Category: From California Healthline.org

Juana Valle never imagined she’d be scared to drink water from her tap or eat fresh eggs and walnuts when she bought her 5-acre farm in San Juan Bautista, California, three years ago. Escaping city life and growing her own food was a dream come true for the 52-year-old.

Then Valle began to suspect water from her well was making her sick.

“Even if everything is organic, it doesn’t matter, if the water underground is not clean,” Valle said.

This year, researchers found worrisome levels of chemicals called PFAS in her well water. Exposure to PFAS, a group of thousands of compounds, has been linked to health problems including cancer, decreased response to vaccines, and low birth weight, according to a federally funded report by the National Academies of Sciences, Engineering, and Medicine. Valle worries that eating food from her farm and drinking the water, found also to contain arsenic, are to blame for health issues she’s experienced recently.

The researchers suspect the toxic chemicals could have made their way into Valle’s water through nearby agricultural operations, which may have used PFAS-laced fertilizers made from dried sludge from wastewater treatment plants, or pesticides found to contain the compounds.

The chemicals have unexpectedly turned up in well water in rural farmland far from known contamination sites, like industrial areas, airports, and military bases. Agricultural communities already face the dangers of heavy metals and nitrates contaminating their tap water. Now researchers worry that PFAS could further harm farmworkers and communities of color disproportionately. They have called for more testing.

“It seems like it’s an even more widespread problem than we realized,” said Clare Pace, a researcher at the University of California-Berkeley who is examining possible exposure from PFAS-contaminated pesticides.

Stubborn Sludge

Concerns are mounting nationwide about PFAS contamination transferred through the common practice of spreading solid waste from sewage treatment across farm fields. Officials in Maine outlawed spreading “biosolids,” as some sewage byproducts are called, on farms and other land in 2022. A study published in August found higher levels of PFAS in the blood of people in Maine who drank water from wells next to farms where biosolids were spread.

Contamination in sewage mostly comes from industrial discharges. But household sludge also contains PFAS because the chemicals are prevalent in personal care products and other commonly used items, said Sarah Alexander, executive director of the Maine Organic Farmers and Gardeners Association.

“We found that farms that were spread with sludge in the ’80s are still contaminated today,” Alexander said.

The first PFAS, or perfluoroalkyl and polyfluoroalkyl substances, were invented in the 1940s to prevent stains and sticking in household products. Today, PFAS chemicals are used in anything from cookware to cosmetics to some types of firefighting foam — ending up in landfills and wastewater treatment plants. Known as “forever chemicals” because they don’t break down in the environment, PFAS are so toxic that in water they are measured in parts per trillion, equivalent to one drop in 20 Olympic-size swimming pools. The chemicals accumulate in the human body.

On Valle’s farm, her well water has PFAS concentrations eight times as high as the safety threshold the Environmental Protection Agency set this year for the PFAS chemical referred to as PFOS. It’s unclear whether the new drinking water standards, which are in a five-year implementation phase, will be enforced by the incoming Trump administration.

Valle’s well is one of 20 sites tested in California’s San Joaquin Valley and Central Coast regions — 10 private domestic wells and 10 public water systems — in the first round of preliminary sampling by UC-Berkeley researchers and the Community Water Center, a clean-water nonprofit. They’re planning community meetings to discuss the findings with residents when the results are finalized. Valle’s results showed 96 parts per trillion of total PFAS in her water, including 32 ppt of PFOS — both considered potentially hazardous amounts.

Hailey Shingler, who was part of the team that conducted the water sampling, said the sites’ proximity to farmland suggests agricultural operations could be a contamination source, or that the chemicals have become ubiquitous in the environment.

The EPA requires public water systems serving at least 3,300 people to test for 29 types of PFAS. But private wells are unregulated and particularly vulnerable to contamination from groundwater because they tend to be shallower and construction quality varies, Shingler said.

A Strain on the Water Supply

California already faces a drinking water crisis that disproportionately hits farmworkers and communities of color. More than 825,000 people spanning almost 400 water systems across the state don’t have access to clean or reliable drinking water because of contamination from nitrates, heavy metals, and pesticides.

California’s Central Valley is one of the nation’s biggest agricultural producers. State data shows the EPA found PFAS contamination above the new safety threshold in public drinking water supplies in some cities there: Fresno, Lathrop, Manteca, and others.

Not long after she moved, Valle started feeling sick. Joints in her legs hurt, and there was a burning sensation. Medical tests revealed her blood had high levels of heavy metals, especially arsenic, she said. She plans to get herself tested for PFAS soon, too.

“So I stopped eating [or drinking] anything from the farm,” Valle said, “and a week later my numbers went down.”

After that, she got a water filter installed for her house, but the system doesn’t remove PFAS, so she and her family continue to drink bottled water, she said.

In recent years, the pesticide industry has increased its use of PFAS for both active and “inert” ingredients, said David Andrews, a senior scientist of the Environmental Working Group, who analyzed pesticide ingredient registrations submitted to the EPA over the past decade as part of a recently published study.

“PFAS not only endanger agricultural workers and communities,” Andrews said, “but also jeopardize downstream water sources, where pesticide runoff can contaminate drinking supplies.”

California’s most concentrated pesticide use is along the Central Coast, where Valle lives, and in the Central Valley, said Pace, whose research found that possible PFAS contamination from pesticides disproportionately affects communities of color.

“Our results indicate racial and ethnic disparities in potential PFAS threats to community water systems, thus raising environmental justice concerns,” the paper states.

Spotty Solutions

Some treatment plants and public water systems have installed filtration systems to catch PFAS, but that can cost millions or even billions of dollars. California Gov. Gavin Newsom, a Democrat, signed laws restricting PFAS in textiles, food packaging, and cosmetics, a move the wastewater treatment industry hopes will address the problem at the source.

Yet the state, like the EPA, does not regulate PFAS in the solid waste generated by sewage treatment plants, though it does require monitoring.

In the past, biosolids were routinely sent to landfills alongside being spread on land. But in 2016, California lawmakers passed a regulation that requested operators to lower their organic waste disposal by 75% by 2025 to reduce methane emissions. That squeeze pushed facilities to repurpose more of their wastewater treatment byproducts as fertilizer, compost, and soil topper on farm fields, forests, and other sites.

Greg Kester, director of renewable resource programs at the California Association of Sanitation Agencies, said there are benefits to using biosolids as fertilizer, including improved soil health, increased crop yields, reduced irrigation needs, and carbon sequestration. “We have to look at the risk of not applying [it on farmland] as well,” he said.

Almost two-thirds of the 776,000 dry metric tons of biosolids California used or disposed of last year was spread this way, most of it hauled from wealthy, populated regions like Los Angeles County and the Bay Area to the Central Valley or out of state.

When asked if California would consider banning biosolids from agricultural use, Wendy Linck, a senior engineering geologist at California’s State Water Resources Control Board, said: “I don’t think that is in the future.”

Average PFAS concentrations found in California’s sampling of biosolids for PFAS collected by wastewater treatment plants are relatively low compared with more industrialized states like Maine, said Rashi Gupta, wastewater practice director at consulting firm Carollo Engineers.

Still, according to monitoring done in 2020 and 2022, San Francisco’s two wastewater treatment facilities produced biosolid samples with total PFAS levels of more than 150 parts per billion.

Starting in 2019, the water board began testing wells — and finding high levels of PFAS — near known sites of contamination, like airports, landfills, and industry.

The agency is now testing roughly 4,000 wells statewide, including those far from known contamination sources — free of charge in disadvantaged communities, according to Dan Newton, assistant deputy director at the state water board’s division of drinking water. The effort will take about two years.

Solano County — home to large pastures about an hour northeast of San Francisco — tested soil where biosolids had been applied to its fields, most of which came from the Bay Area. In preliminary results, consultants found PFAS at every location, including places where biosolids had historically not been applied. In recent years, landowners expressed reservations about the county’s biosolids program, and in 2024 no farms participated in the practice, said Trey Strickland, manager of the environmental health services division.

“It was probably a ‘not in my backyard’ kind of thing,” Strickland said. “Spread the poop somewhere else, away from us.”

Los Angeles County, meanwhile, hauls much of its biosolids to Kern County or out of state. Green Acres, a farm near Bakersfield and owned by the city of Los Angeles, has applied as much as 80,000 dry tons of biosolids annually, fertilizing crops for animal feed like corn and wheat. Concerned about the environmental and health implications, for more than a decade Kern County fought the practice until the legal battle ended in 2017. At the time, Dean Florez, a former state senator, told the Los Angeles Times that “it’s been a David and Goliath battle from Day One.”

“We probably won’t know the effects of this for many years,” he added. “We do know one thing: If it was healthy and OK, L.A. would do it in L.A. County.”

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. 

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A federal judge in North Dakota has ruled in favor of 19 states that challenged a Biden administration rule allowing — for the first time — enrollment in Affordable Care Act coverage by people brought to the U.S. as children without immigration paperwork, known as “Dreamers.”

The move effectively bars those who have qualified for the Deferred Action for Childhood Arrivals program in those 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case said Tuesday.

The Biden administration is likely to appeal, although a Centers for Medicare & Medicaid Services representative said in an email that the agency would not comment on the litigation.

While an appeal may be filed quickly, a final decision may not occur before the incoming Trump administration takes office. “They could take a different position on the litigation,” said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute Health Care Litigation Tracker.

In the meantime, it is not clear what will happen to Dreamer enrollees in the 19 states whose coverage has already started or begins early next year, although the judge’s ruling does not say it is retroactive, Baron noted.

The case was filed in August in U.S. District Court for the District of North Dakota.

Previously, the federal government estimated that about 100,000 uninsured people out of the half-million DACA recipients might sign up starting Nov. 1, the sign-up season start date in all states except Idaho.

The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purposes of enrolling in plans under the ACA, which are open to American citizens and what are called “lawfully present” immigrants.

In granting a preliminary injunction and stay, U.S District Judge Daniel Traynor, who was appointed in 2019 by then-President Donald Trump, noted in his Monday ruling that the plaintiffs were likely to win on the merits of their argument.

States challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. In addition to Kansas and North Dakota, the states that joined the lawsuit are Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Ohio, South Carolina, South Dakota, Tennessee, Texas, and Virginia.

“Judge Traynor’s ruling is both disappointing and wrong on the law,” said Nicholas Espíritu, a deputy legal director of the National Immigration Law Center, in an emailed statement. “While we study the court’s ruling to evaluate the next steps in this case, we will continue to fight on behalf of our clients and hundreds of thousands of DACA recipients who have been waiting over a decade to access life-sustaining care under the Affordable Care Act.”

DACA was established through executive action in June 2012 by President Barack Obama, protecting from deportation and providing work authorization to some unauthorized residents brought to the U.S. as children by their families. It had certain requirements, including that they arrived before June 2007 and had completed high school, were attending school, or were serving in the military.

Before the injunction, 19 other states and the District of Columbia filed a brief in support of the Biden administration rule. Led by New Jersey, those states include many in the East and West, including California, Colorado, Nevada, New Mexico, New York, Oregon, and Washington.

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. 

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Un juez federal en Dakota del Norte falló a favor de 19 estados que impugnaron una regla de la administración Biden que permite —por primera vez— que las personas traídas a Estados Unidos de niños, sin papeles, conocidas como Dreamers, se inscribieran para obtener cobertura de salud a través de los mercados establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

La decisión prohíbe a los beneficiarios del programa de Acción Diferida para los Llegados en la Infancia (DACA) en esos 19 estados inscribirse o recibir subsidios para pagar los planes de ACA.

Abogados que siguen el caso dijeron que este fallo no parece afectar la inscripción ni la cobertura en otros estados.

La administración Biden probablemente apelará, aunque un representante de los Centros de Servicios de Medicare y Medicaid (CMS,) la entidad federal que coordina estos mercados, dijo por correo electrónico que la agencia no comentará sobre el litigio.

Aunque se podría presentar una apelación rápidamente, una decisión final podría no ocurrir antes de que comience la próxima administración Trump. “Podrían tomar una posición diferente sobre el litigio”, dijo Zachary Baron, experto legal de Georgetown Law, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Mientras tanto, no está claro qué sucederá con los Dreamers inscritos en los 19 estados cuya cobertura ya comenzó o comienza a principios del próximo año, aunque la decisión del juez no menciona que sea retroactiva, señaló Baron.

El caso fue presentado en agosto en el Tribunal de Distrito de los EE.UU. para el Distrito de Dakota del Norte.

Anteriormente, el gobierno federal estimó que alrededor de 100.000 personas sin seguro, de medio millón de beneficiarios de DACA, podrían inscribirse a partir del 1 de noviembre, la fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

La regla de la administración Biden, finalizada en mayo, aclaró que quienes califican para DACA serían considerados como “presentes legalmente” en el país a los propósitos de inscripción en planes de salud de ACA, que están disponibles para ciudadanos estadounidenses e inmigrantes denominados “presentes legalmente”.

Al otorgar una orden judicial preliminar y una suspensión, el juez federal Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, señaló en su fallo del lunes 9 de diciembre que es probable que los demandantes ganaran gracias a los méritos de su argumento.

Los estados que impugnan la regla de ACA argumentan que causará cargas administrativas y de recursos al aumentar el número de inscritos y que alentará a más personas a permanecer en el país sin documentos legales.

Además de Kansas y Dakota del Norte, los estados que se unieron a la demanda son Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Ohio, Carolina del Sur, Dakota del Sur, Tennessee, Texas y Virginia.

“El fallo del juez Traynor es tanto decepcionante como erróneo en cuanto a la ley”, dijo Nicholas Espíritu, subdirector legal del Centro Nacional de Leyes de Inmigración, en un comunicado por correo electrónico.

“Mientras estudiamos la decisión del tribunal para evaluar los próximos pasos en este caso, continuaremos luchando en nombre de nuestros clientes y cientos de miles de beneficiarios de DACA que han esperado más de una década para acceder a atención vital bajo la Ley de Cuidado de Salud a Bajo Precio”.

DACA fue establecido mediante acción ejecutiva en junio de 2012 por el presidente Barack Obama, protegiendo de la deportación y proporcionando permiso de trabajo a algunos residentes no autorizados traídos al país de niños. Debían cumplir con ciertos requisites para calificar: haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o servir en el ejército.

Antes de la orden judicial, otros 19 estados y el Distrito de Columbia presentaron un informe en apoyo de la regla de la administración Biden. Liderados por Nueva Jersey, esos estados incluyen muchos en el Este y Oeste del país, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

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“The future is here,” the email announced. Hilda Jaffe, then 88, was letting her children know she planned to sell the family home in Verona, New Jersey. She’d decided to begin life anew — on her own — in a one-bedroom apartment in Hell’s Kitchen in Manhattan.

Fourteen years later, Jaffe, now 102, still lives alone — just a few blocks away from the frenetic flashing lights and crowds that course through Times Square.

She’s the rarest of seniors: a centenarian who is sharp as a tack, who carries grocery bags in each hand when she walks back from her local market, and who takes city buses to see her physicians or attend a matinee at the Metropolitan Opera.

Jaffe cleans her own house, does her own laundry, manages her own finances, and stays in touch with a far-flung network of family and friends via email, WhatsApp, and Zoom. Her son, Richard Jaffe, 78, lives in San Jose, California. Her daughter, Barbara Vendriger, 75, lives in Tel Aviv.

She’s an extraordinary example of an older adult living by herself and thriving.

I’ve spoken with dozens of seniors this past year for a series of columns on older Americans living alone. Many struggle with health issues. Many are isolated and vulnerable. But a noteworthy slice of this growing group of seniors maintain a high degree of well-being.

What might account for this, particularly among people in the farthest reaches of old age?

Sofiya Milman is director of Human Longevity Studies at the Institute for Aging Research at Albert Einstein College of Medicine. She studies people known as “superagers” —95 and older. “As a group, they have a very positive outlook on life” and are notably resilient, like Jaffe, she told me.

Qualities associated with resilience in older adults include optimism and hopefulness, an ability to adapt to changing circumstances, meaningful relationships, community connections, and physical activity, according to a growing body of research on this topic.

Jaffe has those qualities in spades, along with a “can-do” attitude.

“I never expected to be 102. I’m as surprised as everybody else that I am here,” she said recently over lunch at a Chinese restaurant just steps from her 30-story apartment building.

Jaffe’s perspective on her longevity is unsentimental. She credits her genetic heritage, luck, and her commitment to “keep moving,” in that order. “You don’t work toward it: It happens. Every day, you get up and you’re a day older,” she said.

This matter-of-fact stance is characteristic of Jaffe’s approach to life. Asked to describe herself, she quickly responded “pragmatic.” That means having a clear-eyed view of what she can and can’t do and making adjustments as necessary.

Living alone suits her, she added, because she likes being independent and doing things her way. “If a problem comes up, I work it out,” Jaffe said. 

In this, she’s like other older adults who have come to terms with their “I’m on my own” status and, for the most part, are doing quite well. 

Still, Jaffe is unusual, to say the least. There are only 101,000 centenarians in the U.S., according to the most recent Census Bureau data. Of this small group, 15% live independently or operate independently while living with someone, according to Thomas Perls, the founder and director of the New England Centenarian Study, the largest study of centenarians in the world. (Jaffe is one of 2,500 centenarians participating in the study.)

About 20% of centenarians are, like Jaffe, free of physical or cognitive impairments, Perls said. An additional 15% have no age-related illnesses such as arthritis or heart disease.

Practically, that means Jaffe doesn’t know anybody like her. Nor do her physicians. “My primary care doctor says, ‘You’re the only centenarian who walks in without an assistant or a cane. You’re off the charts,’” Jaffe said, when I asked about her health.

She has only a few medical conditions — reflux, an occasional irregular heartbeat, osteoporosis, a touch of sciatica, a lung nodule that appeared and then disappeared. She monitors those conditions vigilantly, following her doctors’ advice to the letter.

Every day, Jaffe tries to walk 3,000 steps — outside if the weather is good or inside, making laps in her hallway, if the weather is bad. Her diet is simple: bread, cheese, and decaffeinated coffee for breakfast; a sandwich or eggs for lunch; often chicken and a vegetable or restaurant leftovers for dinner. She never smoked, doesn’t drink alcohol, and sleeps an average of eight hours each night.

Even more important, Jaffe remains engaged with other people. She has subscriptions to the Metropolitan Opera, the New York Philharmonic, and a chamber music series. She participates in online events and regularly sees new exhibits at four of New York’s premier museums, where she has memberships. She’s in regular contact with family members and friends.

Jaffe also belongs to a book club at her synagogue on Manhattan’s Upper West Side and serves on the synagogue’s adult education committee. For more than a decade, she’s volunteered several times a week as a docent at the New York Public Library’s main branch on Fifth Avenue.

“Loneliness, it’s not an issue,” she said. “I have enough to do within my capability.”

On a recent Tuesday afternoon, I followed Jaffe as she led visitors from Mexico, England, Pittsburgh, and New Jersey through the library’s “Treasures” exhibit. She was a wealth of information about extraordinary objects such as a Gutenberg Bible from 1455 (one of the first books printed in Europe using movable type), Charles Dickens’ writing desk, and an enormous folio of John James Audubon’s “The Birds of America.” She spoke without notes, articulately.

When I asked about the future, Jaffe said she doesn’t worry about what comes next. She just lives day to day.

That change in perspective is common in later life. “Focusing on the present and experiencing the here and now becomes more important to older adults,” said Laura Carstensen, founding director of Stanford University’s Center on Longevity, who has studied emotional changes that accompany aging for decades. “As does savoring positive things in their lives.”

Carstensen’s research group was the first to show that older adults were more resilient emotionally during the covid-19 pandemic than young or middle-aged adults. “Older people are better able to cope with difficulties,” she said. In part, this is because of skills and perspective gained over the course of a lifetime. And, in part, it’s because “when we see our future as shorter, it feels more manageable.”

Jaffe certainly understands the value of facing forward and letting go of the past. Losing her husband, Gerald Jaffe, in 2005 after 63 years of marriage was hard, she admitted, but relinquishing her life and most of her belongings in New Jersey five years later was easy.

“It was enough. We had done what we had wanted to do there. I was 88 at that point and so many people were gone. The world had changed,” she told me. “I didn’t feel a sense of loss.”

“It was so exciting for me, being in New York,” she continued. “Every day you could do something — or nothing. This location couldn’t be better. The building is safe and well maintained, with lots of staff. Everything is here, close by: a market, the pharmacy, restaurants, buses. In a house in New Jersey, I would be isolated. Here, I look out the window and I see people.”

As for the future, who knows what that will hold? “My joke is I’m going to be done in by a bicycle delivery person cutting through the pedestrian crosswalk,” Jaffe said. Until that or something else happens, “I live in a state of surprise. Every day is a new day. I don’t take it for granted at all.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

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. 

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Eloisa Mendoza has spent 18 years helping people who aren’t fluent in English navigate complex legal documents. She guides them through stressful events and accompanying dense paperwork, such as citizenship applications, divorces, and birth certificate translations.

Mendoza works in Elko, Nevada, situated in a remote region in the state’s northeastern corner. Her work has become increasingly important as the town’s Hispanic or Latino population has grown to about 26%. The share of people age 5 or older who speak a language other than English at home increased to 18% as of 2022, while Spanish is the language spoken in nearly 15% of households.

Despite rising demand for local rural governments to communicate with residents in languages other than English, state lawmakers in Nevada left out smaller counties from a recently enacted statewide language-access law. More state and local governments have enacted similar measures during the past few years, but they’re mostly concentrated in urban or suburban jurisdictions.

Rural America is largely white and predominantly English-speaking but has rapidly grown more diverse. Implementing state and local language-access laws, however, is a challenge, researchers say, given standards can vary across state agencies and localities, making it difficult to ensure high-quality assistance is provided to speakers of various non-English languages. Not providing language access to people who need it is not only a violation of civil rights protected by Title VI of the Civil Rights Act, but it also can create public health and safety concerns, said Jake Hofstetter, a policy analyst for the Migration Policy Institute, a think tank focused on immigration policy and research.

While language access is a federal protection, 11 states and Washington, D.C., have created broad policies targeted to their populations. And some states have laws targeting specific sectors, such as education or health care. Other language-access laws have taken root in such municipalities as Austin, Texas; Philadelphia; and Portland, Maine.

At the height of the covid-19 pandemic, state and local governments lacking strong language-access systems struggled to communicate vital public health information to diverse communities. An analysis of covid information posted on health department websites of the 10 most populous U.S. cities found it was not fully provided in Spanish.

The number of white residents in rural parts of the nation decreased by about 2 million from 2010 to 2020, according to an analysis by the Carsey School of Public Policy at the University of New Hampshire. And the percentage of people who are members of a racial or ethnic minority living in rural areas increased from 20% in 2010 to 24% in 2020, with the largest share being Hispanic.

As of 2021, 25 million people age 5 or older in the U.S. had limited English proficiency, of whom nearly two-thirds were Hispanic, according to KFF, a health information nonprofit that includes KFF Health News, the publisher of California Healthline. Nevada is one of nine states where at least 10% of people have limited English proficiency.

According to a 2023 KFF-Los Angeles Times survey of immigrants, about 31% with limited English proficiency said they faced language barriers when trying to access health care. A quarter said they struggled to apply for government financial help with food, housing, or health coverage. And immigrants limited in their ability to speak English were twice as likely to be uninsured as immigrants who were proficient in English, and they had worse health outcomes.

Since the pandemic emergency ended, Hofstetter has seen a significant number of state policies addressing language access, he said, but he doesn’t see many local policies that focus on the issue in rural areas.

Hofstetter said Nevada’s most recent law on language access, approved in 2023, is unique in that it specifically identifies and requires the state’s most populous counties — Clark and Washoe — to create and implement language-access plans. A separate bill, also approved last year, appropriated $25 million to agencies for implementing language access plans.

Democratic state Sen. Edgar Flores, who represents part of Clark County and was a cosponsor on the most recent language-access law, said lawmakers have faced pushback from state agencies for various attempts at strengthening requirements to provide information and documents in languages other than English. He said officials cite limited staffing and funding.

“I think, unfortunately, our rural jurisdictions are already incredibly limited with resources and, at the time of this request, there was a concern that they were not in a position to meet the requirements,” Flores said. “That’s the bottom line.”

He said that while some agencies and jurisdictions had created language-access plans in past years, legislators found they were not always implemented and enforced. For this reason, Flores said, lawmakers decided it would be better to focus on the state’s two largest counties first while they work toward expanding policies to “every ZIP code, every agency.”

“We have folks from all walks of life who have now made Nevada their home,” Flores said. “We have an obligation to them.”

People living in rural areas may still benefit from a patchwork of resources through state agencies that provide services in their counties or local programs that are required to address language access because of federal funding.

But gaps in the framework of federal, state, and local protections exist nationwide, Hofstetter said.

The degree to which local governments offer communications in languages other than English varies for several reasons, including enforcement of civil rights protections. That enforcement relies on civil rights complaints, which often must be filed by residents who may not know their rights related to language access, Hofstetter said.

Community members may also face resistance from local leaders on expanding access to services and information in other languages. In 2018, Mendoza supported offering ballots in Elko County in Spanish as well as English. County commissioners, three of whom are still on the board, unanimously voted to recommend the county clerk delay offering bilingual ballots as long as possible after questioning census demographic data and stating they didn’t have funding to translate the ballots.

Having access to ballots in their preferred language helps voters better understand initiatives affecting them, many of which are health-related, such as a Nov. 5 ballot question that asked voters to weigh in on whether to enshrine a right to abortion within the state’s constitution. The measure passed with 64% of voters in favor and needs to be approved once more in 2026 to be implemented.

The Nevada Legislature convenes again in February, and Flores said he’s certain there will be at least one language-access bill. Hofstetter said he anticipates more state and local policies addressing the issue within the next few years.

“I would imagine that that’s going to include some rural areas,” 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. 

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KINGSPORT, Tenn. — Jerry Qualls had a heart attack in 2022 and was rushed by ambulance to Holston Valley Medical Center, where he was hospitalized for a week and kept alive by a ventilator and blood pump, according to his medical records.

His wife, Katherine Qualls, said his doctors offered little hope. In an interview and a written complaint to the Tennessee government, she said doctors at Holston Valley told her that her husband would not qualify for a heart transplant and shouldn’t be expected to recover.

Defiant, she insisted he be transferred hours away to a hospital in Nashville. Within days of leaving Holston Valley, Jerry Qualls was awake and sitting upright, his wife said, and he ultimately received a lifesaving heart transplant.

“How many families don’t know how to get a transfer and their loved one dies?” Katherine Qualls wrote in her complaint to the state. “My husband would have been dead within a few days if I didn’t get him out when I did.”

Holston Valley Medical Center is a flagship of Ballad Health, a 20-hospital system in northeastern Tennessee and southwestern Virginia that is the only option for hospital care in a large swath of Appalachia. Ballad formed six years ago when lawmakers in both states, in an effort to prevent hospital closures, waived federal antitrust laws so two rival health systems could merge. The merger created the largest state-sanctioned hospital monopoly in the nation.

Since then, Ballad has largely kept those hospitals open. But the monopoly has also fallen short of about three-fourths of the quality-of-care goals set by the states over the last three fiscal years, including failing to meet state benchmarks on infections, mortality, emergency room speed, and patient satisfaction, according to annual reports from the Tennessee Department of Health and Ballad itself.

Some local residents have become wary, afraid, or unwilling to seek care at Ballad hospitals and must drive over an hour to reach other options, according to written complaints to the Tennessee government and state lawmakers, public hearing testimony, and KFF Health News interviews conducted over the past year with patients, family members, local leaders, and some officials who once publicly supported the monopoly, including a former government consultant and one state lawmaker. Many of those who submitted complaints or were interviewed allege that paper-thin staffing at Ballad hospitals and ERs is the root cause of the monopoly’s quality-of-care woes.

In a two-hour interview vigorously defending the company, Ballad Health CEO Alan Levine said the hospitals are rapidly recovering from a quality-of-care slump caused by covid-19 and a subsequent rise in nursing turnover and staff shortages. These issues affected hospitals nationwide, Levine said, and were not related to the Ballad merger or the monopoly it created.

Levine declined to discuss specific complaints from patients. But he said that each of the complaints referenced in this article took issue with medical decisions made by doctors in Ballad hospitals — not “any policy or practice at Ballad.”

“I can understand if the patients, if the wife, was upset about the medical decisions they made if it turned out to be wrong,” Levine said. “But that has nothing to do with the merger, OK? That’s a completely different issue, and it happens in hospitals all over the country.”

In the interview with KFF Health News and in the days that followed, Levine flexed considerable connections to officials in the Tennessee government. As Levine spoke in a boardroom at Ballad’s hilltop headquarters, he was flanked by three local mayors who voiced support for the hospitals and said complaints came from a vocal minority of their constituents. Days later, Levine got two Tennessee state agency directors and a former state health commissioner to provide emails or text messages supporting statements he made during the interview.

Logan Grant, executive director of the Tennessee Health Facilities Commission, which processes complaints against hospitals for the state, said in a statement prompted by Levine that Ballad hospitals are “not an outlier in terms of substantiated survey findings.”

Joe Grandy, the mayor of Tennessee’s Washington County, where Ballad is headquartered, said most residents consider the quality of care in the area “about as good as it gets.”

Brenda Getaz certainly doesn’t.

Getaz, 76, who spent three decades as a hospital official specializing in quality standards before retiring to Washington County, said she plans to move to Atlanta if state governments do not take action to fix Ballad in the coming year. Getaz said local medical professionals she trusts have urged her to move away so she does not have to rely on Ballad for care.

“I’m frightened to be taken to a Ballad facility,” she said.

Glimpses of Government Concern

The Tennessee Department of Health, which has the most direct oversight over Ballad Health, over the past year has declined multiple interview requests to discuss the hospital monopoly. Department emails reviewed by KFF Health News, some of which were obtained through public record requests, offer glimpses of concern inside the agency.

Emails show the health department has attempted to hold Ballad more accountable for its quality of care in closed-door negotiations and is investigating Holston Valley’s treatment of a recent heart patient after receiving detailed complaints from his family. In a 2023 email, Tennessee Health Commissioner Ralph Alvarado reacted to a news story about low job satisfaction among Ballad nurses by writing: “Ouch. … What are they doing to address this?”

In another email from the same year, Alvarado praised an informal report submitted at a public hearing that concluded Ballad’s monopoly had caused more harm than good. The report was written by Wally Hankwitz, a retired health care executive who once led a physician management company in Kingsport. The report levied pages of criticism against Ballad’s “sub-par” performance and called for the monopoly to end.

“THIS communication from the COPA hearing is particularly good,” the health commissioner wrote to some of his staff. “Totally based on data. I would almost like to hear Ballad’s response to this.”

When asked to respond to the Hankwitz report, Levine said it was “full of errors” and that “no credible institution would pay attention to it.”

Despite concerns, Tennessee and Virginia have each year determined that the benefits of the Ballad monopoly outweigh any negative impacts, issuing stamps of approval that allow the monopoly to continue. This has occurred, at least in part, because both states grade Ballad against scoring rubrics that do not prioritize quality of care.

Larry Fitzgerald, a retired Tennessee consultant who monitored the monopoly for the state for more than five years and always gave Ballad high marks, said in an interview that his hands were tied by the state’s lenient grading system, which allowed Ballad to succeed on paper even when it failed to meet the state’s quality-of-care goals.

Fitzgerald said he is unconvinced that the state-sanctioned monopoly had prevented any hospital closures and said the merger had “probably not” benefited local residents overall.

When asked where he would get medical attention if he lived in northeastern Tennessee or southwestern Virginia, Fitzgerald immediately responded, “I’m not going to a Ballad hospital.”

In his interview, Levine alleged Fitzgerald had “basically defrauded the state” by not raising these criticisms of Ballad in his public reports on the monopoly and said it was “irresponsible” and “obscene” to express his concerns about quality of care after retiring.

‘Horror Stories’ From Ballad Patients

Tennessee House member Bud Hulsey, a Republican from Kingsport, wrote in a 2023 letter to the state health department that he “was an avid supporter of the merger” that created Ballad but since then had become “concerned” and “saddened” by the state of the local hospitals.

In a recent interview, Hulsey said that while his family has received excellent care from Ballad, his constituents have told him “horror stories” for years.

“I had people call me from the waiting room after they’ve sat there for 12 or 14 hours,” Hulsey said. “The scales have far more complaints on them than accolades.”

Others have soured on the monopoly, too. Joe Macione, who for years was on the board of Wellmont Health System, one of the rival companies that became Ballad, once publicly advocated for the merger.

In an interview, Macione said state leaders should have admitted years ago that the monopoly was a mistake.

“It has not worked,” said Macione, 87. “All my family knows that, if I have the time, I want to go to a highly graded hospital, either in Asheville or Knoxville.”

Ballad Health was created in 2018 after Tennessee and Virginia officials waived federal anti-monopoly laws and approved the nation’s biggest hospital merger, based on what’s called a Certificate of Public Advantage, or COPA, agreement. Ballad is now the only option for hospital care for most of the approximately 1.1 million people in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina.

In the years since, there have been multiple signs of discontent with and within Ballad hospitals. In 2019, protesters gathered daily for eight months outside Holston Valley to oppose the closure of the neonatal intensive care unit and the downgrading of a trauma center. (Ballad has said the NICU closure was necessary and benefited patients, and a study published this year said the trauma changes saved lives.)

In 2020, Bristol Regional Medical Center CEO Greg Neal resigned after it was discovered he made the initial incision in a heart surgery despite not being a doctor, according to Tennessee state records. (Levine said in his interview that the resignation shows Ballad is holding employees accountable.)

In 2022, 14 cardiologists signed a letter warning of “severe limitations” in the Bristol Regional cardiac catheterization lab that were affecting patient safety and delaying procedures for weeks or months. (Ballad said in a letter to the Tennessee government that it worked with the cardiologists, who it said were partly to blame, to make the lab more efficient.)

In 2023, Ballad Health was ranked last among 200 large health care organizations in an analysis of nurse satisfaction published by an MIT business magazine. (Levine dismissed this analysis as unscientific.) This year, the Federal Trade Commission cited Ballad as a cautionary tale while opposing a similar hospital merger under consideration in Indiana, and a longtime Kingsport doctor took a parting shot at Ballad in his obituary. (Ballad declined to comment on either topic.)

And in August, the widow of a Tennessee sheriff filed a lawsuit alleging that Ballad caused her husband’s death and intentionally understaffed hospitals “to save money.” Brenda Tester, the wife of Johnson County Sheriff Eddie Tester, alleged in that lawsuit that Ballad put her husband on blood thinners and then gave him an unnecessary liver biopsy, causing “life ending internal blood loss” that led to “his cardiac arrest and ultimately his sudden death.”

Ballad has yet to respond to the Tester lawsuit in court. Levine said in his interview that the doctors who treated the sheriff were not employed by Ballad but merely contracted to work in its hospitals.

Some of Ballad’s most determined critics are family members of Anton Maki Jr., a former Holston Valley doctor who returned to the hospital as a patient in February. The family has filed complaints with multiple Tennessee agencies and the federal government and provided emails to KFF Health News showing that Tennessee is investigating Maki’s case.

In an interview and in those complaints, Maki’s family members allege Holston Valley gave Maki improper treatment, even though his symptoms and lab tests made it obvious that he was having a serious heart attack that required urgent attention.

The improper care did “permanent damage” to Maki’s heart, the family’s complaints allege. That damage required him to have a permanent mechanical heart pump surgically implanted at a non-Ballad hospital, said one of his daughters, Alexandra Maki, who is a surgeon in Kentucky. She said her father died after a fall three months later while still in a weakened state.

Alexandra Maki said that her father had been alarmed by the Ballad monopoly for years but that she didn’t fully appreciate his warnings until she witnessed his care at Holston Valley firsthand.

“I filed these complaints because it is my duty as a doctor to report what I saw,” Alexandra Maki said. “That was not care. It is a facade of a hospital. It is a well-oiled death machine.”

KFF Health News reporter Samantha Liss contributed to this article.

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. 

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Veteran California public servant Will Lightbourne has stepped in as interim executive director of the state’s mental health commission after its previous executive director resigned following conflict of interest allegations.

Lightbourne served as head of the state’s Department of Social Services for seven years before retiring in 2018 and had already returned to service once, as interim head of the Department of Health Care Services at the height of the covid-19 pandemic. On Nov. 4, he was tapped to lead the state’s Mental Health Services Oversight and Accountability Commission after executive director Toby Ewing announced he would step down.

Documents obtained by KFF Health News showed that Ewing took a trip to the U.K. funded by Kooth, a London-based company that the state contracted to build a youth mental health app. At the same time, he was working to protect Kooth’s $271 million contract.

During a public hearing the day he announced his resignation, advocates for mental health services accused the commission of favoring the interests of corporations over those of the people it is supposed to serve.

Lightbourne, 75, is now leading the commission, an independent body charged with ensuring that funds from a millionaires tax are used appropriately by counties for mental health services. He said he’ll focus on making the commission as open as possible, as a nationwide search for the next executive director begins.

He comes to the mental health commission at a moment of change. With the passage of the Behavioral Health Services Act last year and its approval by voters this year as part of Proposition 1, the commission will be integrating 11 new members starting in January. And in July 2026, it will stop overseeing county funds for mental health innovation and will instead get its own bucket of up to $20 million a year to spend on innovation. Conversations are already underway about how to spend the funds.

Lightbourne directed social service agencies in Santa Clara, San Francisco, and Santa Cruz counties before being named director of the state social services department, where he launched an effort to move more foster children out of institutions and into family-based settings.

Lightbourne spoke to KFF Health News correspondent Molly Castle Work about his goals for state mental health services. The interview has been edited for length and clarity.

Q: You already came out of retirement once, to lead DHCS during the pandemic. How were you convinced to take this job?

A: Back when I was at DHCS, quite a bit of what is now the sort of health reconceptualization in California happened.

There’s a point where you feel a sense of paternal relationship for a lot of the initiatives. What the commission does in terms of the detailed finish work is really going to be important for this thing to work.

Q: Executive Director Toby Ewing resigned amid accusations of favoritism with the contracts. How can the public have faith that this won’t happen again?

A: I want to be very careful now, because the way you phrase the question implies that I accept the proposition, and I have no way of knowing. What I’ve always said in any setting that I’ve been in is always deal the cards face up. Just be transparent. Be open. When possible, use competitive processes.

There’s the famous three intersecting points of contracting: You can have speed, you can have quality, you can have a good price. Pick two. You can’t have three. And you know, my instinct is always to be a little bit more skeptical of urgency. I mean, there are huge human needs out there that we want to solve, but to say everything should go by the wayside because things have to happen yesterday — let’s take a beat.

Q: As the interim executive director, are there guardrails that you think need to be in place to ensure that taxpayer money is being spent wisely?

A: I don’t know that there’s anything that I am particularly worried about, but I think it’s my role to help the commission as it transitions into Prop 1, into BHSA, and into a permanent executive director — just make sure that they’ve got all the procedures that they think they need — and that we build a culture where we are sure that they are able to fully see things coming in front of them.

It’s going to be interesting that come January we’re going to add 11 commissioners. It’s a huge jump. And doing it in a way that everybody stays engaged — I don’t have an answer yet.

The value-add of this organization is that it’s got a commission of pretty damn committed people who take it very seriously and bring a lot of skill to it. And you wouldn’t want to see that lost.

Q: Our country has seen the mental health crisis spike over the past few years. Are there specific areas you want to focus on?

A: I always want to be a little careful about having one more bright idea. There is definitely initiative fatigue on the ground. People have got that glazed look. So if there are things that the commission can do to bring more resources, more players, more solutions that help, then that’s great. I just don’t want us to be piling on new ideas.

Some of the things the commission has already invested in, and I’m trying to get more familiar with this, like the early psychosis interventions — that could be a real game changer as I understand it.

Q: How do you think funding for mental health initiatives should be prioritized?

A: Certainly the old notion of full-service partnerships is important. It means whatever takes — put a team together, wrap it around the person, address their core needs, like housing.

Don’t think that with somebody sleeping under the bus shelter that you can address their needs while they’re still sitting there, you know? Move them into a setting where they can feel safe, they have dignity, they have their personal human needs met, and also whatever therapeutic needs or medication needs or medically assisted treatment needs.

Q: What are you most looking forward to in this role?

A: Because of where I’ve been previously, I think there are some obvious connections to make. We don’t want to subordinate the commission to the other systems. It’s got to have its own thing. But just knowing who to dance with can be helpful.

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The availability of safe, effective covid vaccines less than a year into the pandemic marked a high point in the 300-year history of vaccination, seemingly heralding an age of protection against infectious diseases.

Now, after backlash against public health interventions culminated in President-elect Donald Trump’s nominating Robert F. Kennedy Jr., the country’s best-known anti-vaccine activist, as its top health official, infectious disease and public health experts and vaccine advocates say a confluence of factors could cause renewed, deadly epidemics of measles, whooping cough, and meningitis, or even polio.

“The litany of things that will start to topple is profound,” said James Hodge, a public health law expert at Arizona State University’s Sandra Day O’Connor College of Law. “We’re going to experience a seminal change in vaccine law and policy.”

“He’ll make America sick again,” said Lawrence Gostin, a professor of public health law at Georgetown University.

State legislators who question vaccine safety are poised to introduce bills to weaken school-entry vaccine requirements or do away with them altogether, said Northe Saunders, who tracks vaccine-related legislation for the SAFE Communities Coalition, a group supporting pro-vaccine legislation and lawmakers.

Even states that keep existing requirements will be vulnerable to decisions made by a Republican-controlled Congress as well as by Kennedy and former House member Dave Weldon, should they be confirmed to lead the Department of Health and Human Services and the Centers for Disease Control and Prevention, respectively.

Both men — Kennedy as an activist, Weldon as a medical doctor and congressman from 1995 to 2009— have endorsed debunked theories blaming vaccines for autism and other chronic diseases. (Weldon has been featured in anti-vaccine films in the years since he left Congress.) Both have accused the CDC of covering up evidence this was so, despite dozens of reputable scientific studies to the contrary.

Kennedy’s staff did not respond to requests for comment. Karoline Leavitt, the Trump campaign’s national press secretary, did not respond to requests for comment or interviews with Kennedy or Weldon.

Kennedy recently told NPR that “we’re not going to take vaccines away from anybody.”

It’s unclear how far the administration would go to discourage vaccination, but if levels drop enough, vaccine-preventable illnesses and deaths might soar.

“It is a fantasy to think we can lower vaccination rates and herd immunity in the U.S. and not suffer recurrence of these diseases,” said Gregory Poland, co-director of the Atria Academy of Science & Medicine. “One in 3,000 kids who gets measles is going to die. There’s no treatment for it. They are going to die.”

During a November 2019 measles epidemic that killed 80 children in Samoa, Kennedy wrote to the country’s prime minister falsely claiming that the measles vaccine was probably causing the deaths. Scott Gottlieb, who was Trump’s first FDA commissioner, said on CNBC on Nov. 29 that Kennedy “will cost lives in this country” if he undercuts vaccination.

Kennedy’s nomination validates and enshrines public mistrust of government health programs, said Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

“The notion that he’d even be considered for that position makes people think he knows what he’s talking about,” Offit said. “He appeals to lessened trust, the idea that ‘There are things you don’t see, data they don’t present, that I’m going to find out so you can really make an informed decision.’”

Targets of Anti-Vaccine Groups

Hodge has compiled a list of 20 actions the administration could take to weaken national vaccination programs, from spreading misinformation to delaying FDA vaccine approvals to dropping Department of Justice support for vaccine laws challenged by groups like Children’s Health Defense, which Kennedy founded and led before campaigning for president.

Kennedy could also cripple the National Vaccine Injury Compensation Program, which Congress created in 1986 to take care of children believed harmed by vaccines — while partially protecting vaccine makers from lawsuits.

Before the law passed, the threat of lawsuits had shrunk the number of companies making vaccines in the United States — from 26 in 1967 to 17 in 1980 — and the remaining pertussis vaccine producers were threatening to stop making it. The vaccine injury program “played an integral role in keeping manufacturers in the business,” Poland said.

Kennedy could abolish the CDC’s Advisory Committee on Immunization Practices, whose recommendation for using a vaccine determines whether the government pays for it through the 30-year-old Vaccines for Children program, which makes free immunizations available to more than half the children in the United States. Alternatively, Kennedy could stack the committee with allies who oppose new vaccines, and could, in theory at least, withdraw recommendations for vaccines like the 53-year-old measles-mumps-rubella shot, a favorite target of the anti-vaccine movement.

Meanwhile, infectious disease threats are on the rise or on the horizon. Instead of preparing, as a typical incoming administration might, Kennedy has threatened to shake up the federal health agencies. Once in office, he’ll “give infectious disease a break” to focus on chronic ailments, he said at a Children’s Health Defense conference last month in Georgia.

The H5N1 virus, or bird flu, that has spread through cattle herds and infected at least 55 people could erupt in a new pandemic, and other threats like mosquito-borne dengue fever are rising in the U.S.

Traditional childhood diseases are also making their presence felt, in part because of neglected vaccination. The U.S. has seen 16 measles outbreaks this year — 89% of cases are in unvaccinated people — and a whooping cough epidemic is the worst since 2012.

“So that’s how we’re starting out,” said Peter Hotez, a pediatrician and virologist at the Baylor College of Medicine. “Then you throw into the mix one of the most outspoken and visible anti-vaccine activists at the head of HHS, and that gives me a lot of concern.”

The share prices of drug companies with big vaccine portfolios have plunged since Kennedy’s nomination. Even before Trump’s victory, vaccine exhaustion and skepticism had driven down demand for newer vaccines like GSK’s RSV and shingles shots.

Kennedy has ample options to slow or stop new vaccine releases or to slow sales of existing vaccines — for example, by requiring additional post-market studies or by highlighting questionable studies that suggest safety risks.

Kennedy, who has embraced conspiracy theories such as that HIV does not cause AIDS and that pesticides cause gender dysphoria, told NPR there are “huge deficits” in vaccine safety research. “We’re going to make sure those scientific studies are done and that people can make informed choices,” he said.

Kennedy’s nomination “bodes ill for the development of new vaccines and the use of currently available vaccines,” said Stanley Plotkin, a vaccine industry consultant and inventor of the rubella vaccine in the 1960s. “Vaccine development requires millions of dollars. Unless there is prospect of profit, commercial companies are not going to do it.”

Vaccine advocates, with less money on hand than the better-funded anti-vaccine advocates, see an uphill battle to defend vaccination in courts, legislatures, and the public square. People are rarely inclined to celebrate the absence of a conquered illness, making vaccines a hard sell even when they are working well.

While many wealthy people, including potion and supplement peddlers, have funded the anti-vaccine movement, “there hasn’t been an appetite from science-friendly people to give that kind of money to our side,” said Karen Ernst, director of Voices for Vaccines.

‘He’s Serious as Hell’

“RFK Jr. was a punch line for a lot of people, but he’s serious as hell,” Ernst said. “He has a lot of power, money, and a vast network of anti-vaccine parents who’ll show up at a moment’s notice.” That’s not been the case with groups like hers, Ernst said.

On Oct. 22, when an Idaho health board voted to stop providing covid vaccines in six counties, there were no vaccine advocates at the meeting. “We didn’t even know it was on the agenda,” Ernst said. “Mobilization on our side is always lagging. But I’m not giving up.”

The kaleidoscopic change has been jarring for Walter Orenstein, who persuaded states to tighten school mandates to fight measles outbreaks as head of the CDC’s immunization division from 1988 to 2004.

“People don’t understand the concept of community protection, and if they do they don’t seem to care,” said Orenstein, who saw some of the last cases of smallpox as a CDC epidemiologist in India in the 1970s, and frequently cared for children with meningitis caused by H. influenzae type B bacteria, a disease that has mostly disappeared because of a vaccine introduced in 1987.

“I was so naïve,” he said. “I thought that covid would solidify acceptance of vaccines, but it was the opposite.”

Lawmakers opposed to vaccines could introduce legislation to remove school-entry requirements in nearly every state, Saunders said. One bill to do this has been introduced in Texas, where what’s known as the vaccine choice movement has been growing since 2015 and took off during the pandemic, fusing with parents’ rights and anti-government groups opposed to measures like mandatory shots and masking.

“The genie is out of the bottle, and you can’t put it back in,” said Rekha Lakshmanan, chief strategy officer at the Immunization Partnership in Texas. “It’s become this multiheaded thing that we’re having to reckon with.”

In the last full school year, more than 100,000 Texas public school students were exempted from one or more vaccinations, she said, and many of the 600,000 homeschooled Texas kids are also thought to be unvaccinated.

In Louisiana, the state surgeon general distributed a form letter to hospitals exempting medical professionals from flu vaccination, claiming the vaccine is unlikely to work and has “real and well established” risks. Research on flu vaccination refutes both claims.

The biggest threat to existing vaccination policies could be plans by the Trump administration to remove civil service protections for federal workers. That jeopardizes workers at federal health agencies whose day-to-day jobs are to prepare for and fight diseases and epidemics. “If you overturn the administrative state, the impact on public health will be long-term and serious,” said Dorit Reiss, a professor at the University of California’s Hastings College of Law.

Billionaire Elon Musk, who has the ear of the incoming president, imagines cost-cutting plans that are also seen as a threat.

“If you damage the core functions of the FDA, it’s like killing the goose that laid the golden egg, both for our health and for the economy,” said Jesse Goodman, the director of the Center on Medical Product Access, Safety and Stewardship at Georgetown University and a former chief science officer at the FDA. “It would be the exact opposite of what Kennedy is saying he wants, which is safe medical products. If we don’t have independent skilled scientists and clinicians at the agency, there’s an increased risk Americans will have unsafe foods and medicine.”

Outbreaks of vaccine-preventable illness could be alarming, but would they be enough to boost vaccination again? Ernst of Voices for Vaccines isn’t sure.

“We’re already having outbreaks. It would take years before enough children died before people said, ‘I guess measles is a bad thing,’” she said. “One kid won’t be enough. The story they’ll tell is, ‘There was something wrong with that kid. It can’t happen to my kid.’”

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. 

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