to decrease enrollment also in anti-hunger programs, such as the Supplemental Nutrition Assistance Program, known in California as CalFresh. Mark Lowry, who heads the Orange County Food Bank, said that that — along with disenrollment related to the One Big Beautiful Bill Act — could overwhelm food pantries, since federal nutrition programs account for the vast majority of food aid.

“There’s no way that the emergency food system has the capacity or resources to address those needs,” he said.

Health Care Needs

Fear of Medi-Cal enrollment doesn’t extend to all immigrants. Juana Zaragoza manages a program in Oxnard that helps mostly Indigenous Mexican farmworkers sign up for Medi-Cal. Overall enrollment and reenrollment has remained steady over the past few months, she said. Neither she nor the community members she serves know much about the public charge proposal, she added.

Often, any concerns they have are outweighed by an immediate need for health care.

“We encounter a lot of people who are balancing: what benefits me now and what benefits me later,” she said. “Some just want to cover their needs in the moment.”

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El gobierno federal no lleva un registro de cuántos niños han ingresado a este sistema como consecuencia de operativos de control migratorio, lo que dificulta saber con qué frecuencia ocurre.

En Oregon, hasta febrero, dos niños habían sido ubicados en hogares temporales luego de ser separados de sus padres en casos de detención migratoria, según Jake Sunderland, vocero del Departamento de Servicios Humanos del estado.

“Antes del otoño de 2025, esto nunca había ocurrido”, aseguró.

Hasta mediados de febrero, casi por el Servicio de Inmigración y Control de Aduanas (ICE, por sus siglas en inglés).

El récord de 73.000 personas detenidas en enero representó un comparado con el año anterior. Según una , hasta agosto de 2025, padres de 11.000 niños con ciudadanía estadounidense habían sido detenidos desde el inicio del mandato de Trump.

El medio NOTUS que por lo menos 32 niños de padres detenidos o deportados habían sido colocados en hogares temporales en siete estados.

Sandy Santana, director ejecutivo de Children’s Rights, una organización de defensa legal, dijo que sospechan que el número real es mucho mayor.

“Ese número nos parece realmente muy bajo”, dijo.

La separación de sus padres es profundamente traumática para los niños y suele provocar , incluido el trastorno de estrés postraumático. El estrés prolongado e intenso también puede causar infecciones más frecuentes en los niños y problemas en el desarrollo. Ese “estrés tóxico” también se asocia con daños en áreas del cerebro responsables del aprendizaje y la memoria, , una organización sin fines de lucro dedicada a la información en salud que incluye a Â鶹ŮÓÅ Health News.

Durante el primer mandato de Trump, . y modificaron algunas leyes para permitir que tutores recibieran derechos parentales temporales en casos relacionados con migración. Ahora, tras el regreso de Trump al poder el año pasado, el aumento en los controles migratorios está impulsando una nueva ola de respuestas estatales.

En Nueva Jersey, legisladores están considerando un proyecto para modificar estatal que permite que los padres designen tutores temporales para casos de muerte o incapacidad. La nueva versión agregaría como otra razón válida la separación por control migratorio federal.

El año pasado, Nevada y California aprobaron leyes para proteger a las familias separadas por acciones de control migratorio. La ley de California, llamada Ley del Plan de Preparación Familiar (), permite que los padres designen tutores y compartan derechos de custodia, en lugar de que sus derechos se suspendan mientras están detenidos. Si son liberados y pueden reunirse con sus hijos, recuperan sus derechos parentales completos.

Existen importantes obstáculos legales para la reunificación familiar una vez que un niño entra bajo custodia estatal, explicó Juan Guzman, director del tribunal de menores y tutela en Alliance for Children’s Rights, una organización de defensa legal en Los Ángeles.

Si el niño es colocado en cuidado temporal y ni el padre ni la madre pueden participar en los procesos judiciales requeridos porque están detenidos o han sido deportados, es menos probable que puedan volver a reunirse con su hijo, afirmó Guzman.

Se estima que que son ciudadanos estadounidenses viven con un padre u otro familiar que no tiene estatus migratorio legal, según investigaciones de Brookings Institution, un centro de estudios en Washington, D.C. Dentro de ese grupo, 2,6 millones de niños tienen a ambos padres sin estatus legal.

Santana dijo que es probable que el número de casos de separación familiar aumente a medida que el gobierno de Trump avance con su campaña migratoria. Por lo tanto, más niños corren el riesgo de terminar en el sistema de cuidado temporal.

Las exigen que la agencia se esfuerce en facilitar la participación de los padres detenidos en los procedimientos de los tribunales de familia, de bienestar infantil o de tutela, pero Santana indicó que no está claro que el ICE esté cumpliendo con estas normas.

Los funcionarios de ICE no respondieron a las solicitudes de comentarios para este artículo.

Antes de que cambiara la ley de California, la única razón por la que un padre podía compartir derechos de custodia con otro tutor era si tenía una enfermedad terminal, contó Guzman.

Ahora, si los padres preparan un plan con anticipación y designan a alguien de confianza que pueda hacerse cargo de sus hijos si llegara a ser necesario, la agencia estatal de bienestar infantil puede iniciar el proceso para entregar a los niños a esa persona sin tener que abrir un caso formal de cuidado temporal, agregó.

Aunque los legisladores de Nevada el año pasado ampliaron una ley de tutela ya existente para incluir el control migratorio, la medida exige que los padres presenten documentación notarial ante la oficina del secretario de estado, un trámite administrativo que puede resultar costoso, dijo Cristian González-Pérez, abogado en Make the Road Nevada, una organización sin fines de lucro que ofrece recursos a comunidades inmigrantes.

González-Pérez señaló que algunos inmigrantes dudan en completar formularios gubernamentales por temor a que el ICE pueda acceder a esa información y los persiga. Él les asegura a los miembros de la comunidad que los formularios estatales son confidenciales y solo pueden ser consultados por hospitales y tribunales.

El gobierno de Trump ha tomado para acceder a información sensible a través de los Centros de Servicios de Medicare y Medicaid, el Servicio de Impuestos Internos (IRS), el Programa de Asistencia Nutricional Suplementaria (SNAP), el Departamento de Vivienda y Desarrollo Urbano y otras entidades.

González-Pérez y Guzmán consideran que muchos padres inmigrantes no conocen sus derechos. Designar un tutor temporal y crear un plan familiar es una forma de no sentirse impotentes, afirmó González-Pérez.

“La gente no quiere hablar de esa cuestión”, reflexionó Guzman. “Que un padre tenga que hablar con un niño sobre la posibilidad de separarse da miedo. No es algo que nadie quiera hacer”, concluyó.

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The federal government doesn’t track how many children have entered foster care because of immigration enforcement actions, leaving it unclear how often it happens. In Oregon, as of February two children had been placed in foster care after being separated from their parents in immigration detention cases, according to Jake Sunderland, a spokesperson for the Oregon Department of Human Services.

“Before fall 2025, this simply had never happened before,” Sunderland said.

As of mid-February, nearly by Immigration and Customs Enforcement. The record 73,000 people in detention in January represented an compared with one year before. According to , parents of 11,000 children who are U.S. citizens were detained from the beginning of Trump’s term through August.

The news outlet NOTUS that at least 32 children of detained or deported parents had been placed in foster care in seven states.

Sandy Santana, executive director of Children’s Rights, a legal advocacy organization, said he thinks the actual number is much higher.

“That, to us, seems really, really low,” he said.

Separation from a parent is deeply traumatic for children and can lead to , including post-traumatic stress disorder. Prolonged, intense stress can lead to more-frequent infections in children and developmental issues. That “toxic stress” is also associated with responsible for learning and memory, according to Â鶹ŮÓÅ.

, and amended existing laws during Trump’s first term to allow guardians to be granted temporary parental rights for immigration enforcement reasons. Now the enforcement surge that began after Trump returned to office last year has prompted a new wave of state responses.

In New Jersey, lawmakers are considering to amend a state law that allows parents to nominate standby, or temporary, guardians in the cases of death, incapacity, or debilitation. The bill would add separation due to federal immigration enforcement as another allowable reason.

Nevada and California passed laws last year to protect families separated by immigration enforcement actions. California’s law, called the , allows parents to nominate guardians and share custodial rights, instead of having them suspended, while they’re detained. They regain their full parental rights if they are released and are able to reunite with their children.

There are significant legal barriers to reunification once a child is placed in state custody, said Juan Guzman, director of children’s court and guardianship at the Alliance for Children’s Rights, a legal advocacy organization in Los Angeles.

If a parent’s child is placed in foster care and the parent cannot participate in required court proceedings because they are in detention or have been deported, it’s less likely they will be able to reunite with their child, Guzman said.

are U.S. citizens who live with a parent or family member who does not have legal immigration status, according to research from the Brookings Institution, a Washington, D.C.-based think tank. Within that group, 2.6 million children have two parents lacking legal status.

Santana said he expects the number of family separation cases to grow as the Trump administration continues its immigration enforcement campaign, putting more children at risk of being placed in foster care.

the agency to make efforts to facilitate detained parents’ participation in family court, child welfare, or guardianship proceedings, but Santana said it’s uncertain whether ICE is complying with those rules.

ICE officials did not respond to requests for comment for this report.

Before the change in California’s law, the only way a parent could share custodial rights with another guardian was if the parent was terminally ill, Guzman said.

If parents create a preparedness plan and identify an individual to assume guardianship of their children, the state child welfare agency can begin the process of placing the children with that individual without opening a formal foster care case, he added.

While Nevada lawmakers expanded an existing guardianship law last year to include immigration enforcement, the measure requires the parents to file notarized paperwork with the secretary of state’s office, an administrative step that may be burdensome, said Cristian Gonzalez-Perez, an attorney at Make the Road Nevada, a nonprofit that provides resources to immigrant communities.

Gonzalez-Perez said some immigrants are still hesitant to fill out government forms, out of fear that ICE might access their information and target them. He reassures community members that the state forms are secure and can be accessed only by hospitals and courts.

The Trump administration has taken through the Centers for Medicare & Medicaid Services, the IRS, the Supplemental Nutrition Assistance Program, the Department of Housing and Urban Development, and other entities.

Gonzalez-Perez and Guzman said that not enough immigrant parents know their rights. Nominating a temporary guardian and creating a plan for their families is one way they can prevent feelings of helplessness, Gonzalez-Perez said.

“Folks don’t want to talk about it, right?” Guzman said. “The parent having to speak to a child about the possibility of separation, it’s scary. It’s not something anybody wants to do.”

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Mayor Helena Moreno signed an on April 7 that creates a task force to improve the New Orleans Recreation Development Commission. One of the task force’s duties will be to “consider and make recommendations regarding the costs and practicalities of implementing a program to assess and remediate safety and environmental concerns at NORDC facilities and playgrounds, including the existence of lead in soil” and other environmental issues, according to the order.

About a week before Moreno signed that order, Deputy Mayor of Health and Human Services Jennifer Avegno announced that city officials were working with the state’s congressional delegation to request $5 million in federal funds for the federal fiscal year that starts in October. That money would go toward testing and the possible cleanup of playgrounds with elevated levels of lead. She said her office is also reviewing past city records, working with the city’s in-house experts in its Planning Commission’s Brownfield Program, and reviewing Verite’s soil test results.

“We’re trying to figure out, with whatever pots of money we can get, how can we make a more sustained and meaningful impact than we have been able to in the past?” Avegno said during an of Verite’s lead contamination investigation.

In the investigation published in February, Verite reporters tested more than 80 playgrounds for lead and documented unsafe levels of the toxic metal at just over half of them. Since then, parents across the city have called the New Orleans Recreation Development Commission, their elected officials, and other city offices seeking action.

But with the city in the midst of a budget crisis, parents and community groups in one neighborhood are taking action themselves. They are trying to raise $8,000 to hire a contractor to do extensive testing in the Bywater neighborhood’s Mickey Markey Playground, where Verite recorded lead samples that exceeded the federal hazard level of 200 parts per million — one sample registered at 403 parts per million.

“I’m aware of the city budget issues right now, and I’m also aware that fixing one playground in one neighborhood might not be a giant priority,” said Devin DeWulf, a father of two who lives in Bywater and founded the , a community organization helping with the fundraising.

Lead contamination persists in New Orleans soil, older buildings, and drinking water, posing a significant public health threat to children. Children under 6 can absorb the toxic metal more easily than adults, contaminating their blood and harming the long-term development of their brains and nervous systems.

There is no known safe exposure level for children or adults. In children, even trace amounts can result in behavioral problems and lower cognitive abilities. Chronic lead exposure for adults can increase the risk of heart problems and other health issues.

Beyond the effects on a single child or family, Avegno said, lead exposure has long-term implications, including its , which makes the issue even more critical.

“We knew we had to exhaust every avenue,” she said.

Due to low rates of testing, it’s unclear how many children across New Orleans are exposed to lead. In 2023, just 17% of children were tested for lead poisoning in New Orleans, despite a that requires medical providers to test all children by age 1 and again by 2. Currently, the state Department of Health doesn’t have a mechanism for enforcing the law.

Public health researchers recommend parents avoid playgrounds with lead contamination because it can be difficult to prevent young children from placing dirt in their mouths or breathing in dust kicked up during play.

Vann Joines, a Bywater neighborhood resident who often takes his 2-year-old daughter to Mickey Markey Playground, is part of the group raising money to independently test the playground.

“It’s really important for us to be exceedingly mindful at public playgrounds and at public parks,” Joines said.

DeWulf and Joines said they anticipate the work will take a few years and hope to create a playbook that other neighborhoods can follow for their own playgrounds.

“We could create a how-to guide on how we could effectively do this in partnerships in the city,” Joines said.

On top of the $5 million the city is requesting for soil testing and possible remediation, Avegno said the city planned to apply for a grant to help address lead at early childhood education centers.

“Your story was amazing timing,” she told a Verite reporter.

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Researchers say the children at about a mile away pay the price. They discovered the students there and at other elementary schools near major pollution sites in Pennsylvania had than other children in the state.

Residents and environmental advocates saw reason for hope and relief in the form of a designed to tamp down on coke oven plant pollution. But even before it took effect, President Donald Trump granted in the U.S. — including the one in Clairton — a from the standards.

Trump and Republicans have sought to align themselves with the Make America Healthy Again movement’s populist ideals, such as improving Americans’ food choices and reducing corporate harm to the environment. But the administration is ratcheting up its attacks on the very environmental protections that MAHA followers hold dear.

Taken together, these anti-environmental initiatives will lead to more pollution-related illnesses and higher health care spending, health researchers say. They could also have political ramifications, eroding MAHA’s support for GOP candidates in the November midterm elections if followers believe the party is more beholden to industry than to the movement’s agenda.

, including about a quarter of Republicans, support rolling back environmental regulations, according to a poll by the Energy Policy Institute at the University of Chicago and The Associated Press-NORC Center for Public Affairs Research.

Some MAHA supporters believe voters will support Republicans because the Trump administration is delivering on other goals important to the movement.

“MAHA has a pretty diverse set of policy goals, ranging from medical freedom to food and the environment,” said David Mansdoerfer, who served in Health and Human Services leadership during Trump’s first term. “In totality, the Trump administration has strongly delivered on much of the MAHA agenda.”

While MAHA voters have been upset at some of the administration’s actions that promote industry, it’s hard to know how that may play out in the midterms, said Christopher Bosso, a professor of public policy and politics at Northeastern University. Many were disillusioned by a Trump they viewed as promoting glyphosate, which HHS Secretary Robert F. Kennedy Jr. has .

“The glyphosate thing really ticks off a lot of them; they’re really upset,” Bosso said. “Kennedy said it was poison. If it is a poison, why aren’t we regulating it? That’s where the tension plays out.”

The situation with the Clairton coke plant and the others granted exemptions from regulations underscores the potential public health risks. Six of the 11 factories had “high priority” violations of the Clean Air Act as of last May, according to a Â鶹ŮÓÅ Health News analysis. Five coke oven plants logged major violations every quarter for at least three years straight.

“Poisoning continues to some of the most vulnerable residents of Allegheny County,” , who had lived in nearby Glassport, Pennsylvania, said at a about the coke plant.

Environmental Protection Agency spokesperson Brigit Hirsch said the president gave companies extra time because the technology needed to meet a new standard isn't ready yet.

“Forcing plants to comply before the tools exist doesn't make the air cleaner, it just shuts down facilities and kills jobs with nothing to show for it,” Hirsch said.

But environmental groups disagree that the plants were unable to comply at a reasonable cost, and they say the exemption from the EPA requirements shows the Trump administration is prioritizing the coal industry at the expense of public health.

“The Trump administration’s relentless actions to dismantle lifesaving environmental protections are a gut punch to the administration’s own promise to Make America Healthy Again,” said Cathleen Kelly, a senior fellow at the Center for American Progress, a liberal think tank.

Hard Times in Clairton

Sprawled across , the Clairton plant operates ovens in which coal is heated to as much as 2,000 degrees Fahrenheit to make up to 4.3 million tons annually of the carbon-rich fuel known as coke. The product is used in blast furnaces to produce iron.

It’s a dirty operation. The process leads to hazardous emissions of that the Centers for Disease Control and Prevention says can lead to anemia and leukemia, as well as , which can trigger severe asthma.

The Clairton operation has had repeated problems with its emissions and operations, including and of toxic chemicals. The plant has received more than from the Allegheny County Health Department since 2022, stemming largely from a fire in 2018 that led to high emissions, and violated the Clean Air Act in each of the last , with the last compliance monitoring in July 2025, according to the EPA.

Nippon Steel Corp. last year acquired U.S. Steel, which now operates as a subsidiary. The company didn’t respond to an email seeking comment. U.S. Steel said it spends $100 million annually on environmental compliance at Clairton.

“Environmental stewardship is a core value at U. S. Steel, and we remain committed to the safety of our communities,” spokesperson Andrew Fulton said in a written statement.

Clairton was once bustling with movie theaters, a mix of grocery stores, and riverside parks, with a dance pavilion and . But the decline of steel hit hard. The town’s population dwindled from more than in the mid-20th century to as of 2024. until they were razed and replaced with signs saying to keep out. The 1978 movie , which depicts a hardscrabble industrial town, is partly set there. Today, about 33% of residents live in poverty.

While the plant brings jobs and revenue, residents of the town and the surrounding areas have long complained about health problems they attribute to its emissions.

“My parents are gone. My mom had cancer, my dad,” , a Clairton resident, said at a 2025 County Council meeting. “I lost a lot of loved ones and seen other ones pass because of this mill.”

Pediatric allergist looked into asthma rates among 1,200 children who attended school near major pollution sites in the area — including students at Clairton Elementary School. They had nearly triple the national rate of asthma, with the highest rate among African American youth, according to she led.

“We were shocked,” she said. “It was double or triple what we expected. The people are proud of their industrial background. We need steel, but they’re not running a good enough operation.”

A found children with asthma living near the coke plant had an 80% higher chance of missing school when sulfur dioxide pollution was elevated.

Allegheny County, which includes Clairton and Pittsburgh, is home to a number of industrial plants, and to increased deaths, chronic heart disease, and adverse birth outcomes. It was ranked in the top 1% of counties in the nation for cancer risk from stationary industrial air pollutants in a 2018 .

Clairton has an age-adjusted cancer death rate of 170 per 100,000 people, higher than the broader county’s rate of 150 deaths per 100,000 people, based on a Â鶹ŮÓÅ Health News analysis of .

The American Lung Association in 2025 gave the county an F rating for its particle pollution levels. PennEnvironment, an environmental group that was party to a settlement with U.S. Steel involving the Clairton plant, says the coke operation caused of toxic releases in 2021, which amounted to 60% of all such releases in the county that year.

From 2020 through 2025, the Clairton plant racked up more in fines from Clean Air Act penalties than any other coke oven facility nationwide, costing U.S. Steel over $10 million, according to EPA facility reports.

“We are deeply concerned with exemptions, which allow air toxics to affect public health,” Allegheny County Health Department spokesperson Ronnie Das said in a statement.

The Clairton plant provides and hundreds of millions of dollars in tax revenue to the area. The jobs help generate nearly $3 billion in annual economic output, according to estimates from the Pennsylvania Manufacturers’ Association.

Some community members and advocacy groups hoped air quality would improve after the coke plant was sold. has pledged to upgrade facilities in the Monongahela River Valley.

Politics, Waivers, and Environmental Concerns

Under the Biden-era rule, coke plants were supposed to start meeting from the lids and doors of ovens that heat coal. They would also have had to monitor for benzene at their property lines and take steps to lower emissions of the carcinogen if they exceeded certain levels. Compliance deadlines were set for July 2025.

The Trump administration, which has sought to revive the coal industry, intervened. Last year, it , including coke plants such as Clairton’s, to seek from issued in 2024 by the EPA.

Then Trump in November went further, granting all coke plants a two-year compliance break.

The reprieve was necessary, the EPA spokesperson Hirsch said, because the requirements would have meant extra costs for the industry when standards already in effect work “extremely well” at reducing pollution.

Hirsch also said the agency under Trump is protecting the environment, pointing to action the administration has taken to called PFAS, prevent lead poisoning, strengthen chemical safety, and protect Americans’ food and water supply.

“We are building a future where the next generation of Americans is the healthiest in our nation's history, and they inherit the cleanest air, land and water in the world,” Hirsch said.

However, the administration has taken several steps that environmental advocates say weaken health protections.

The president's executive order on glyphosate, an herbicide the World Health Organization has linked to cancer, which touched off a furor among MAHA enthusiasts who said they felt betrayed. The EPA has decided to stop considering the of reducing pollution when making policy decisions, instead focusing on the cost to industry of complying with rules. The agency also rescinded the legal and scientific basis that had long established as dangerous to public health.

The actions have rankled some MAHA enthusiasts who counted on the administration to tackle chronic disease, especially among children. A petition to Trump on with more than 15,000 signatures called for the removal of EPA Administrator Lee Zeldin, it said supported corporations over MAHA goals.

Some MAHA enthusiasts have sounded off on social media.

“No one should believe that MAHA is being upheld at the EPA at this point,” , a leader of American Regeneration, which focuses on a conservation approach to farming, said Feb. 8 on X.

, host of a , also aired her concerns on X, saying “there is something really freaking spooky going on at the EPA and I refuse to let the American people be gaslit into thinking they’re upholding the MAHA agenda.”

“A significant number of people who supported Trump are worried these rollbacks are going to hurt their health,” said , a Democratic strategist and the founder of the communications firm Third Degree Strategies. “The MAHA voters, especially women, are very sensitive to this. Republicans have put themselves in a bind.”

MAHA supporters shouldn’t be surprised by a Trump administration that doesn’t prioritize environmental protections over industry, because the president has always championed fossil fuels, said Kyle Kondik, managing editor of Sabato’s Crystal Ball, a nonpartisan election forecasting newsletter published by the University of Virginia Center for Politics.

The coke plant exemptions have disappointed some community members, environmental groups, and regulators concerned about public health and emissions.

Nearly 300,000 people live within 3 miles of the 11 active coke plants across the U.S., according to EPA data compiled by the Environmental Defense Fund.

Weakening environmental rules has helped boost Trump with the U.S. coal industry. In February, mining industry executives and lobbyists gathered at the White House, .

Coal miners, including some in white hard hats bedecked with American flags, with a bronze-colored trophy emblazoned “The Undisputed Champion of Beautiful Clean Coal.”

At the event, Trump praised their work. “We love clean, beautiful coal,” he said.

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Other drivers stopped, broke the car window, and pulled him to safety. A passing volunteer firefighter performed CPR until an ambulance arrived to take Masterson to UPMC Mercy hospital.

He spent 18 days in the medical intensive care unit there, 14 of them on a ventilator. He developed delirium, a common ICU condition, and needed antipsychotic drugs. Despite a feeding tube, he lost weight. “We honestly weren’t confident that he would pull through,” said Ron Dedes, his brother-in-law.

But he did. Masterson was discharged Feb. 1 and returned home with near-constant family support. Working diligently with several kinds of therapists, he has regained his ability to walk, despite lingering weakness, and to manage his personal care. His once-garbled speech has markedly improved. He can make himself a sandwich.

Now, “our biggest concern is his memory,” Dedes said. Masterson, who so recently handled complex legal matters, forgets conversations and events that happened a few hours earlier, said Patti Dedes, his sister. He can’t yet operate a microwave or place a phone call.

In an interview, he described himself, accurately, as “much, much better than I was” — but misstated his age. Screening tests after his discharge indicated cognitive impairment and depression.

Among critical-care doctors, prolonged symptoms like his are known as “post-intensive care syndrome,” or PICS. The fallout can be physical or psychological, as well as cognitive, and can persist for months or years.

More than are admitted to intensive care across about 5,000 American hospitals, and research shows that . Older age increases the odds.

Patients and families are often startled by these continuing difficulties. “The belief is that they’ll be discharged from the hospital and in two or three weeks, they’ll be back to normal,” said Brad Butcher, who was Masterson’s doctor and in the medical journal JAMA. “That doesn’t comport with reality.”

In fact, with greater ICU use and improved treatments — the Society of Critical Care Medicine estimates that their stays — the population likely to encounter the syndrome is growing.

“Everyone is grateful that the patient has survived,” said Lauren Ferrante, a pulmonary critical-care doctor and researcher at the Yale School of Medicine. “But that’s just the start of a long road to recovery.” In a study of patients 70 and older that she co-authored, within six months after discharge only about half had .

Intensive care patients face a . PICS symptoms — weakness, pain, neuropathy (tingling in arms and legs), and malnutrition — to , primarily anxiety and depression. like Masterson’s are commonplace, including problems with memory, attention and concentration, and language.

“For many people, surviving a critical illness is a life-altering experience,” Butcher said. Patients in intensive care after emergency or elective surgery also of new physical, mental, and cognitive problems a year later.

The same aggressive treatments that save lives contribute to the syndrome. Intensive care patients “have some sort of dramatic organ failure that requires immediate attention” and constant monitoring, explained Carla Sevin, a pulmonary critical-care doctor who directs the ICU Recovery Center at Vanderbilt University Medical Center.

That could mean a breathing tube attached to a ventilator, which in turn often requires sedating drugs. Sedation “can precipitate delirium, and delirium is the key factor in cognitive symptoms,” Butcher said.

It doesn’t help that constant beeps and alarms from monitors and round-the-clock bright lighting disrupt sleep, and that restrictive family visiting hours deprive patients of reassuring faces and voices.

Gregory Matthews, a retired accountant in St. Petersburg, Florida, spent nearly a month in an ICU after a lung transplant in 2014. He still vividly remembers his hallucinations, including mice running across the wall and someone trying to frame him for drug running.

“One day, I thought a doctor was an assassin — I could see the rifle,” said Matthews, now 80. “So I jumped out of bed,” he said, and yanked out his IVs. The staff put his arms in restraints for days.

But immobilization exacts its own toll as patients quickly lose muscle mass and strength. “Our bodies were not meant to lie in bed all day,” Ferrante said.

Psychologically, “PTSD is pretty common, similar to what’s seen in combat veterans or sexual assault survivors,” Sevin said, referring to post-traumatic stress disorder. Families can suffer anxiety and depression along with the patients.

Alarmed by such discoveries, doctors and administrators at about 35 U.S. hospitals have established , where teams of doctors, nurses, pharmacists, therapists (physical, occupational, cognitive, speech), and social workers screen for a host of conditions and help guide patients through them.

Vanderbilt’s clinic saw its first patient in 2012. The Critical Illness Recovery Center at the University of Pittsburgh Medical Center, which Butcher founded in 2018, works with about 100 patients a year, including Masterson. Yale opened its clinic in 2022.

They rely on six practices recommended by the Society of Critical Care Medicine that are shown to . The measures call for changes such as using lighter sedation, getting patients up and moving earlier, testing their breathing daily to wean them from ventilators sooner, and removing restrictions on family visiting.

Clinics often offer support groups for patients and families. There’s evidence that keeping an ICU diary, in which patients and caregivers record their experiences, and engaging in exercise and physical rehabilitation after discharge.

Also on the clinics’ agenda: discussions of what other options patients might prefer if they face another critical illness, as many do. Would they agree to undergo intensive care and risk its aftereffects again? Or choose palliative care, which emphasizes comfort rather than cure? Some post-ICU patients remain permanently impaired.

Butcher, although he said that the use of the new practices needed to expand dramatically, sounded optimistic about the future of critical care. “We’re going to find better diagnostic tools, better preventive strategies, and better therapies,” he said.

For now, though, the ICU experience remains disorienting and sometimes traumatic. When Butcher asked 117 patients in his post-ICU clinic those next-time questions, many wanted to place limits on further medical interventions.

About a third would want to lower the level of aggressive care. Of those, about a quarter would want “do not resuscitate” and “do not intubate” orders, and almost 7% said they never wanted to return to an ICU.

Masterson is working hard to further his recovery. “I haven’t been out and about much,” he said. “I’ve been kind of homebound.” He hopes to get strong enough to resume running — he used to log 3 to 4 miles several times a week.

The future for patients contending with post-ICU syndrome often depends on their physical, mental, and cognitive health before their admission. Masterson’s previous fitness and cognitively demanding work bode well for his further progress, Butcher said.

His family remains alternatively hopeful and worried. “Down the road, what’s it going to be like?” Dedes, his brother-in-law, wondered. “We just take it day by day.”

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That monthly total is $200 higher than what he paid last year, due in part to the expiration in December of covid pandemic-era premium tax credits. But the self-employed St. Louis property manager isn’t in any hurry to investigate a new type of coverage that might be cheaper than his marketplace plan: farm bureau health plans.

“Although I’m not a fan of rising costs, I’m not going to sacrifice coverage for my kids to save a buck,” Carlton said.

Carlton finds himself among a growing number of Americans who have confronted difficult choices because of rising Affordable Care Act premiums and other affordability issues. For instance, a found that many returning marketplace enrollees reported higher costs this year.

In addition, most expressed worry about affording routine and unexpected medical care, as well as the cost of prescription drugs. Worries were greater among those with lower incomes and chronic health conditions. And about 5% of respondents said they had switched to some type of non-ACA coverage.

Health policy experts say such concerns are giving new legs to alternative forms of coverage — for instance, farm bureau plans.

As of this year, that allow health coverage through state farm bureaus, grassroots membership organizations that advocate for the agricultural industry and rural interests. An annual membership in the bureau typically costs $30 to $50, and in many of the states anyone can join. With membership comes the option of buying into the health plan.

Plan details vary by state, but they typically share many features of marketplace plans, including coverage of a wide range of services, a broad practitioner network, and a way to file complaints.

But because states have passed laws exempting from health insurance requirements, they don’t offer many of the coverage protections provided by insurance. That means their benefits and coverage rules may be less generous or predictable than Obamacare plans.

Crucially, farm bureau plans don’t have to accept everyone who applies for coverage. People must pass underwriting first, a process in which plans evaluate applicants’ medical history and health conditions and decide whether to offer them coverage. This practice was routine before the ACA passed, and people were often rejected due to preexisting medical conditions.

Because farm bureau plans can turn down people with expensive chronic conditions or a history of cancer or other medical issues, farm bureau plans may be than unsubsidized marketplace plans, plan managers say.

As people struggle to keep family farms afloat, they may face Obamacare premiums totaling thousands of dollars a month, leading some to forgo coverage, said Missouri Farm Bureau president Garrett Hawkins.

“We’re trying to present another option,” he said.

Sowing Choices

In 2026, with the expiration of enhanced premium tax credits, average ACA premium payments were estimated to for subsidized enrollees who retained their marketplace plan, according to Â鶹ŮÓÅ.

Last year, was one of four states that passed laws permitting farm bureau health plans. The others were , , and .

Although the number of states offering them has ticked up in recent years, farm bureau health plans aren’t new. Tennessee has been offering the coverage . Tennessee’s Farm Bureau Health Plans administers the plans in 10 of the 14 states that permit them.

In Missouri, the farm bureau offers with varying deductibles, copayments, and annual limits on out-of-pocket spending. Many of the benefits and cost-sharing amounts look like the coverage someone might get on the state health insurance exchanges or through an employer. They include emergency care and hospitalization, physician office visits, prescription drugs, free preventive care, and dental and vision services. Members have access to providers through the UnitedHealthcare Choice Plus national network.

Hawkins said he’s pleased with the interest the plans are generating. People could apply for coverage through the website starting Jan. 1, and by mid-March, 520 people had submitted applications, he said.

It’s uncertain how many of those people will clear the underwriting hurdle and buy a farm bureau plan, however. Farm bureau health plans can deny coverage for any reason. Even if coverage is offered, plans in Missouri don’t cover any for at least six or 12 months. In addition, plans may exclude coverage of any benefits related to a “known risk” for two to seven years, depending on the issue. So people with a range of conditions, such as diabetes, high cholesterol, heart problems, or successfully treated cancer, may be turned down or have to pay out-of-pocket for any related care for at least a year and possibly as long as seven years.

“People don’t like that we underwrite, but if we did everything like the ACA, we’d be just like an ACA plan,” said , general counsel and chief compliance and privacy officer at Tennessee’s Farm Bureau Health Plans. “We’re trying to be an option for folks that would otherwise not have coverage.”

Staying Rooted in Coverage

Under the Missouri law, once someone is covered by a farm bureau plan, they can’t be kicked off or charged a higher rate if they get sick. That’s also true for the nine other states where Tennessee administers the plans, Beard said.

“We do not contractually have the right to raise premiums or cancel plans based on [an individual’s] health experience,” he said.

And yet, “it can be really confusing to people” because the plans look like insurance products, but they don’t have the same protections, said , principal for policy development, access to, and quality of care at the American Cancer Society Cancer Action Network.

Someone with a history of cancer would be unlikely to get approved for a farm bureau plan in the first place, Howard said. If they were accepted, the services they might need would likely be excluded from coverage, she said.

“We’re just concerned that there’s going to be more people enrolled in these plans now because there’s so many more states that are allowing them,” Howard said.

Carlton, the self-employed property manager, knows firsthand how underwriting can limit coverage options. Before the Affordable Care Act required that anyone be accepted regardless of health status, Carlton, who has diabetes, had to buy coverage through his state’s high-risk pool, which was often the only option for people with preexisting conditions.

Meanwhile, policy experts share Howard’s concerns.

Insurance companies in the ACA marketplaces “have to offer maternity coverage, and they have to give you benefits on day one for a preexisting condition, and they can’t charge you more because you have that condition,” said , vice president for health policy at the Center on Budget and Policy Priorities. This creates an uneven playing field for insurers and drives up premiums for the people who can’t get into farm bureau plans.

Farm bureau plans “get to use, you know, the standard market as a high-risk pool, essentially, if they want to,” Lueck said.

Still, with the huge jump in premiums that many people are facing for ACA coverage, it’s easy to understand the appeal of farm bureau plans.

“I’m not saying it’s a good thing that states have abdicated their regulatory responsibility here,” said , co-director of the Center on Health Insurance Reforms at Georgetown University. “I’m just saying that there are a lot of people out there who are struggling, who need health care, and simply can’t afford the premiums in these ACA marketplaces anymore.”

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“The first time, it’ll ring interminably. Next time, it’ll go to a voicemail that just hangs up on you,” said the 48-year-old, who lives in Delaware. “Sometimes you’ll get a person who says they’re not the right one. They transfer you, and it hangs up. Sometimes, it picks up and there’s just nobody on the line.”

She spent months trying to figure out whether her Medicaid coverage had been renewed. As of late March, she hadn’t been reapproved for the year for the state-federal program, which provides health insurance for people with low incomes and disabilities.

Crouch, who suffered a debilitating brain aneurysm a decade ago, also has Medicare, which covers people who are 65 or older or have disabilities. Medicaid had been paying her monthly Medicare deductibles of $200, but she’d been on the hook for them for the past three months, straining her family’s fixed income, she said.

Crouch’s challenges with Delaware’s Medicaid call center aren’t unique. State Medicaid agencies can struggle to keep enough staff to help people sign up for benefits and field calls from enrollees with questions. A shortage of such workers can keep people from fully using their benefits, health policy researchers said.

Now, congressional Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will soon demand more from staff at state agencies in places where lawmakers expanded Medicaid to more low-income adults — nearly all states and the District of Columbia.

Under the law, which is expected to reduce Medicaid spending by almost $1 trillion over the next eight years, these staffers will have to not only determine whether millions of enrollees meet the program’s new work requirements but also verify more frequently that they qualify for the program — every six months instead of yearly.

Â鶹ŮÓÅ Health News reached out to agencies that will need to stand up the work rules, and many said they’ll need additional staff.

The mandates will put extra strain on an already-stressed workforce, potentially making it harder for enrollees like Crouch to get basic customer service. And many could lose access to benefits they’re legally entitled to, said consumer advocates and health policy researchers, some of them with direct experience working at state agencies.

States are already “struggling significantly,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities and a former associate director of the Illinois Department of Human Services. “There will be significant additional challenges caused by these changes.”

Long Wait Times for Help

Republicans argue the Medicaid changes, which will take effect Jan. 1, 2027, in most states, will encourage enrollees to find jobs. Research on other Medicaid work requirement programs has found little evidence they increase employment.

The Congressional Budget Office would cause more people to lose health coverage by 2034 than any other part of the GOP budget law. It said last year more than 5 million people could be affected.

Many states don’t have the staff to process Medicaid applications or renewals quickly, said consumer advocates and researchers.

The Centers for Medicare & Medicaid Services tracks whether states can handle the most common type of benefit application within a 45-day window.

In December, about 30% of all Medicaid and Children’s Health Insurance Program, or CHIP, applications in Washington, D.C., and Georgia to process. More than a quarter took that long in Wyoming. In Maine, 1 in 5 applications missed that deadline.

CMS began publicly sharing state Medicaid call center data in 2023, revealing a taxed system, researchers and consumer advocates said.

In Hawaii, people waited on the phone for more than three hours in December. They waited for nearly an hour in Oklahoma, and more than an hour in Nevada.

In 2023, state Medicaid agencies began making sure enrollees who were protected from being dropped from the program during the covid pandemic still qualified for coverage. That Medicaid unwinding process didn’t go well in many states, and lost their benefits.

Health policy researchers and consumer advocates say rolling out the new Medicaid rules will be a bigger challenge. The Medicaid work rules will require extensive IT system changes and training for workers verifying eligibility on a tight timeline.

“It is a much larger scale of administrative complexity,” said Sophia Tripoli, senior director of policy at Families USA, a health care consumer advocacy organization.

After months of trying to get someone on the phone, Crouch said, she finally got answers to questions about her Medicaid benefits after writing to the office of U.S. Rep. Sarah McBride (D-Del.). McBride’s office contacted the state’s Medicaid agency, which eventually called with an update, Crouch said.

Crouch didn’t qualify for Medicaid after all. She said that had never come up in two years of interactions with the state.

“It makes absolutely no sense” that the state never realized she shouldn’t have been on the program, Crouch said.

Delaware’s Medicaid agency didn’t respond to requests for comment on Crouch’s situation.

States Short-Staffed for Medicaid

Some states told Â鶹ŮÓÅ Health News in late March that they’ll need more staff to roll out the work rules effectively.

Idaho said it has 40 eligibility worker vacancies. New York estimated it will need 80 new employees to handle the additional administrative work, at a cost of $6.2 million. Pennsylvania said it has nearly 400 open positions in county human services offices in the state. Indiana’s Medicaid agency has 94 open positions. Maine wants to hire 90 additional staffers, and Massachusetts wants to hire 70 more.

As of early March, Montana had filled 39 of 59 positions state officials projected it would need. The state still plans to roll out the rules early, starting July 1, despite its long struggle with system backlogs that applicants said have delayed benefits.

Missouri’s social services agency has been cutting staff and has 1,000 fewer front-line workers than it did roughly a decade ago — with more than double the number of enrollees in Medicaid and the Supplemental Nutrition Assistance Program, or SNAP, according to comments Jessica Bax, the agency director, made in November.

“The department thought that there would be a gain in efficiency due to eligibility system upgrades,” Bax said. “Many of those did not come to fruition.”

States could have a hard time finding people interested in taking those jobs, which require months-long training, can be emotionally challenging, and generally offer low pay, said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families.

“They get yelled at a lot,” said Brooks, who formerly ran New Hampshire’s Medicaid and CHIP customer service program. “People are frustrated. They’re crying. They’re concerned. They’re losing access to health care, and so sometimes it’s not an easy job to take if it’s hard to help someone.”

States are paying government contractors millions of dollars to help them comply with the new federal law.

Maximus, a government services contractor, provides eligibility support, such as running call centers, in 17 states that expanded Medicaid and interacts with nearly 3 in 5 people enrolled in the program nationally, according to the company.

During a February earnings call, company leadership said Maximus can charge based on the number of transactions it completes for enrollees, independent of how many people are enrolled in a state’s Medicaid program.

Maximus has “no one-size-fits-all approach” to the services it offers or the way it charges for those services, spokesperson Marci Goldstein told Â鶹ŮÓÅ Health News.

The company, which reported bringing in $1.76 billion in 2025 from the part of its business that includes Medicaid work, expects that revenue to continue to grow, even as people fall off the Medicaid rolls, “because of the additional transactions that will need to take place,” David Mutryn, Maximus’ chief financial officer and treasurer, said during the earnings call.

Losing Medicaid health coverage isn’t just an inconvenience, since many people enrolled in the program probably don’t make enough money to pay for health care on their own and may not qualify for financial help for Affordable Care Act coverage, said Elizabeth Edwards, a senior attorney with the National Health Law Program.

People could be unable to afford medications or get essential care, which could lead to “devastating” health impacts, she said.

“The human stakes of this are people’s lives,” she said.

Â鶹ŮÓÅ Health News correspondents Katheryn Houghton and Samantha Liss contributed to this report.

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But she also wasn’t expecting the Planned Parenthood in Marquette to shut down last spring. Roughly 1,100 patients relied on that clinic each year for cancer screenings, IUD insertions, and medication abortions. Now the area has no other in-person resource for abortions. “It’s a 500-mile stretch of no access,” Brown said.

So the doctor, who describes herself as “individually pro-life,” added medication abortions to Marquette Medical Urgent Care’s already busy practice, which treats a steady flow of kids with the flu, college students with migraines, and tourists with skiing injuries.

At least 38 abortion clinics shut down last year in states where they’re still legal, according to data collected by , a project supported by a number of nonprofits that helps people find abortion options. Even states that recently protecting abortion rights, such as Michigan, have had clinics close since the U.S. Supreme Court overturned Roe v. Wade in 2022. And as shutter , patients are losing access to pregnancy care. “You cannot have a high-risk pregnancy up here,” Brown said. “It’s a scary place.”

Now communities are coming up with alternatives, such as Brown’s urgent care.

The idea that urgent cares “could be an untapped solution to closures for abortion clinics across the country is really exciting,” said Kimi Chernoby, the chief operating and legal officer at , a national nonprofit that works to improve professional training and patient outcomes for women in emergency medicine.

One patient at the Marquette urgent care on a recent day was a woman whom Â鶹ŮÓÅ Health News agreed to identify by only her first initial, “A,” to protect her medical privacy. She drove more than an hour on snowy backroads while her kids were in day care to get to her appointment.

Her youngest is still a baby, A said, and she got pregnant again while taking the progestin-only birth control pill, which is less likely to interfere with breast milk production but slightly less effective than the regular pill.

“Financials, housing, vehicles — it’s a lot,” she said. And another baby is “just not something that we could really do even at this time.”

She said she was making the long round trip because receiving abortion care in an office felt more secure than being treated by “someone that I’ve never met, or receiving meds that were just shipped to me.”

Face-to-Face Care

In one of the urgent care’s exam rooms, A sat in a chair against the wall, waiting quietly for the doctor. Viktoria Koskenoja, an emergency medicine physician, knocked on the door and then greeted her warmly, pulling up a stool across from her.

“Are you confident in your decision that you want to go ahead? Or do you want to talk about options?” she said.

“No, I’m pretty set on it,” A said.

Koskenoja previously worked at Planned Parenthood. When she learned its Marquette clinic was closing, she started crying and making calls. She recalled asking everyone she knew in health care in Marquette: “What are we going to do?”

One of her first calls was to Brown, a friend and fellow emergency medicine doctor. Their families harvest maple syrup together each spring.

In the wake of the Planned Parenthood closure, Koskenoja convened a community meeting downtown at the Women’s Federated Clubhouse, an 1880s-era building where guests sip from gold-rimmed china teacups on lace tablecloths. The goal: brainstorm new ways to provide abortion access in the Upper Peninsula.

officials said that growing financial challenges and the Trump administration’s cuts to funding, including for the public insurance program Medicaid, had prompted the closures of some brick-and-mortar clinics in the state.

Plus, the availability of pills by mail exploded after the 2022 Dobbs v. Jackson Women’s Health Organization decision overturned Roe. As abortion became illegal in many states, telehealth abortions went from 5% of all abortions provided to 25% by the end of 2024, , a national reporting project that tracks shifts in abortion volume.

Planned Parenthood of Michigan’s telehealth appointments increased 13% for patients in the Upper Peninsula after the Marquette location closed, said Paula Thornton Greear, president and CEO of Planned Parenthood in the state.

All the abortion patients Koskenoja sees at the urgent care have one thing in common: They want to talk to someone in person.

“I had a patient order the pills online and then get scared to use them because they felt like they were going to screw it up, or they weren’t sure they could rely on the pills,” she said. “So they literally came in here with the pills in their hand.”

Others have medical complications or need an ultrasound to determine how far along they are with the pregnancy.

“It annoys me that telehealth is considered an acceptable thing in rural areas,” Koskenoja said. “As though we’re not the human beings that like talking to human beings and looking someone in the eye, especially when something serious is going on.”

The Urgent Care Option

The options presented at that community clubhouse meeting were limited. The few family medicine doctors and OB-GYNs in the area were either already putting patients on months-long waitlists or were too “rightward leaning,” Brown said.

But urgent cares are designed to fill gaps in the system, she said, ready to take walk-ins who aren’t already patients.

Brown knew from her years in the emergency room that medication abortions aren’t that complicated. The for first-trimester and are essentially the same: one dose of mifepristone, followed by misoprostol after 24 to 48 hours.

“Clinically, I was never worried about it,” she said.

The biggest hurdle was getting medical malpractice insurance, Brown said. At first, insurers balked, demanding “onerous and unrealistic” documentation and additional training, she said. Then they quoted a $60,000 annual premium for medication abortions — about three times the cost of insuring the entire urgent care. Ultimately, Brown said, the urgent care’s broker pushed back, providing data that medication abortions didn’t add “significant liability.”

The company agreed to a premium of about $6,000 per year, she said.

The community pitched in, too. A local donor covered an ultrasound machine. And supporters started a nonprofit to help pay for the costs of the medication and additional staffing, bringing the price for patients down from about $450 to an average of about $225, based on a sliding scale.

Word spread quickly once Marquette Medical began offering medication abortions, Brown said. Now the office provides as many as four per week, with patients traveling from as far away as Louisiana. The clinic is on track to match the volume of abortion patients treated at the local Planned Parenthood office before its closure, Brown said.

As pills by mail become the next major target for abortion opponents, Chernoby said, it will be critical to offer more care in more brick-and-mortar places. Brown said the Marquette clinic has already fielded questions from a large academic medical center that plans to start providing medication abortion at its own urgent cares later this year.

“It’s a wonderful idea, but it’s potentially got major pitfalls,” said David Cohen, a professor at the Drexel University Kline School of Law who studies abortion access.

Urgent cares that provide medication abortion would have to abide by state-specific laws — some mandate 24-hour waiting periods or facility structural requirements — and federal regulations, such as the FDA’s requirement that mifepristone prescribers be certified by the drug’s distributors and obtain signed patient agreements.

If abortion access isn’t a core part of a health organization’s mission, “do you want to be on that list? I don’t know if you do,” Cohen said. “There’s just a very particular regulatory environment” around abortion.

Making a Choice

In the exam room, Koskenoja listened as A talked about why she decided to seek an abortion. She has four kids at home, including the baby.

“You OK if we do an ultrasound, just confirm how far along you are, make sure it’s not an ectopic pregnancy?” Koskenoja asked. 

“Yeah,” A said.

Koskenoja noted A’s reaction to the question. “OK. You’re making a face?”

“Yeah, I just don’t — yeah, it’s fine. I just don’t want to see it.”

“Oh, you don’t have to see it,” Koskenoja said.

“I just don’t want to hear a heartbeat or anything like that,” A said.

“Definitely not,” Koskenoja said.

After the ultrasound, Koskenoja stepped out into the hall to give A time to call her partner.

When A said she was ready, Koskenoja stepped in and asked her how she was feeling. A had made up her mind. She said that her partner would be supportive of whatever she decided and that she didn’t want to have another baby right now.

“As much as I know this baby would be loved no matter what, it’s just not a good time,” A said quietly, her hands in her lap.

“Most people who get abortions love babies,” Koskenoja said. And you can still have more in the future, she assured A. 

This kicked off a long conversation about the mental load of parenting and the pros and cons of various birth control options. A said she wanted to get her tubes tied, but Koskenoja suggested her partner consider a vasectomy instead. It’s a much less invasive procedure, she said. “You’ve had a lot of kids. I feel like it could be his turn to take some responsibility.”

Koskenoja handed her a small, handsewn “comfort bag” that all medication abortion patients receive. It was filled with the pills, reminders about when to take them, a handwritten note of support from local community members, pain meds, comfortable socks, and a heating pad.

“Call us if you need anything,” she told A. “Any questions?”

“No,” A said.

“OK. Good luck,” Koskenoja said before A walked out past the waiting room, filled with sick babies and other patients, to drive back to her kids.

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