Author: bkellaway

PLEASANTVILLE, Iowa — Zach Mecham has heard politicians demand that Medicaid recipients work or lose their benefits. He also has run into a jumble of Medicaid rules that effectively prevent many people with disabilities from holding full-time jobs.

“Which is it? Do you want us to work or not?” he said.

Mecham, 31, relies on the public insurance program to pay for services that help him live on his own despite a disability caused by muscular dystrophy. He uses a wheelchair to get around and a portable ventilator to breathe.

A paid assistant stays with Mecham at night. Then a home health aide comes in the morning to help him get out of bed, go to the bathroom, shower, and get dressed for work at his online marketing business. Without the assistance, he would have to shutter his company and move into a nursing home, he said.

Private health insurance plans generally do not cover such support services, so he relies on Medicaid, which is jointly financed by federal and state governments and covers millions of Americans who have low incomes or disabilities.

Like most other states, Iowa has a Medicaid “buy-in program,” which allows people with disabilities to join Medicaid even if their incomes are a bit higher than would typically be permitted. About two-thirds of such programs charge premiums, and most have caps on how much money participants can earn and save.

Some states have raised or eliminated such financial caps for people with disabilities. Mecham has repeatedly traveled to the Iowa Capitol to lobby legislators to follow those states’ lead. The “Work Without Worry” bill would remove income and asset caps and instead require Iowans with disabilities to pay 6% of their incomes as premiums to remain in Medicaid. Those fees would be waived if participants pay premiums for employer-based health insurance, which would help cover standard medical care.

Disability rights advocates say income and asset caps for Medicaid buy-in programs can prevent participants from working full time or accepting promotions. “It’s a trap — a poverty trap,” said Stephen Lieberman, a policy director for the United Spinal Association, which supports the changes.

Lawmakers in Florida, Hawaii, Indiana, Iowa, Maine, Mississippi, and New Jersey have introduced bills to address the issue this year, according to the National Conference of State Legislatures.

Several other states have raised or eliminated their program’s income and asset caps. Iowa’s proposal is modeled on a Tennessee law passed last year, said Josh Turek, a Democratic state representative from Council Bluffs. Turek, who is promoting the Iowa bill, uses a wheelchair and earned two gold medals as a member of the U.S. Paralympics basketball team.

Proponents say allowing people with disabilities to earn more money and still qualify for Medicaid would help ease persistent worker shortages, including in rural areas where the working-age population is shrinking.

Turek believes now is a good time to seek expanded employment rights for people with disabilities, since Republicans who control the state and federal governments have been touting the value of holding a job. “That’s the trumpet I’ve been blowing,” he said with a smile.

The Iowa Legislature has been moving to require many nondisabled Medicaid recipients to work or to document why they can’t. Opponents say most Medicaid recipients who can work already do so, and the critics say work requirements add red tape that is expensive to administer and could lead Medicaid recipients to lose their coverage over paperwork issues.

Iowa Gov. Kim Reynolds has made Medicaid work requirements a priority this year. “If you can work, you should. It’s common sense and good policy,” the Republican governor told legislators in January in her “Condition of the State Address.” “Getting back to work can be a lifeline to stability and self-sufficiency.”

Her office did not respond to KFF Health News’ queries about whether Reynolds supports eliminating income and asset caps for Iowa’s buy-in program, known as Medicaid for Employed People with Disabilities.

National disability rights activists say income and asset caps on Medicaid buy-in programs discourage couples from marrying or even pressure them to split up if one or both partners have disabilities. That’s because in many states a spouse’s income and assets are counted when determining eligibility.

In Iowa, for example, the monthly net income cap is $3,138 for a single person and $4,259 for a couple.

Iowa’s current asset cap for a single person in the Medicaid buy-in plan is $12,000. For a couple, that cap rises only to $13,000. Countable assets include investments, bank accounts, and other things that could be easily converted to cash, but not a primary home, vehicle, or household furnishings.

“You have couples who have been married for decades who have to go through what we call a ‘Medicaid divorce,’ just to get access to these supports and services that cannot be covered in any other way,” said Maria Town, president of the American Association of People with Disabilities.

Town said some states, including Massachusetts, have removed income caps for people with disabilities who want to join Medicaid. She said the cost of adding such people to the program is at least partially offset by the premiums they pay for coverage and the increased taxes they contribute because they are allowed to work more hours. “I don’t think it has to be expensive” for the state and federal governments, she said.

Congress has considered a similar proposal to allow people with disabilities to work more hours without losing their Social Security disability benefits, but that bill has not advanced.

Although most states have Medicaid buy-in programs, enrollment is relatively low, said Alice Burns, a Medicaid analyst at KFF, a health information nonprofit that includes KFF Health News, the publisher of California Healthline.

Fewer than 200,000 people nationwide are covered under the options, Burns said. “Awareness of these programs is really limited,” she said, and the income limits and paperwork can dissuade potential participants.

In states that charge premiums for Medicaid buy-in programs, monthly fees can range from $10 to 10% of a person’s income, according to a KFF analysis of 2022 data.

The Iowa proposal to remove income and asset caps has drawn bipartisan backing from legislators, including a 20-0 vote of approval from the House Health and Human Services Committee. “This aligns with things both parties are aiming to do,” said state Rep. Carter Nordman, a Republican who chaired a subcommittee meeting on the bill. Nordman said he supports the idea but wants to see an official estimate of how much it would cost the state to let more people with disabilities participate in the Medicaid buy-in program.

Mecham, the citizen activist lobbying for the Iowa bill, said he hopes it allows him to expand his online marketing and graphic design business, “Zach of All Trades.”

On a recent morning, health aide Courtnie Imler visited Mecham’s modest house in Pleasantville, a town of about 1,700 people in an agricultural region of central Iowa. Imler chatted with Mecham while she used a hoist to lift him out of his wheelchair and onto the toilet. Then she cleaned him up, brushed his hair, and helped him put on jeans and a John Deere T-shirt. She poured him a cup of coffee and put a straw in it so he could drink it on his own, swept the kitchen floor, and wiped the counters. After about an hour, she said goodbye.

After getting cleaned up and dressed, Mecham rolled his motorized wheelchair over to his plain wooden desk, fired up his computer, and began working on a social media video for a client promoting a book. He scrolled back and forth through footage of an interview she’d done, so he could pick the best clip to post online. He also shoots video, takes photos, and writes advertising copy.

Mecham loves feeling productive, and he figures he could work at least twice as many hours if not for the risk of losing Medicaid coverage. He said he’s allowed to make a bit more money than Iowa Medicaid’s standard limit because he signed up for a federal option under which he eventually expects to work his way off Social Security disability payments.

There are several such options for people with disabilities, but they all involve complicated paperwork and frequent reports, he said. “This is such a convoluted system that I have to navigate to build any kind of life for myself,” he said. Many people with disabilities are intimidated by the rules, so they don’t apply, he said. “If you get it wrong, you lose the health care your life depends on.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

On a sunny weekday in Atlanta, a small crowd of people gathered for a rally outside of a labor union headquarters building.

The event, put together by Atlanta-area Democratic U.S. Rep. Nikema Williams, was attended mostly by union members and recently fired federal workers, including Ryan Sloane.

“I was fired by an anonymous email at 9 p.m. in the middle of a holiday weekend,” he said.

Sloane is still seeking reinstatement, but he feels he no longer has much to lose by speaking out.

“I’m only here today because they cannot fire me twice,” Sloane said.

When he received his termination notice, he was a few months into a job as a public affairs specialist at the Centers for Disease Control and Prevention.

At the CDC, his days were spent updating far-flung local TV, radio, and newspaper journalists about threats such as seasonal flu, measles, and food safety in their communities.

A judge has ordered the reinstatement of some fired federal employees, at least temporarily. But their jobs are still on the line.

Sloane said his former colleagues at the CDC whose jobs aren’t yet in limbo are scared.

“They are terrified that their life’s work is going to be deleted from servers and not backed up because it does not comport with the ideologies of the new administration,” he said. “No one is benefiting from this.”

From the end of January to mid-February, the Trump administration took offline some CDC webpages and froze external communications, including its widely read Morbidity and Mortality Weekly Report epidemiological digest.

The webpages that were removed included CDC public health reports, datasets, and guidance on infectious diseases and sexual health. After a court order, some agency information was restored, at least for now.

But even temporary disruptions to CDC communications could have big ripple effects.

It is information that state and local health departments, hospitals, university researchers, and others rely on to help them respond to outbreaks.

“CDC is there to provide technical information, provide funding, provide support, but it’s a collaborative work, working together to keep Americans safe,” said former CDC Director Tom Frieden, who headed the agency from 2009 to 2017. He is now president and CEO of the nonprofit organization Resolve to Save Lives. “In this country, we have a patchwork or network of public health. It’s really up to the local, city, and state health departments to get the job done.”

City and state health agencies also need the collaboration of CDC experts to help investigate local disease outbreaks and other threats to public health.

A clinician who has worked at the agency for more than two decades pointed to the CDC’s singular ability to send medical supplies and deploy highly specialized teams of scientists to help local communities identify and contain outbreaks. KFF Health News agreed not to use the clinician’s name because she fears she will be fired for airing these views publicly.

“A lot of them are assigned to state and local health departments, so really even beyond individual positions, any funding cuts that the agency takes are also passed on to state and local health departments,” the clinician said. “A lot of their budget comes from federal money as well.”

The Trump administration has attempted to terminate hundreds of employees from the CDC alone, along with hundreds more workers at the National Institutes of Health and other federal agencies with a U.S. health and safety role.

Many public health and science researchers are concerned about the cuts’ impacts on the nation’s ability to respond to threats — and about whether state and local public health departments will be able to keep communities healthy without the CDC’s partnership.

Billionaire Elon Musk has said his Department of Government Efficiency intends to keep cutting federal agencies’ budgets and staff, targeting what it calls “fraud.”

“Anytime someone gets fired, it’s always difficult. But with $36 trillion in debt, we have to reduce the size of the federal government,” Republican U.S. Rep. Marjorie Taylor Greene told WABE during a March visit to the Georgia State Capitol.

Her district includes parts of suburban Atlanta about 30 miles from CDC headquarters.

Greene also chairs a House subcommittee also called “DOGE,” for “Delivering on Government Efficiency.”

“Fortunately, with all the investments that are being brought back into the country under President Trump, I really hope that those federal workers are able to find new jobs,” she said.

She did not comment on whether local public health departments around the country would be able to work efficiently without the support of CDC experts who have been terminated.

But many U.S. public health experts are expressing concern.

The CDC has long been a key training ground for the next generation of U.S. public health researchers.

Emory University epidemiology professor Patrick Sullivan was one of them earlier in his career. The HIV expert previously worked at the CDC for about 15 years.

“When I started working in HIV prevention at CDC in the early 1990s, we didn’t have the treatments that essentially allowed people living with HIV to have a full, healthy, normal lifespan,” he said. “We didn’t have the treatments that essentially allowed people living with HIV to have a test that people could take home to test themselves.”

Sullivan said the progress he has seen over the last several decades gave him optimism, and that advances in HIV treatment and prevention are a great example of the importance of federal support for public health work.

“Discovery science and pharmacy science really have given us the tools that we need to end the HIV epidemic in the United States,” he said.

But, to have those scientific tools without adequate public health staff or funding to use them, he said, will cost American lives.

This article is from a partnership that includes WABE, NPR, and KFF Health News.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

BOULDER, Colo. — Colorado regulators are issuing licenses for providing psychedelic mushrooms and are planning to authorize the state’s first “healing centers,” where the mushrooms can be ingested under supervision, in late spring or early summer.

The dawn of state-regulated psychedelic mushrooms has arrived in Colorado, nearly two years since Oregon began offering them. The mushrooms are a Schedule I drug and illegal under federal law except for clinical research. But more than a dozen cities nationwide have deprioritized or decriminalized them in the past five years, and many eyes are turned toward Oregon’s and Colorado’s state-regulated programs.

“In Oregon and Colorado, we’re going to learn a lot about administration of psychedelics outside of clinical, religious, and underground settings because they’re the first to try this in the U.S.,” said William R. Smith, an assistant professor of psychiatry at the University of North Carolina School of Medicine.

Psychedelic mushrooms and their psychoactive compound psilocybin have the potential to treat people with depression and anxiety, including those unresponsive to other medications or therapy. The National Institute on Drug Abuse, part of the National Institutes of Health, says the risk of mental health problems caused by ingesting mushrooms in a supervised clinical setting is low, but may be higher outside of a clinical setting. Robert F. Kennedy Jr. said in a social media post last year, before his nomination as U.S. health secretary, that his “mind is open to the idea of psychedelics for treatment.”

Medical experts say more research is needed, particularly in people with a diagnosis or family history of psychotic or bipolar disorder. Adverse effects of psilocybin, including headache and nausea, typically resolve within one to two days. However, extended difficulties from using psychedelics can last weeks, months, or years; anxiety and fear, existential struggle, social disconnection, and feeling detached from oneself and one’s surroundings are most common. After the decriminalization and legalization in Oregon and Colorado, psychedelic mushroom exposures reported to poison control centers ticked up in these states and nationally.

In February, about 40 people organized by the psychedelic advocacy group the Nowak Society gathered in Boulder to talk about the coming changes in Colorado. They included Mandy Grace, who received her state license to administer psychedelic mushrooms, and Amanda Clark, a licensed mental health counselor from Denver, who both praised the therapeutic power of mushrooms.

“You get discouraged in your practice because the current therapies are not enough for people,” Clark said.

Colorado voters approved Proposition 122 in 2022 to legalize natural psychedelics, after Oregon voters in 2020 approved legalizing psilocybin for therapeutic use. Colorado’s program is modeled after, but not the same as, Oregon’s, under which 21,246 psilocybin products have been sold as of March, a total that could include secondary doses, according to the Oregon Health Authority.

As of mid-March, Colorado has received applications for at least 15 healing center licenses, nine cultivation licenses, four manufacturer licenses, and one testing facility license for growing and preparing the mushrooms, under rules developed over two years by the governor-appointed Natural Medicine Advisory Board.

Psychedelic treatments in Oregon are expensive, and are likely to be so in Colorado, too, said Tasia Poinsatte, Colorado director of the nonprofit Healing Advocacy Fund, which supports state-regulated programs for psychedelic therapy. In Oregon, psychedelic mushroom sessions are typically $1,000 to $3,000, are not covered by insurance, and must be paid for up front.

The mushrooms themselves are not expensive, Poinsatte said, but a facilitator’s time and support services are costly, and there are state fees. In Colorado, for doses over 2 milligrams, facilitators will screen participants at least 24 hours in advance, then supervise the session in which the participant consumes and experiences mushrooms, lasting several hours, plus a later meeting to integrate the experience.

Facilitators, who may not have experience with mental health emergencies, need training in screening, informed consent, and postsession monitoring, Smith said. “Because these models are new, we need to gather data from Colorado and Oregon to ensure safety.”

Facilitators generally pay a$420 training fee, which allows them to pursue the necessary consultation hours, and roughly $900 a year for a license, and healing centers pay $3,000 to $6,000 for initial licenses in Colorado. But the up-front cost for facilitators is significant: The required 150 hours in a state-accredited program and 80 hours of hands-on training can cost $10,000 or more, and Clark said she wouldn’t pursue a facilitator license due to the prohibitive time and cost.

To increase affordability for patients in Colorado, Poinsatte said, healing centers plan to offer sliding-scale pay options, and discounts for veterans, Medicaid enrollees, and those with low incomes. Group sessions are another option to lower costs.

Colorado law does not allow retail sales of psilocybin, unlike cannabis, which can be sold both recreationally and medically in the state. But it allows adults 21 and older to grow, use, and share psychedelic mushrooms for personal use.

Despite the retail ban, adjacent businesses have mushroomed. Inside the warehouse and laboratory of Activated Brands in Arvada, brown bags of sterilized grains such as corn, millet, and sorghum and plastic bags of soil substrate are for sale, along with genetic materials and ready-to-grow kits.

Co-founder Sean Winfield sells these supplies for growing psychedelic or functional mushrooms such as lion’s mane to people hoping to grow their own at home. Soon, Activated Brands will host cultivation and education classes for the public, Winfield said.

Winfield and co-founder Shawn Cox recently hosted a psychedelic potluck at which experts studying and cultivating psychedelic mushrooms discussed genetics, extraction, and specialized equipment.

Psychedelic mushrooms have a long history in Indigenous cultures, and provisions for their use in spiritual, cultural, or religious ceremonies are included in Colorado law, along with recognition of the cultural harm that could occur to federally recognized tribes and Indigenous people if natural medicine is overly commercialized or exploited.

Several studies over the past five years have shown the long-term benefits of psilocybin for treatment-resistant major depressive disorder, and the Food and Drug Administration designated it a breakthrough therapy. Late-stage trials, often a precursor to application for FDA approval, are underway.

Smith said psilocybin is a promising tool for treating mental health disorders but has not yet been shown to be better than other advanced treatments. Joshua Woolley, an associate professor of psychiatry and behavioral sciences at the University of California-San Francisco, said he has seen the benefits of psilocybin as an investigator in clinical trials.

“People can change hard-set habits. They can become unstuck. They can see things in new ways,” he said of treating patients with a combination of psilocybin and psychotherapy.

Colorado, unlike Oregon, allows integration of psilocybin into existing mental health and medical practices with a clinical facilitator license, and through micro-healing centers that are more limited in the amounts of mushrooms they can store.

Still, Woolley said, between the federal ban and new state laws for psychedelics, this is uncharted territory. Most drugs used to treat mental health disorders are regulated by the FDA, something that Colorado is “taking into its own hands” by setting up its own program to regulate manufacturing and administration of psilocybin.

The U.S. Attorney’s Office for the District of Colorado declined to comment on its policy toward state-regulated psychedelic programs or personal use provisions, but Poinsatte hopes the same federal hands-off approach to marijuana will be taken for psilocybin in Oregon and Colorado.

Winfield said he looks forward to the upcoming rollout and potential addition of other plant psychedelics, such as mescaline. “We’re talking about clandestine industries coming into the light,” he said.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

The Host

Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.

As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.

Among the takeaways from this week’s episode:

• Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
• The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
• The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.

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

Julie Rovner: The Washington Post’s “The Free-Living Bureaucrat,” by Michael Lewis.

Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.

Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.

Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.

Also mentioned in this week’s podcast:

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

SACRAMENTO — A judge has initiated a federal court takeover of California’s troubled prison mental health system by naming the former head of the Federal Bureau of Prisons to serve as receiver, giving her four months to craft a plan to provide adequate care for tens of thousands of prisoners with serious mental illness.

Senior U.S. District Judge Kimberly Mueller issued her order March 19, identifying Colette Peters as the nominated receiver. Peters, who was Oregon’s first female corrections director and known as a reformer, ran the scandal-plagued federal prison system for 30 months until President Donald Trump took office in January. During her tenure, she closed a women’s prison in Dublin, east of Oakland, that had become known as the “rape club.”

Michael Bien, who represents prisoners with mental illness in the long-running prison lawsuit, said Peters is a good choice. Bien said Peters’ time in Oregon and Washington, D.C., showed that she “kind of buys into the fact that there are things we can do better in the American system.”

“We took strong objection to many things that happened under her tenure at the BOP, but I do think that this is a different job and she’s capable of doing it,” said Bien, whose firm also represents women who were housed at the shuttered federal women’s prison.

California corrections officials called Peters “highly qualified” in a statement, while Gov. Gavin Newsom’s office did not immediately comment. Mueller gave the parties until March 28 to show cause why Peters should not be appointed.

Peters is not talking to the media at this time, Bien said. The judge said Peters is to be paid $400,000 a year, prorated for the four-month period.

About 34,000 people incarcerated in California prisons have been diagnosed with serious mental illnesses, representing more than a third of California’s prison population, who face harm because of the state’s noncompliance, Mueller said.

Appointing a receiver is a rare step taken when federal judges feel they have exhausted other options. A receiver took control of Alabama’s correctional system in 1976, and they have otherwise been used to govern prisons and jails only about a dozen times, mostly to combat poor conditions caused by overcrowding. Attorneys representing inmates in Arizona have asked a judge to take over prison health care there.

Mueller’s appointment of a receiver comes nearly 20 years after a different federal judge seized control of California’s prison medical system and installed a receiver, currently J. Clark Kelso, with broad powers to hire, fire, and spend the state’s money.

California officials initially said in August that they would not oppose a receivership for the mental health program provided that the receiver was also Kelso, saying then that federal control “has successfully transformed medical care” in California prisons. But Kelso withdrew from consideration in September, as did two subsequent candidates. Kelso said he could not act “zealously and with fidelity as receiver in both cases.”

Both cases have been running for so long that they are now overseen by a second generation of judges. The original federal judges, in a legal battle that reached the U.S. Supreme Court, more than a decade ago forced California to significantly reduce prison crowding in a bid to improve medical and mental health care for incarcerated people.

State officials in court filings defended their improvements over the decades. Prisoners’ attorneys countered that treatment remains poor, as evidenced in part by the system’s record-high suicide rate, topping 31 suicides per 100,000 prisoners, nearly double that in federal prisons.

“More than a quarter of the 30 class-members who died by suicide in 2023 received inadequate care because of understaffing,” prisoners’ attorneys wrote in January, citing the prison system’s own analysis. One prisoner did not receive mental health appointments for seven months “before he hanged himself with a bedsheet.”

They argued that the November passage of a ballot measure increasing criminal penalties for some drug and theft crimes is likely to increase the prison population and worsen staffing shortages.

California officials argued in January that Mueller isn’t legally justified in appointing a receiver because “progress has been slow at times but it has not stalled.”

Mueller has countered that she had no choice but to appoint an outside professional to run the prisons’ mental health program, given officials’ intransigence even after she held top officials in contempt of court and levied fines topping $110 million in June. Those extreme actions, she said, only triggered more delays.

The 9th U.S. Circuit Court of Appeals on March 19 upheld Mueller’s contempt ruling but said she didn’t sufficiently justify calculating the fines by doubling the state’s monthly salary savings from understaffing prisons. It upheld the fines to the extent that they reflect the state’s actual salary savings but sent the case back to Mueller to justify any higher penalty.

Mueller had been set to begin additional civil contempt proceedings against state officials for their failure to meet two other court requirements: adequately staffing the prison system’s psychiatric inpatient program and improving suicide prevention measures. Those could bring additional fines topping tens of millions of dollars.

But she said her initial contempt order has not had the intended effect of compelling compliance. Mueller wrote as far back as July that additional contempt rulings would also be likely to be ineffective as state officials continued to appeal and seek delays, leading “to even more unending litigation, litigation, litigation.”

She went on to foreshadow her latest order naming a receiver in a preliminary order: “There is one step the court has taken great pains to avoid. But at this point,” Mueller wrote, “the court concludes the only way to achieve full compliance in this action is for the court to appoint its own receiver.”

As Congress mulls potentially massive cuts to federal Medicaid funding, health centers that serve Native American communities, such as the Oneida Community Health Center near Green Bay, Wisconsin, are bracing for catastrophe.

That’s because more than 40% of the about 15,000 patients the center serves are enrolled in Medicaid. Cuts to the program would be detrimental to those patients and the facility, said Debra Danforth, the director of the Oneida Comprehensive Health Division and a citizen of the Oneida Nation.

“It would be a tremendous hit,” she said.

The facility provides a range of services to most of the Oneida Nation’s 17,000 people, including ambulatory care, internal medicine, family practice, and obstetrics. The tribe is one of two in Wisconsin that have an “open-door policy,” Danforth said, which means that the facility is open to members of any federally recognized tribe.

But Danforth and many other tribal health officials say Medicaid cuts would cause service reductions at health facilities that serve Native Americans.

Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls from the Indian Health Service, the federal agency responsible for providing health care to Native Americans.

Medicaid has accounted for about two-thirds of third-party revenue for tribal health providers, creating financial stability and helping facilities pay operational costs. More than a million Native Americans enrolled in Medicaid or the closely related Children’s Health Insurance Program also rely on the insurance to pay for care outside of tribal health facilities without going into significant medical debt. Tribal leaders are calling on Congress to exempt tribes from cuts and are preparing to fight to preserve their access.

“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit policy advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.

Tribes face an arduous task in providing care to a population that experiences severe health disparities, a high incidence of chronic illness, and, at least in western states, a life expectancy of 64 years — the lowest of any demographic group in the U.S. Yet, in recent years, some tribes have expanded access to care for their communities by adding health services and providers, enabled in part by Medicaid reimbursements.

During the last two fiscal years, five urban Indian organizations in Montana saw funding growth of nearly $3 million, said Lisa James, director of development for the Montana Consortium for Urban Indian Health, during a webinar in February organized by the Georgetown University Center for Children and Families and the National Council of Urban Indian Health.

The increased revenue was “instrumental,” James said, allowing clinics in the state to add services that previously had not been available unless referred out for, including behavioral health services. Clinics were also able to expand operating hours and staffing.

Montana’s five urban Indian clinics, in Missoula, Helena, Butte, Great Falls, and Billings, serve 30,000 people, including some who are not Native American or enrolled in a tribe. The clinics provide a wide range of services, including primary care, dental care, disease prevention, health education, and substance use prevention.

James said Medicaid cuts would require Montana’s urban Indian health organizations to cut services and limit their ability to address health disparities.

American Indian and Alaska Native people under age 65 are more likely to be uninsured than white people under 65, but 30% rely on Medicaid compared with 15% of their white counterparts, according to KFF data for 2017 to 2021. More than 40% of American Indian and Alaska Native children are enrolled in Medicaid or CHIP, which provides health insurance to kids whose families are not eligible for Medicaid. KFF is a health information nonprofit that includes KFF Health News, the publisher of California Healthline.

A Georgetown Center for Children and Families report from January found the share of residents enrolled in Medicaid was higher in counties with a significant Native American presence. The proportion on Medicaid in small-town or rural counties that are mostly within tribal statistical areas, tribal subdivisions, reservations, and other Native-designated lands was 28.7%, compared with 22.7% in other small-town or rural counties. About 50% of children in those Native areas were enrolled in Medicaid.

The federal government has already exempted tribes from some of Trump’s executive orders. In late February, Department of Health and Human Services acting general counsel Sean Keveney clarified that tribal health programs would not be affected by an executive order that diversity, equity, and inclusion government programs be terminated, but that the Indian Health Service is expected to discontinue diversity and inclusion hiring efforts established under an Obama-era rule.

HHS Secretary Robert F. Kennedy Jr. also rescinded the layoffs of more than 900 IHS employees in February just hours after they’d received termination notices. During Kennedy’s Senate confirmation hearings, he said he would appoint a Native American as an assistant HHS secretary. The National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for tribes, in December endorsed elevating the director of the Indian Health Service to assistant secretary of HHS.

Jessica Schubel, a senior health care official in Joe Biden’s White House, said exemptions won’t be enough.

“Just because Native Americans are exempt doesn’t mean that they won’t feel the impact of cuts that are made throughout the rest of the program,” she said.

State leaders are also calling for federal Medicaid spending to be spared because cuts to the program would shift costs onto their budgets. Without sustained federal funding, which can cover more than 70% of costs, state lawmakers face decisions such as whether to change eligibility requirements to slim Medicaid rolls, which could cause some Native Americans to lose their health coverage.

Tribal leaders noted that state governments do not have the same responsibility to them as the federal government, yet they face large variations in how they interact with Medicaid depending on their state programs.

President Donald Trump has made seemingly conflicting statements about Medicaid cuts, saying in an interview on Fox News in February that Medicaid and Medicare wouldn’t be touched. In a social media post the same week, Trump expressed strong support for a House budget resolution that would likely require Medicaid cuts.

The budget proposal, which the House approved in late February, requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid and Medicare, is instructed to slash $880 billion over the next decade. The possibility of cuts to the program that, together with CHIP, provides insurance to 79 million people has drawn opposition from national and state organizations.

The federal government reimburses IHS and tribal health facilities 100% of billed costs for American Indian and Alaska Native patients, shielding state budgets from the costs.

Because Medicaid is already a stopgap fix for Native American health programs, tribal leaders said it won’t be a matter of replacing the money but operating with less.

“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.

Congress isn’t required to consult tribes during the budget process, Davis added. Only after changes are made by the Centers for Medicare & Medicaid Services and state agencies are tribes able to engage with them on implementation.

The amount the federal government spends funding the Native American health system is a much smaller portion of its budget than Medicaid. The IHS projected billing Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.

“We are saving more lives,” Malerba said of the additional services Medicaid covers in tribal health care. “It brings us closer to a level of 21st century care that we should all have access to but don’t always.”

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

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

The Trump administration’s crackdown on DEI programs could exacerbate an unexpectedly steep drop in diversity among medical school students, even in states like California, where public universities have been navigating bans on affirmative action for decades. Education and health experts warn that, ultimately, this could harm patient care.

Since taking office, President Donald Trump has issued a handful of executive orders aimed at terminating all diversity, equity, and inclusion, or DEI, initiatives in federally funded programs. And in his March 4 address to Congress, he described the Supreme Court’s 2023 decision banning the consideration of race in college and university admissions as “brave and very powerful.”

Last month, the Education Department’s Office for Civil Rights — which lost about 50% of its staff in mid-March — directed schools, including postsecondary institutions, to end race-based programs or risk losing federal funding. The “Dear Colleague” letter cited the Supreme Court’s decision.

Paulette Granberry Russell, president and CEO of the National Association of Diversity Officers in Higher Education, said that “every utterance of ‘diversity’ is now being viewed as a violation or considered unlawful or illegal.” Her organization filed a lawsuit challenging Trump’s anti-DEI executive orders.

While California and eight other states — Arizona, Florida, Idaho, Michigan, Nebraska, New Hampshire, Oklahoma, and Washington — had already implemented bans of varying degrees on race-based admissions policies well before the Supreme Court decision, schools bolstered diversity in their ranks with equity initiatives such as targeted scholarships, trainings, and recruitment programs.

But the court’s decision and the subsequent state-level backlash — 29 states have since introduced bills to curb diversity initiatives, according to data published by the Chronicle of Higher Education — have tamped down these efforts and led to the recent declines in diversity numbers, education experts said.

After the Supreme Court’s ruling, the numbers of Black and Hispanic medical school enrollees fell by double-digit percentages in the 2024-25 school year compared with the previous year, according to the Association of American Medical Colleges. Black enrollees declined 11.6%, while the number of new students of Hispanic origin fell 10.8%. The decline in enrollment of American Indian or Alaska Native students was even more dramatic, at 22.1%. New Native Hawaiian or other Pacific Islander enrollment declined 4.3%.

“We knew this would happen,” said Norma Poll-Hunter, AAMC’s senior director of workforce diversity. “But it was double digits — much larger than what we anticipated.”

The fear among educators is the numbers will decline even more under the new administration.

At the end of February, the Education Department launched an online portal encouraging people to “report illegal discriminatory practices at institutions of learning,” stating that students should have “learning free of divisive ideologies and indoctrination.” The agency later issued a “Frequently Asked Questions” document about its new policies, clarifying that it was acceptable to observe events like Black History Month but warning schools that they “must consider whether any school programming discourages members of all races from attending.”

“It definitely has a chilling effect,” Poll-Hunter said. “There is a lot of fear that could cause institutions to limit their efforts.”

Numerous requests for comment from medical schools about the impact of the anti-DEI actions went unreturned. University presidents are staying mum on the issue to protect their institutions, according to reporting from The New York Times.

Utibe Essien, a physician and UCLA assistant professor, said he has heard from some students who fear they won’t be considered for admission under the new policies. Essien, who co-authored a study on the effect of affirmative action bans on medical schools, also said students are worried medical schools will not be as supportive toward students of color as in the past.

“Both of these fears have the risk of limiting the options of schools folks apply to and potentially those who consider medicine as an option at all,” Essien said, adding that the “lawsuits around equity policies and just the climate of anti-diversity have brought institutions to this place where they feel uncomfortable.”

In early February, the Pacific Legal Foundation filed a lawsuit against the University of California-San Francisco’s Benioff Children’s Hospital Oakland over an internship program designed to introduce “underrepresented minority high school students to health professions.”

Attorney Andrew Quinio filed the suit, which argues that its plaintiff, a white teenager, was not accepted to the program after disclosing in an interview that she identified as white.

“From a legal standpoint, the issue that comes about from all this is: How do you choose diversity without running afoul of the Constitution?” Quinio said. “For those who want diversity as a goal, it cannot be a goal that is achieved with discrimination.”

UC Health spokesperson Heather Harper declined to comment on the suit on behalf of the hospital system.

Another lawsuit filed in February accuses the University of California of favoring Black and Latino students over Asian American and white applicants in its undergraduate admissions. Specifically, the complaint states that UC officials pushed campuses to use a “holistic” approach to admissions and “move away from objective criteria towards more subjective assessments of the overall appeal of individual candidates.”

The scrutiny of that approach to admissions could threaten diversity at the UC-Davis School of Medicine, which for years has employed a “race-neutral, holistic admissions model” that reportedly tripled enrollment of Black, Latino, and Native American students.

“How do you define diversity? Does it now include the way we consider how someone’s lived experience may be influenced by how they grew up? The type of school, the income of their family? All of those are diversity,” said Granberry Russell, of the National Association of Diversity Officers in Higher Education. “What might they view as an unlawful proxy for diversity equity and inclusion? That’s what we’re confronted with.”

California Attorney General Rob Bonta, a Democrat, recently joined other state attorneys general to issue guidance urging that schools continue their DEI programs despite the federal messaging, saying that legal precedent allows for the activities. California is also among several states suing the administration over its deep cuts to the Education Department.

If the recent decline in diversity among newly enrolled students holds or gets worse, it could have long-term consequences for patient care, academic experts said, pointing toward the vast racial disparities in health outcomes in the U.S., particularly for Black people.

A higher proportion of Black primary care doctors is associated with longer life expectancy and lower mortality rates among Black people, according to a 2023 study published by the JAMA Network.

Physicians of color are also more likely to build their careers in medically underserved communities, studies have shown, which is increasingly important as the AAMC projects a shortage of up to 40,400 primary care doctors by 2036.

“The physician shortage persists, and it’s dire in rural communities,” Poll-Hunter said. “We know that diversity efforts are really about improving access for everyone. More diversity leads to greater access to care — everyone is benefiting from it.”