Category: Rehab News

In April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist window of her OB-GYN’s office when she was asked to pay $960, the total the office estimated she would owe after she delivered.

Clark, 39, was shocked that she was asked to pay that amount during this second prenatal visit. Normally, patients receive the bill after insurance has paid its part, and for pregnant women that’s usually only when the pregnancy ends. It would be months before the office filed the claim with her health insurer.

Clark said she felt stuck. The Cleveland, Tennessee, obstetrics practice was affiliated with a birthing center where she wanted to deliver. Plus, she and her husband had been wanting to have a baby for a long time. And Clark was emotional, because just weeks earlier her mother had died.

“You’re standing there at the window, and there’s people all around, and you’re trying to be really nice,” recalled Clark, through tears. “So, I paid it.”

On online baby message boards and other social media forums, pregnant women say they are being asked by their providers to pay out-of-pocket fees earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers argue that asking for payment up front ensures they get compensated for their services.

How frequently this happens is hard to track because it is considered a private transaction between the provider and the patient. Therefore, the payments are not recorded in insurance claims data and are not studied by researchers.

Patients, medical billing experts, and patient advocates say the billing practice causes unexpected anxiety at a time of already heightened stress and financial pressure. Estimates can sometimes be higher than what a patient might ultimately owe and force people to fight for refunds if they miscarry or the amount paid was higher than the final bill.

Up-front payments also create hurdles for women who may want to switch providers if they are unhappy with their care. In some cases, they may cause women to forgo prenatal care altogether, especially in places where few other maternity care options exist.

It’s “holding their treatment hostage,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

Medical billing and women’s health experts believe OB-GYN offices adopted the practice to manage the high cost of maternity care and the way it is billed for in the U.S.

When a pregnancy ends, OB-GYNs typically file a single insurance claim for routine prenatal care, labor, delivery, and, often, postpartum care. That practice of bundling all maternity care into one billing code began three decades ago, said Lisa Satterfield, senior director of health and payment policy at the American College of Obstetricians and Gynecologists. But such bundled billing has become outdated, she said.

Previously, pregnant patients had been subject to copayments for each prenatal visit, which might lead them to skip crucial appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. Plus, it’s become more common for pregnant women to switch providers, or have different providers handle prenatal care, labor, and delivery — especially in rural areas where patient transfers are common.

Some providers say prepayments allow them to spread out one-time payments over the course of the pregnancy to ensure that they are compensated for the care they do provide, even if they don’t ultimately deliver the baby.

“You have people who, unfortunately, are not getting paid for the work that they do,” said Pamela Boatner, who works as a midwife in a Georgia hospital.

While she believes women should receive pregnancy care regardless of their ability to pay, she also understands that some providers want to make sure their bill isn’t ignored after the baby is delivered. New parents might be overloaded with hospital bills and the costs of caring for a new child, and they may lack income if a parent isn’t working, Boatner said.

In the U.S., having a baby can be expensive. People who obtain health insurance through large employers pay an average of nearly $3,000 out-of-pocket for pregnancy, childbirth, and postpartum care, according to the Peterson-KFF Health System Tracker. In addition, many people are opting for high-deductible health insurance plans, leaving them to shoulder a larger share of the costs. Of the 100 million U.S. people with health care debt, 12% attribute at least some of it to maternity care, according to a 2022 KFF poll.

Families need time to save money for the high costs of pregnancy, childbirth, and child care, especially if they lack paid maternity leave, said Joy Burkhard, CEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to prepay “is another gut punch,” she said. “What if you don’t have the money? Do you put it on credit cards and hope your credit card goes through?”

Calculating the final costs of childbirth depends on multiple factors, such as the timing of the pregnancy, plan benefits, and health complications, said Erin Duffy, a health policy researcher at the University of Southern California’s Schaeffer Center for Health Policy and Economics. The final bill for the patient is unclear until a health plan decides how much of the claim it will cover, she said.

But sometimes the option to wait for the insurer is taken away.

During Jamie Daw’s first pregnancy in 2020, her OB-GYN accepted her refusal to pay in advance because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private midwifery practice in New York told her that since she had a high-deductible plan, it was mandatory to pay $2,000 spread out with monthly payments.

Daw, a health policy researcher at Columbia University, delivered in September 2023 and got a refund check that November for $640 to cover the difference between the estimate and the final bill.

“I study health insurance,” she said. “But, as most of us know, it’s so complicated when you’re really living it.”

While the Affordable Care Act requires insurers to cover some prenatal services, it doesn’t prohibit providers from sending their final bill to patients early. It would be a challenge politically and practically for state and federal governments to attempt to regulate the timing of the payment request, said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobbying groups are powerful and contracts between insurers and medical providers are proprietary.

Because of the legal gray area, Lacy Marshall, an insurance broker at Rapha Health and Life in Texas, advises clients to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring payment up front.

If the insurer says they can refuse to pay up front, Marshall said, she tells clients to get established with a practice before declining to pay, so that the provider can’t refuse treatment.

Clark said she met her insurance deductible after paying for genetic testing, extra ultrasounds, and other services out of her health care flexible spending account. Then she called her OB-GYN’s office and asked for a refund.

“I got my spine back,” said Clark, who had previously worked at a health insurer and a medical office. She got an initial check for about half the $960 she originally paid.

In August, Clark was sent to the hospital after her blood pressure spiked. A high-risk pregnancy specialist — not her original OB-GYN practice — delivered her son, Peter, prematurely via emergency cesarean section at 30 weeks.

It was only after she resolved most of the bills from the delivery that she received the rest of her refund from the other OB-GYN practice.

This final check came in October, just days after Clark brought Peter home from the hospital, and after multiple calls to the office. She said it all added stress to an already stressful period.

“Why am I having to pay the price as a patient?” she said. “I’m just trying to have a baby.”

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

Come January, Republicans will control the House of Representatives, Senate, and White House, regaining full power for the first time since 2018. That will give them significant clout to dramatically change health policy. But slim margins in Congress will leave little room for dissent.

Meanwhile, President-elect Donald Trump has vowed not to touch Medicare, though there are Medicare-related issues — including drug price negotiations and physician pay — that will soon demand attention.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Rachel Roubein of The Washington Post, and Lauren Weber of The Washington Post.

Among the takeaways from this week’s episode:

• Republicans will control the House and the Senate beginning next year, potentially offering Trump crucial votes in support of his nominees and agenda. However, the party will govern with only a narrow majority in both chambers, which could hamper its ability to make sweeping or controversial changes. Regardless, the GOP will steer legislative efforts, such as setting government spending levels and limits, and control committees that decide what to prioritize and oversee.
• Trump this week named several people he intends to nominate to his Cabinet. Yet many of his picks lack relevant experience or have staked out controversial policy positions — or both — raising the question: Can they clear the Senate confirmation process? Trump has suggested using recess appointments to get around that, a method that would largely bypass the Senate and limit his Cabinet secretaries’ authority.
• Meanwhile, among the issues on Robert F. Kennedy Jr.’s health agenda are some that resonate with Democrats, such as cracking down on ultra-processed foods and food dyes. Notably, those sorts of initiatives — which could tighten rules for businesses, for instance — have not been part of the traditional conservative playbook.
• And, looking ahead, there’s a lot the Trump administration could do to further erode abortion rights, and the GOP is likely to see this as a moment for trying things.

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

Julie Rovner: KFF Health News’ “In Vermont, Where Almost Everyone Has Insurance, Many Can’t Find or Afford Care,” by Phil Galewitz.

Anna Edney: The Atlantic’s “Throw Out Your Black Plastic Spatula,” by Zoë Schlanger.

Rachel Roubein: Politico’s “‘Been a Long Time Since I Felt That Way’: Sexually Transmitted Infection Numbers Provide New Hope,” by Alice Miranda Ollstein.

Lauren Weber: JAMA Network Open’s “Medical Board Discipline of Physicians for Spreading Medical Misinformation,” by Richard S. Saver.

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. 

Many scientists at the federal health agencies await the second Donald Trump administration with dread as well as uncertainty over how the president-elect will reconcile starkly different philosophies among the leaders of his team.

Trump has promised he would allow Robert F. Kennedy Jr. to “go wild” on medicines, food, and health. With that, a radical antiestablishment medical movement with roots in past centuries could threaten the achievements of a science-based public health order painstakingly built since World War II, some of these scientists fear.

If Kennedy makes good on his vision for transforming public health, childhood vaccine mandates could wither. New vaccines might never win approval, even as the FDA allows dangerous or inefficient therapies onto the market. Agency websites could trumpet unproven or debunked health ideas. And if Trump’s plan to weaken civil service rights goes through, anyone who questions these decisions could be summarily fired.

“Never has anybody like RFK Jr. gotten anywhere close to the position he may be in to actually shape policy,” said Lewis Grossman, a law professor at American University and the author of “Choose Your Medicine,” a history of U.S. public health.

Kennedy and entrepreneur Calley Means say dramatic changes are needed because of the high levels of chronic disease in the United States. Government agencies have corruptly tolerated or promoted unhealthy diets and dangerous drugs and vaccines, they say.

Means and Kennedy did not respond to requests for comment. Four conservative members of the first Trump health bureaucracy spoke on condition of anonymity. They eagerly welcomed the former president’s return but voiced few opinions about specific policies. Days after last week’s election, RFK Jr. announced that the Trump administration would immediately fire and replace 600 National Institutes of Health officials. He set up a website seeking crowdsourced nominees for federal appointments, with a host of vaccination foes and chiropractors among the early favorites.

At meetings last week at Mar-a-Lago involving Elon Musk, Tucker Carlson, Donald Trump Jr., Kennedy, and Means, according to Politico, some candidates for leading health posts included Jay Bhattacharya, a Stanford University scientist who opposed covid lockdowns; Florida Surgeon General Joseph Ladapo, who opposes mRNA covid vaccines and rejected well-established disease control practices during a measles outbreak; Johns Hopkins University surgeon Marty Makary; and Means’ sister, health guru Casey Means.

All are mavericks of a sort, though their ideas are not uniform. Yet the notion that they could elbow aside a century of science-based health policy is profoundly troubling to many health professionals. They see Kennedy’s presence at the heart of the Trump transition as a triumph of the “medical freedom” movement, which arose in opposition to the Progressive Era idea that experts should guide health care policy and practices.

It could represent a turning away from the expectation that mainstream doctors be respected for their specialized knowledge, said Howard Markel, an emeritus professor of pediatrics and history at the University of Michigan, who began his clinical career treating AIDS patients and ended it after suffering a yearlong bout of long covid.

“We’ve gone back to the idea of ‘every man his own doctor,’” he said, referring to a phrase that gained currency in the 19th century. It was a bad idea then and it’s even worse now, he said.

“What does that do to the morale of scientists?” Markel asked. The public health agencies, largely a post-WWII legacy, are “remarkable institutions, but you can screw up these systems, not just by defunding them but by deflating the true patriots who work in them.”

FDA Commissioner Robert Califf told a conference on Nov. 12 that he worried about mass firings at the FDA. “I’m biased, but I feel like the FDA is sort of at peak performance right now,” he said. At a conference the next day, CDC Director Mandy Cohen reminded listeners of the horrors of vaccine-preventable diseases like measles and polio. “I don’t want to have to see us go backward in order to remind ourselves that vaccines work,” she said.

Exodus From the Agencies?

With uncertainty over the direction of their agencies, many older scientists at the NIH, FDA, and Centers for Disease Control and Prevention are considering retirement, said a senior NIH scientist who spoke on the condition of anonymity for fear of losing his job.

“Everybody I talk to sort of takes a deep breath and says, ‘It doesn’t look good,’” the official said.

“I hear of many people getting CVs ready,” said Arthur Caplan, a professor of bioethics at New York University. They include two of his former students who now work at the FDA, Caplan said.

Others, such as Georges Benjamin, executive director of the American Public Health Association, have voiced wait-and-see attitudes. “We worked with the Trump administration last time. There were times things worked reasonably well,” he said, “and times when things were chaotic, particularly during covid.” Any wholesale deregulation efforts in public health would be politically risky for Trump, he said, because when administrations “screw things up, people get sick and die.”

At the FDA, at least, “it’s very hard to make seismic changes,” former FDA chief counsel Dan Troy said.

But the administration could score easy libertarian-tinged wins by, for example, telling its new FDA chief to reverse the agency’s refusal to approve the psychedelic drug MDMA from the company Lykos. Access to psychedelics to treat post-traumatic stress disorder has grabbed the interest of many veterans. Vitamins and supplements, already only lightly regulated, will probably get even more of a free pass from the next Trump FDA.

‘Medical Freedom’ or ‘Nanny State‘

Trump’s health influencers are not monolithic. Analysts see potential clashes among Kennedy, Musk, and more traditional GOP voices. Casey Means, a “holistic” MD at the center of Kennedy’s “Make America Healthy Again” team, calls for the government to cut ties with industry and remove sugar, processed food, and toxic substances from American diets. Republicans lampooned such policies as exemplifying a “nanny state” when Mike Bloomberg promoted them as mayor of New York City.

Both the libertarian and “medical freedom” wings oppose aspects of regulation, but Silicon Valley biotech supporters of Trump, like Samuel Hammond of the Foundation for American Innovation, have pressed the agency to speed drug and device approvals, while Kennedy’s team says the FDA and other agencies have been “captured” by industry, resulting in dangerous and unnecessary drugs, vaccines, and devices on the market.

Kennedy and Casey Means want to end industry user fees that pay for drug and device rules and support nearly half the FDA’s $7.2 billion budget. It’s unclear whether Congress would make up the shortfall at a time when Trump and Musk have vowed to slash government programs. User fees are set by laws Congress passes every five years, most recently in 2022.

The industry supports the user-fee system, which bolsters FDA staffing and speeds product approvals. Writing new rules “requires an enormous amount of time, effort, energy, and collaboration” by FDA staff, Troy said. Policy changes made through informal “guidance” alone are not binding, he added.

Kennedy and the Means siblings have suggested overhauling agricultural policies so that they incentivize the cultivation of organic vegetables instead of industrial corn and soy, but “I don’t think they’ll be very influential in that area,” Caplan said. “Big Ag is a powerful entrenched industry, and they aren’t interested in changing.”

“There’s a fine line between the libertarian impulse of the ‘medical freedom’ types and advocating a reformation of American bodies, which is definitely ‘nanny state’ territory,” said historian Robert Johnston of the University of Illinois-Chicago.

Specific federal agencies are likely to face major changes. Republicans want to trim the NIH’s 27 research institutes and centers to 15, slashing Anthony Fauci’s legacy by splitting the National Institute of Allergy and Infectious Diseases, which he led for 38 years, into two or three pieces.

Numerous past attempts to slim down the NIH have failed in the face of campaigns by patients, researchers, and doctors. GOP lawmakers have advocated substantial cuts to the CDC budget in recent years, including an end to funding gun violence, climate change, and health equity research. If carried out, Project 2025, a policy blueprint from the conservative Heritage Foundation, would divide the agency into data-collecting and health-promoting arms. The CDC has limited clout in Washington, although former CDC directors and public health officials are defending its value.

“It would be surprising if CDC wasn’t on the radar” for potential change, said Anne Schuchat, a former principal deputy director of the agency, who retired in 2021.

The CDC’s workforce is “very employable” and might start to look for other work if “their area of focus is going to be either cut or changed,” she said.

Kennedy’s attacks on HHS and its agencies as corrupted tools of the drug industry, and his demands that the FDA allow access to scientifically controversial drugs, are closely reminiscent of the 1970s campaign by conservative champions of Laetrile, a dangerous and ineffective apricot-pit derivative touted as a cancer treatment. Just as Kennedy championed off-patent drugs like ivermectin and hydroxychloroquine to treat covid, Laetrile’s defenders claimed that the FDA and a profit-seeking industry were conspiring to suppress a cheaper alternative.

The public and industry have often been skeptical of health regulatory agencies over the decades, Grossman said. The agencies succeed best when they are called in to fix things — particularly after bad medicine kills or damages children, he said.

The 1902 Biologics Control Act, which created the NIH’s forerunner, was enacted in response to smallpox vaccine contamination that killed at least nine children in Camden, New Jersey. Child poisonings linked to the antifreeze solvent for a sulfa drug prompted the modern FDA’s creation in 1938. The agency, in 1962, acquired the power to demand evidence of safety and efficacy before the marketing of drugs after the thalidomide disaster, in which children of pregnant women taking the anti-nausea drug were born with terribly malformed limbs.

If vaccination rates plummet and measles and whooping cough outbreaks proliferate, babies could die or suffer brain damage. “It won’t be harmless for the administration to broadly attack public health,” said Alfredo Morabia, a professor of epidemiology at Columbia University and the editor-in-chief of the American Journal of Public Health. “It would be like taking away your house insurance.”

Sam Whitehead, Stephanie Armour, and David Hilzenrath contributed to this report.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.

If you bring a baby into the Hurley Children’s Center clinic in downtown Flint, Michigan, Mona Hanna will find you. The pediatrician, who gained national prominence for helping uncover the city’s water crisis in 2015, strode across the waiting room in her white lab coat, eyes laser-focused on the chubby baby in the lap of an unsuspecting parent.

“Hi! I’m Dr. Mona!” she said warmly. “Any chance you guys live in Flint?” She learned the family is from neighboring Grand Blanc.

“That’s so sad!” Hanna said. “You should move to Flint! And have another baby! And you could be part of the Rx Kids program!” The parents chuckled politely. But the doctor was not kidding.

Billed as the first-ever citywide cash aid program for pregnant moms and babies, Rx Kids gives Flint residents $1,500 mid-pregnancy, and $500 each month for the baby’s first year. There are no strings attached. No income limits. And it’s universal; nearly every baby born since the program launched in January is enrolled.

Parents who bring their babies in for checkups at this clinic rattle off the ways the money has helped, from the cribs, diapers, clothes, and wipes they’ve bought to how it’s “kept them afloat” during maternity leave or provided crucial income when a spouse died.

But the true goal of Rx Kids goes far beyond Flint, as Hanna acknowledged, scooping up one of the Rx Kids babies in an exam room. “Do you think we should do this for babies everywhere? What do you think?” she asked, cooing. The baby gurgled happily, smiling. “That was an affirmative yes.”

Cash Payments as a Tool To Reduce Child Poverty

Many other countries, including Austria, Belgium, Canada, France, Germany, Ireland, Norway, Sweden, and the United Kingdom, already offer a child cash benefit. The U.S. essentially did, too, during the coronavirus pandemic: The 2021 expanded child tax credit gave low- and middle-income families (including those previously excluded because of insufficient income) hundreds of dollars per kid in direct, monthly payments for six months.

The child poverty rate fell to a historic low. But the expanded program expired at the end of 2021 and Congress did not renew it. The child poverty rate went back up.

For Luke Shaefer, director of the Poverty Solutions initiative at the University of Michigan’s Ford School of Public Policy and a longtime advocate of child cash benefits, it was “the most brutal day” of his career.

Soon after, he got an email from Hanna asking if he wanted to collaborate on the program that would become Rx Kids. The program’s goals go beyond cash aid for Michigan families: It is also aimed at getting donors, lawmakers, and voters excited about how child cash benefits could help their communities.

The list of the recently converted includes Republican state Sen. John Damoose, who has become an outspoken advocate for expanding Rx Kids. Referring to himself as “a pro-life person,” Damoose said, “I sure as heck better be concerned about making it easier for mothers to make the decision to have their children.” He said the Republican Party needs to get serious about supporting programs like Rx Kids. “We’ve been accused for years about being pro-birth, not pro-life. And I think that’s not without merit. We need to put our money where our mouth is and support these children and support their mothers.”

Already, what once seemed like a moon shot is gaining traction: Shaefer and Hanna say their communications with Vice President Kamala Harris’ presidential campaign helped shape Harris’ “baby bonus” proposal. President-elect Donald Trump’s campaign also supported expanding the child tax credit.

Meanwhile, Michigan has budgeted some $20 million in state Temporary Assistance for Needy Families cash to partially fund an expansion of Rx Kids to a short list of communities, if those areas can raise local matching funds. Those areas include rural communities like Michigan’s remote eastern Upper Peninsula, part of which is in Damoose’s district. “We want to make the tent as big as possible,” Hanna said.

But some Upper Peninsula health officials were initially wary. Each new Rx Kids community will need to raise millions of dollars in private donations to start and sustain the program in their community. “It could be a good thing,” Leann Espinoza, maternal-infant health program manager for the eastern Upper Peninsula, said in August. “But I’m not getting my hopes up. I know that sounds terrible.”

Upper Peninsula Families ‘Fall Through the Cracks’

In the wood-paneled rec room of the Clark Township Community Center, Espinoza broke the news to her team this summer: Rx Kids is not a program the eastern Upper Peninsula will be able to fund on its own.

It’s about “$3 million that we would need to raise,” she said, looking at three other LMAS District Health Department staff members.

Tonya Winberg, the public health nurse for Mackinac County, looked stunned. “It’s just, where does that $3 million come from?” Winberg asked. Other potential Rx Kids expansion sites, like Kalamazoo, have wealthy private foundations that can fund the program. The eastern Upper Peninsula does not.

“And how do we sustain it?” Espinoza added. “We hate to start programs, and then the funding is gone and we have to tell people, ‘It’s not here anymore; we can’t do it anymore.’”

The ruggedly beautiful and densely forested Upper Peninsula is used to feeling forgotten. There’s a running joke about how often it’s mislabeled as Canada or Wisconsin on maps. It has about a third of Michigan’s land mass, but just 3% of its residents. The sheer scale and sparse population mean options for food, housing, and child care are limited. Poverty rates are higher than the state average in much of Espinoza’s territory, and the region has some of the highest rates of newborns suffering from prebirth drug exposure in the state, according to the state health department.

At the community center, Espinoza and her colleagues start listing all the ways Rx Kids would be a lifesaver for families in the Upper Peninsula, many of whom have some income and some resources but “don’t make enough to make it,” Espinoza said. “The fall-through-the-cracks families. And those are the ones that I really, really, really think this program would benefit, especially up here.”

Espinoza’s next meeting was with one of those families. Jessica Kline and her 18-month-old daughter, Aurora, live in Munising, a tourist town on Lake Superior. “She’s got a big personality, and her hair is red, so she came with a warning label,” Kline said of her daughter, laughing.

Aurora is a tiny force, speeding around the family’s apartment, unfazed by the nasal tube that connects her to an oxygen machine. She was born early, at just 24 weeks gestation, weighing less than 2 pounds. No hospital in the Upper Peninsula was equipped to care for a preemie that young. So Aurora and her parents spent seven months at a hospital in Ann Arbor, five hours south of their home. “We didn’t have a reliable vehicle,” Kline said. “We didn’t have a source of income.” Hospital social services provided $19 a day for food, which Kline would save up to buy supplies for Aurora.

When they finally got Aurora home to the Upper Peninsula, their house had been vandalized, the copper pipes stripped out. Espinoza’s team helped them find housing, and drove them to get groceries. Every day is a series of small battles, from finding the medical supplies Aurora needs to figuring out how to get to a revolving door of specialists hundreds of miles away. Still, Aurora’s dad has a job in town. They’ve got family nearby. They’re making it work, Kline said.

But having a program like Rx Kids could have made a huge difference in her daughter’s first year. “Five hundred dollars a month would have been enough to actually be able to get ourselves on our feet,” she said.

After Espinoza left Kline’s apartment, she drove south to her office in Manistique. It was late. Everyone else had gone home. Espinoza sat at her desk, trying to be pragmatic. She knows Rx Kids would not magically solve the lack of child care and housing and all the other things you need to break the cycle of poverty. But it would fix Kline’s car. It would help.

There will undoubtedly be critics, Espinoza said — people who believe parents will just use this money to buy drugs. “‘What did they do to earn it?’” she imagined them saying. “‘You’re just giving them free money, and they didn’t do anything to get it?’ Because they don’t understand. They don’t understand the barriers. They don’t understand that sometimes the choice isn’t always yours. Like, I’ve talked to moms who desperately want to go to work, and they want to support their family, but there’s no child care. And so they have no other choice.”

Espinoza recently got an update from Rx Kids’ Hanna: Largely because of private foundations outside the Upper Peninsula, the program has raised enough money to fund a “perinatal” version of Rx Kids for five counties in the eastern Upper Peninsula. The perinatal program would provide the $1,500 payment mid-pregnancy, plus $500 a month for a baby’s first three months, rather than the full year. “But the goal really is the full program, so we are still raising money,” Hanna said via email.

“I think it’s fantastic if we even just get the perinatal version to start,” Espinoza said. “That’s more than we had before.”

This article is from a partnership that includes Michigan Public, 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. 

SACRAMENTO — California public health officials are dipping into state and federal stockpiles to equip up to 10,000 farmworkers with masks, gloves, goggles, and other safety gear as the state confirms at least 21 human cases of bird flu as of early November. It’s the latest reminder of the state’s struggle to remain prepared amid multibillion-dollar deficits.

Officials said they began distributing more than 2 million pieces of personal protective equipment in late May, four months before the first human case was confirmed in the state. They said they began ramping up coordination with local health officials in April after bird flu was first detected in cattle in the U.S. Bird flu has now been confirmed at more than 270 dairies in central California, and traces were recently detected at a wastewater sampling site in Los Angeles County. Bird flu was also recently detected in a flock of commercial turkeys in Sacramento County.

California is putting a number of lessons from the covid-19 pandemic to use, such as coordinating emergency response with local health officials and tracking infectious diseases through wastewater surveillance, as the state tries to limit the spread of bird flu to humans. It’s striving to maintain an adequate emergency stockpile to withstand the first wave of any new public health disaster without hemorrhaging the state budget.

“We are far better prepared to respond to a pandemic than we were in 2020,” said Amy Palmer, a spokesperson for the Governor’s Office of Emergency Services.

For instance, before the coronavirus struck in 2020, the state’s emergency supplies stockpile was barely big enough to crowd two basketball courts.

By the time California ramped up its pandemic response, it had enough personal protective equipment and other disaster supplies to fill 52 football fields. California spent $15.6 billion on direct pandemic response during the covid crisis years, much of it provided by the federal government.

Today, the stockpile fits into about 12½ football fields, though it can seesaw from month to month.

According to the state, the current stockpile includes 101 million face masks, 26 million more than the 90-day supply recommended by the state’s pandemic preparedness guideline.

That includes 88 million N95 masks, more than the emergency services agency said was needed last year. The high-efficiency masks are considered crucial to protect against airborne viruses such as covid-19.

Although the state is building up its stockpile, Palmer could not say if the additional masks are related to fears of bird flu, only that planners are always working “to keep pace with the current risk environment.”

The state’s goal, Palmer said, is to have “an initial supply during emergencies to allow us the time to secure resources,” whether through the federal government or by buying more.

There is no indication of spread between humans in the recent California bird flu cases, and health officials say public risk remains low. Human transmission of bird flu is among several worst-case scenarios for a new pandemic, alongside the possibility of a resurgent mutant coronavirus; wider international spread of mpox, Marburg virus, or Ebola; or an entirely new virus for which there initially is no immunity or vaccine.

Yet, health officials nationwide have struggled to track bird flu transmission. And California has a history of swinging back and forth on preparedness.

Republican Gov. Arnold Schwarzenegger ordered an increase in California’s pandemic preparedness in 2006 in response to an earlier threat from bird flu. That included three mobile hospitals that could immediately be deployed during disasters.

Gov. Jerry Brown, a Democrat, ended the program in 2011 as state finances went bust. By the time covid struck, the state released 21 million N95 masks, some so old they were past their expiration date.

Now hospitals are required to maintain their own three-month supply of masks, gowns, and other personal protective equipment under a state law passed in 2020. California’s aerosol transmissible disease standard also uniquely requires hospitals and other high-risk workplaces to follow precautions such as using negative pressure isolation rooms and the highest level of protective equipment until more is known about a new pathogen.

“It is difficult to overstate the level of unpreparedness exhibited by hospitals both in and outside of California in dealing with the 2020 outbreak of COVID-19,” according to a legislative analysis. “Harrowing images of nurses walking the corridors of hospitals in makeshift masks and garbage bags became commonplace.”

California Hospital Association spokesperson Jan Emerson-Shea said hospitals “continuously prepare to respond to all types of disasters, including outbreaks of transmissible viruses.”

In addition, Palmer said California has five mobile hospitals acquired from the federal government, though they got little use during the pandemic. She said they have to be maintained, such as making sure pulse oximeters have working batteries.

But, once again, the current deficit has the state trying to strike a balance.

While lawmakers rejected most of Democratic Gov. Gavin Newsom’s $300 million proposed cut to public health funding, the state slashed funding for its stockpile of personal protective equipment by one-third a year ago after it determined that no additional covid-related purchases were necessary, according to the Department of Finance. California eliminated funding this year for eight 53-foot-long trailers that would have moved stockpiled items between warehouses. It’s also cutting nearly $40 million over the next four years from its $175 million disaster stockpile budget.

The state’s preparedness wasn’t good enough for Californians Against Pandemics, which gathered more than 1 million signatures to put a ballot measure before voters in November. The measure would have increased taxes on people with incomes over $5 million and used that money for pandemic prevention and response.

But that effort collapsed after one of its key financial supporters, former cryptocurrency executive Sam Bankman-Fried, was convicted of defrauding customers and investors. In exchange for initiative backers dropping the measure, state officials agreed to broaden the scope of the California Initiative to Advance Precision Medicine, which was created in 2015 to focus on developing new medicines and therapies, to include technologies for preventing another pandemic.

“By harnessing the power of precision medicine, California is moving to the forefront of pandemic preparedness and prevention,” Newsom said at the time.

Rodger Butler, a spokesperson for the state Health and Human Services Agency, said it’s unclear if the precision medicine initiative will receive additional funding.