Category: Rehab News

Every year, a health care think tank called the Lown Institute ranks the 10 worst examples of “profiteering and dysfunction” in health care and “honors” the winners.

The “Shkreli Awards” are a kind of Oscars for the most outrageous examples of greed, fraud, and general brokenness in American health care.

The awards are named after Martin Shkreli, a former pharmaceutical executive who infamously raised the price of Daraprim, a lifesaving treatment for toxoplasmosis, from around $13 a pill to $750. The media dubbed him “the pharma bro,” and he became a symbol of brazen pharmaceutical greed.

In this episode of “An Arm and a Leg,” you’ll hear highlights from this year’s ceremony and reflections from the Lown Institute’s president, Vikas Saini.

“Showing all these stories together paints a picture of a health care system in desperate need of transformation,” Saini said at the event. “Not just because the stories are shocking, but because often what they’re depicting, like Martin Shkreli’s infamous price hike, is perfectly legal.”

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” 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. 

Just a few years ago, children with Type 1 diabetes reported to the school nurse several times a day to get a finger pricked to check whether their blood sugar was dangerously high or low.

The introduction of the continuous glucose monitor (CGM) made that unnecessary. The small device, typically attached to the arm, has a sensor under the skin that sends readings to an app on a phone or other wireless device. The app shows blood sugar levels at a glance and sounds an alarm when they move out of a normal range.

Blood sugar that’s too high could call for a dose of insulin — delivered by injection or the touch of a button on an insulin pump — to stave off potentially life-threatening complications including loss of consciousness, while a sip of juice could remedy blood sugar that’s too low, preventing problems such as dizziness and seizures.

Schools around the country say teachers listen for CGM alarms from students’ phones in the classroom. Yet many parents say that there’s no guarantee a teacher will hear an alarm in a busy classroom and that it falls to them to ensure their child is safe when out of a teacher’s earshot by monitoring the app themselves, though they may not be able to quickly contact their child.

Parents say school nurses or administrative staff should remotely monitor CGM apps, making sure someone is paying attention even when a student is outside the classroom — such as at recess, in a noisy lunchroom, or on a field trip.

But many schools have resisted, citing staff shortages and concerns about internet reliability and technical problems with the devices. About one-third of schools do not have a full-time nurse, according to a 2021 survey by the National Association of School Nurses, though other staffers can be trained to monitor CGMs.

Caring for children with Type 1 diabetes is nothing new for schools. Before CGMs, there was no alarm that signaled a problem; instead, it was caught with a time-consuming finger-prick test, or when the problem had progressed and the child showed symptoms of complications.

With the proliferation of insulin pumps, many kids can respond to problems themselves, reducing the need for schools to provide injections as well.

Parents say they are not asking schools to continuously monitor their child’s readings, but rather to ensure that an adult at the school checks that the child responds appropriately.

“People at the [school] district don’t understand the illness, and they don’t understand the urgency,” said Julie Calidonio of Lutz, Florida.

Calidonio’s son Luke, 12, uses a CGM but has received little support from his school, she said. Relying on school staff to hear the alarms led to instances in which no one was nearby to intervene if his blood sugar dropped to critical levels.

“Why have this technology that is meant to prevent harms, and we are not acting on it,” she said.

Corey Dierdorff, a spokesperson for the Pasco County School District, where Luke attends school, said in a statement to KFF Health News that staff members react when they hear a student’s CGM sound an alert. Asked why the district won’t agree to have staff remotely monitor the alarms, he noted concerns about internet reliability.

In September, Calidonio filed a complaint with the U.S. Justice Department against the district, saying its inability to monitor the devices violates the Americans with Disabilities Act, which requires schools to make accommodations for students with diabetes, among other conditions. She is still awaiting a decision.

The complaint comes about four years after the Connecticut U.S. attorney’s office determined that having school staffers monitor a student’s CGM was a “reasonable accommodation” under the ADA. That determination was made after four students filed complaints against four Connecticut school districts.

“We fought this fight and won this fight,” said Jonathan Chappell, one of two attorneys who filed the complaints in Connecticut. But the decision has yet to affect students outside the state, he said.

Chappell and Bonnie Roswig, an attorney and director of the nonprofit Center for Children’s Advocacy Disability Rights Project, both said they have heard from parents in 40 states having trouble getting their children’s CGMs remotely monitored in school. Parents in 10 states have filed similar complaints, they said.

CGMs today are used by most of the estimated 300,000 people in the U.S. with Type 1 diabetes under age 20, health experts say. Also known as juvenile diabetes, it is an autoimmune disease typically diagnosed in early childhood and treated with daily insulin to help regulate blood sugar. It affects about 1 in 400 people under 20, according to the American Academy of Pediatrics.

(CGMs are also used by those with Type 2 diabetes, a different disease tied to risk factors such as diet and exercise that affects tens of millions of people — including a growing number of children, though it is usually not diagnosed until the early teens. Most people with Type 2 diabetes do not take insulin.)

Students with diabetes or another disease or disability typically have a health care plan, developed by their doctor, that works with a school-approved plan to get the support they need. It details necessary accommodations to attend school, such as allowing a child to eat in class or ensuring staff members are trained to check blood glucose or give a shot of insulin.

For children with Type 1 diabetes, the plan usually includes monitoring CGMs several times a day and responding to alarms, Roswig said.

Lynn Nelson, president-elect of the National Association of School Nurses, said when doctors and parents deem a student needs their CGM remotely monitored, the school is obligated under the ADA to meet that need. “It is legally required and the right thing to do.”

Nelson, who also manages school nurse programs in Washington state, said schools often must balance the students’ needs with having enough administrative staff.

“There are real workforce challenges, but that means schools have to go above and beyond for an individual student,” she said.

Henry Rodriguez, a pediatric endocrinologist at the University of South Florida and a spokesperson for the American Diabetes Association, said remote monitoring can be challenging for schools. While they advocate for giving every child what they need to manage their diabetes at school, he said, schools can be limited by a lack of support staff, including nurses.

The association last year updated its policy around CGMs, stating: “School districts should remove barriers to remote monitoring by school nurses or trained school staff if this is medically necessary for the student.”

In San Diego, Taylor Inman, a pediatric pulmonologist, said her daughter, Ruby, 8, received little help from her public school after being diagnosed with Type 1 diabetes and starting to use a CGM.

She said alerts from Ruby’s phone often went unheard outside the classroom, and she could not always reach someone at the school to make sure Ruby was reacting when her blood sugar levels moved into the abnormal range.

“We kept asking for the school to follow my daughter’s CGM and were told they were not allowed to,” she said.

In a 2020 memo to school nurses that remains in effect, Howard Taras, the San Diego Unified School District’s medical adviser, said if a student’s doctor recommends remote monitoring, it should be done by their parents or doctor’s office staff.

CGM alarms can be “disruptive to the student’s education, to classmates and to staff members with other responsibilities,” Taras wrote.

“Alarms are closely monitored, even those that occur outside of the classroom,” Susan Barndollar, the district’s executive director of nursing and wellness, said in a statement. Trained adults, including teachers and aides, listen for the alarms when in class, at recess, at gym class, or during a field trip, she said.

She said the problem with remote monitoring is that staff in the school office doing the monitoring may not know where the student is to tend to them quickly.

Inman said last year they paid $20,000 for a diabetes support dog trained to detect high or low blood sugar and later transferred Ruby to a private school that remotely tracks her CGM.

“Her blood sugar is better controlled, and she is not scared and stressed anymore and can focus on learning,” she said. “She is happy to go to school and is thriving.”

Some schools have changed their policies. For more than a year, several parents lobbied Loudoun County Public Schools in Northern Virginia to have school nurses follow CGM alerts from their own wireless devices.

The district board approved the change, which took effect in August and affects about 100 of the district’s more than 80,000 students.

Before, Lauren Valentine would get alerts from 8-year-old son Leo’s CGM and call the school he attends in Loudoun County, not knowing if anyone was taking action. Valentine said the school nurse now tracks Leo’s blood sugar from an iPad in the clinic.

“It takes the responsibility off my son and the pressure off the teacher,” she said. “And it gives us peace of mind that the school clinic nurses know what is happening.”

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. 

Hace apenas unos años, los niños con diabetes tipo 1 iban a la enfermería de la escuela varias veces al día para que les pincharan un dedo y ver si su nivel de azúcar en sangre era peligrosamente alto o bajo.

La llegada del monitor continuo de glucosa (MCG) hizo que eso ya no fuera necesario. El pequeño dispositivo, que normalmente se coloca en el brazo, tiene un sensor bajo la piel que envía lecturas a una aplicación en un teléfono u otro dispositivo inalámbrico. La aplicación muestra los niveles de azúcar en sangre en un instante, y emite una alarma cuando están fuera del rango normal.

Un nivel de azúcar en sangre demasiado alto podría requerir una dosis de insulina —con una inyección o solo tocando un botón en una bomba de insulina— para evitar complicaciones potencialmente mortales, como la pérdida del conocimiento. Un sorbo de jugo podría solucionar un nivel muy bajo de azúcar en sangre, previniendo problemas como mareos y convulsiones.

En las escuelas, los maestros están atentos a las alarmas de los MCG de los teléfonos de los alumnos. Sin embargo, muchos dicen que no hay garantía de que un maestro escuche una alarma en un aula ruidosa, y que les corresponde a ellos como padres garantizar la seguridad de sus hijos, supervisando ellos mismos la aplicación, aunque no puedan ponerse en contacto rápidamente.

Los padres dicen que las enfermeras escolares y el personal administrativo deberían supervisar de forma remota las aplicaciones de MCG, asegurándose de que alguien esté atento incluso cuando el estudiante esté fuera del aula, en el recreo, en un comedor ruidoso o en una excursión.

Pero muchas escuelas se han resistido, argumentando escasez de personal y preocupación por la fiabilidad de internet y los problemas técnicos con los dispositivos.

“La gente del distrito [escolar] no entiende la enfermedad, y no entiende la urgencia”, dijo Julie Calidonio, de Lutz, Florida.

El hijo de Calidonio, Luke, de 12 años, usa un MCG, pero ha recibido poco apoyo de su escuela, según la madre: nadie escuchaba la alarma o intervenía si su nivel de azúcar en sangre bajaba a niveles críticos.

“¿Por qué tenemos esta tecnología que está diseñada para prevenir daños y no la utilizamos?”, preguntó.

Corey Dierdorff, vocera del Distrito Escolar del condado de Pasco, donde Luke va a la escuela, dijo a KFF Health News que el personal reacciona cuando escuchan que el MCG de un estudiante emite una alerta. Cuando se le preguntó por qué el distrito no acepta que el personal supervise las alarmas de forma remota, dijo que duda de la eficacia de internet.

En septiembre, Calidonio presentó una denuncia ante el Departamento de Justicia contra el distrito, alegando que su incapacidad para supervisar los dispositivos viola la Ley de Estadounidenses con Discapacidades (ADA), que exige a las escuelas adaptarse para ayudar a los estudiantes que viven con diabetes, entre otras afecciones. Todavía está a la espera de una decisión.

La denuncia ocurrió unos cuatro años después que la fiscalía federal de Connecticut determinara que supervisar el MCG de un alumno en la escuela era una “adaptación razonable” bajo ADA. Esa determinación se tomó después que cuatro estudiantes presentaran denuncias contra cuatro distritos escolares de Connecticut.

“Luchamos y ganamos esta batalla”, dijo Jonathan Chappell, uno de los dos abogados que presentaron las denuncias en Connecticut. Pero la decisión aún no ha impactado en estudiantes en otros estados, agregó.

Chappell y Bonnie Roswig, abogada y directora de la organización sin fines de lucro Center for Children’s Advocacy Disability Rights Project, explicaron que han escuchado de padres en 40 estados que tienen problemas para que las escuelas monitoreen de manera remota los MCG de sus hijos.

Expertos en salud afirman que, en la actualidad, la mayoría de las aproximadamente 300.000 personas menores de 20 años con diabetes tipo 1 en Estados Unidos utilizan MCG. También conocida como diabetes juvenil, es una enfermedad autoinmune que suele diagnosticarse en la primera infancia y que se trata con insulina diaria para ayudar a regular el azúcar en sangre.

(Los MCG también se utilizan en casos de diabetes tipo 2, una afección diferente vinculada a factores de riesgo como la dieta y el ejercicio que afecta a millones de personas, incluyendo un número creciente de niños, aunque por lo general no se diagnostica hasta principios de la adolescencia. La mayoría de las personas con diabetes tipo 2 no utilizan insulina).

Los estudiantes que viven con diabetes, u otra afección o discapacidad, suelen tener un plan de salud desarrollado por su médico, que funciona con otro aprobado por la escuela para tener el apoyo que necesitan. Detalla adaptaciones necesarias, como permitir que un niño coma en el aula o asegurarse que el personal esté capacitado para controlar la glucosa o administrar una inyección de insulina.

Para los niños con diabetes tipo 1, el plan suele incluir monitorear los MCG varias veces al día y responder a las alarmas, indicó Roswig.

Lynn Nelson, presidenta electa de la National Association of School Nurses, dijo que cuando los médicos y los padres consideran que un estudiante necesita que su MCG sea monitoreado de forma remota, la escuela está obligada, bajo ADA, a satisfacer esa necesidad. “Es un requisito legal y es lo correcto”.

Nelson, que también gestiona programas de enfermería escolar en el estado de Washington, señaló que las escuelas a menudo deben equilibrar las necesidades de los estudiantes con la disponibilidad de personal.

“Hay verdaderos desafíos en materia de personal, pero eso significa que las escuelas tienen que hacer todo lo posible, y más, por ayudar a cada estudiante”, afirmó.

Henry Rodríguez, endocrinólogo pediátrico de la Universidad del Sur de Florida y vocero de la American Diabetes Association, dijo que este monitoreo puede ser un reto para las escuelas. Aunque abogan para que cada niño reciba lo que necesita para controlar su diabetes en la escuela, según Rodríguez, las escuelas pueden verse limitadas por la falta de personal de apoyo, incluidas enfermeras.

El año pasado, la asociación actualizó su política sobre los MCG estableciendo que “los distritos escolares deben eliminar las barreras para que las enfermeras escolares o el personal escolar capacitado monitoree los MCG de manera remota, si esto es médicamente necesario para el estudiante”.

En San Diego, Taylor Inman, neumonóloga infantil, dijo que su hija Ruby, de 8 años, recibió poca ayuda de su escuela pública después que le diagnosticaran diabetes tipo 1 y empezara a usar uno de estos dispositivos.

Contó que las alertas del teléfono de Ruby a menudo no se escuchaban fuera del aula, y que no siempre podía comunicarse con alguien para asegurarse de que Ruby reaccionaba cuando sus niveles de azúcar en sangre se volvían anormales.

“Seguimos pidiendo a la escuela que siguiera el MCG de mi hija y nos dijeron que no estaban autorizados a hacerlo”, afirmó.

En un memorando de 2020 enviado a las enfermeras escolares, que sigue vigente, Howard Taras, asesor médico del Distrito Escolar Unificado de San Diego, comunicó que si el médico de un estudiante recomienda el monitoreo remoto, debe hacerlo un padre o personal del consultorio del médico.

Las alarmas del MCG pueden ser “perturbadoras para la educación del estudiante, para los compañeros de clase y para los miembros del personal con otras responsabilidades”, escribió Taras.

Susan Barndollar, directora ejecutiva de enfermería y bienestar del distrito aseguró en un comunicado que el problema con la supervisión remota es que el personal de la oficina de la escuela que la realiza puede no saber dónde está el estudiante para asistirlo rápidamente.

Inman dijo que el año pasado pagaron $20.000 por un perro de apoyo para la diabetes entrenado para detectar niveles altos o bajos de azúcar en sangre y luego transfirieron a Ruby a una escuela privada que rastrea de forma remota su MCG.

“Su nivel de azúcar en sangre está mejor controlado, ya no está asustada ni estresada y puede concentrarse en aprender”, dijo Inman. “Está feliz de ir a la escuela y está progresando mucho”.

Algunas escuelas han cambiado sus políticas. Durante más de un año, varios padres presionaron a las escuelas públicas del condado de Loudoun, en el norte de Virginia, para que las enfermeras escolares siguieran las alertas del MCG desde sus propios dispositivos inalámbricos.

La junta del distrito aprobó el cambio, que entró en vigencia en agosto y afecta a cerca de 100 de los más de 80.000 estudiantes del distrito.

Antes, Lauren Valentine recibía alertas del MCG de su hijo Leo, de 8 años, y llamaba su escuela, en el condado de Loudoun, sin saber si alguien estaba tomando medidas. Valentine dijo que la enfermera del colegio ahora controla el azúcar en sangre de Leo desde un iPad en la clínica.

“Le quita la responsabilidad a mi hijo y la presión al maestro”, afirmó. “Y nos da tranquilidad que las enfermeras de la clínica escolar sepan lo que está pasando”.

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. 

In his return to the White House this week, President Donald Trump issued a flurry of executive orders on immigration, including declaring an emergency at the U.S.-Mexico border, suspending refugee admissions, and calling to roll back birthright citizenship.

His administration rescinded a long-standing policy not to arrest people without legal status at or near sensitive locations, including hospitals. That has left different states offering starkly different guidelines to hospitals, community clinics, and other health facilities for interacting with immigrant patients.

• California is advising health care providers to avoid including patients’ immigration status in bills and medical records and telling them that, while they should not physically obstruct immigration agents, they are under no obligation to assist with an arrest. The guidance from Democratic Attorney General Rob Bonta also encourages facilities to post information about patients’ right to remain silent and provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.”
• Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization. Still, patients can refuse to answer questions about their immigration status without losing access to care.

Some health care providers fear immigration authorities will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. They point to examples from Trump’s first term, when agents arrested a child during an ambulance transfer, a young man leaving the hospital, and a woman waiting for emergency surgery.

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

On Tuesday, Trump directed the U.S. Department of Justice to investigate state and local officials who don’t cooperate with immigration enforcement.

But no matter the guidelines that states issue, hospitals around the U.S. stress one thing: Patients won’t be turned away for care because of their immigration status.

“None of this changes the care patients receive,” said Carrie Williams, a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

For decades, the United States has held considerable power in determining the direction of global health policies and programs. President Donald Trump issued three executive orders on his first day in office that may signal the end of that era, health policy experts said.

Trump’s order to withdraw from the World Health Organization means the U.S. will probably not be at the table in February when the WHO executive board next convenes. The WHO is shaped by its members: 194 countries that set health priorities and make agreements about how to share critical data, treatments, and vaccines during international emergencies. With the U.S. missing, it would cede power to others.

“It’s just stupid,” said Kenneth Bernard, a visiting fellow at the Hoover Institution at Stanford University who served as a top biodefense official during the George W. Bush administration. “Withdrawing from the WHO leaves a gap in global health leadership that will be filled by China,” he said, “which is clearly not in America’s best interests.”

Executive orders to withdraw from the WHO and to reassess America’s approach to international assistance cite the WHO’s “mishandling of the COVID-19 pandemic” and say that U.S. aid serves “to destabilize world peace.” In action, they echo priorities established in Project 2025’s “Mandate for Leadership,” a conservative policy blueprint from the Heritage Foundation.

The 922-page report says the U.S. “must be prepared” to withdraw from the WHO, citing its “manifest failure,” and advises an overhaul to international aid at the State Department. “The Biden Administration has deformed the agency by treating it as a global platform to pursue overseas a divisive political and cultural agenda that promotes abortion, climate extremism, gender radicalism, and interventions against perceived systemic racism,” it says.

As one of the world’s largest funders of global health — through both international and national agencies, such as the WHO and the U.S. Agency for International Development — America’s step back may curtail efforts to provide lifesaving health care and combat deadly outbreaks, especially in lower-income countries without the means to do so alone.

“This not only makes Americans less safe, it makes the citizens of other nations less safe,” said Tom Bollyky, director of global health at the Council on Foreign Relations.

“The U.S. cannot wall itself off from transnational health threats,” he added, referring to policies that block travelers from countries with disease outbreaks. “Most of the evidence around travel bans indicates that they provide a false sense of security and distract nations from taking the actions they need to take domestically to ensure their safety.”

Less Than 1%

Technically, countries cannot withdraw from the WHO until a year after official notice. But Trump’s executive order cites his termination notice from 2020. If Congress or the public pushes back, the administration can argue that more than a year has elapsed.

Trump suspended funds to the WHO in 2020, a measure that doesn’t require congressional approval. U.S. contributions to the agency hit a low of $163 million during that first year of covid, falling behind Germany and the Gates Foundation. Former President Joe Biden restored U.S. membership and payments. In 2023, the country gave the WHO $481 million.

As for 2024, Suerie Moon, a co-director of the global health center at the Geneva Graduate Institute, said the Biden administration paid biennium dues for 2024-25 early, which will cover some of this year’s payments.

“Unfairly onerous payments” are cited in the executive order as a reason for WHO withdrawal. Countries’ dues are a percentage of their gross domestic product, meaning that as the world’s richest nation, the United States has generally paid more than other countries.

Funds for the WHO represent about 4% of America’s budget for global health, which in turn is less than 0.1% of U.S. federal expenditures each year. At about $3.4 billion, the WHO’s entire budget is roughly a third of the budget for the Centers for Disease Control and Prevention, which got $9.3 billion in core funding in 2023.

The WHO’s funds support programs to prevent and treat polio, tuberculosis, HIV, malaria, measles, and other diseases, especially in countries that struggle to provide health care domestically. The organization also responds to health emergencies in conflict zones, including places where the U.S. government doesn’t operate — in parts of Gaza, Sudan, and the Democratic Republic of the Congo, among others.

In January 2020, the WHO alerted the world to the danger of the covid outbreak by sounding its highest alarm: a public health emergency of international concern. Over the next two years, it vetted diagnostic tests and potential drugs for covid, regularly updated the public, and advised countries on steps to keep citizens safe.

Experts have cited missteps at the agency, but numerous analyses show that internal problems account for the United States’ having one of the world’s highest rates of death due to covid. “All nations received the WHO’s alert of a public health emergency of international concern on Jan. 30,” Bollyky said. “South Korea, Taiwan, and others responded aggressively to that — the U.S. did not.”

‘It’s a Red Herring’

Nonetheless, Trump’s executive order accuses the WHO of “mishandling” the pandemic and failing “to adopt urgently needed reforms.” In fact, the WHO has made some changes through bureaucratic processes that involve input from the countries belonging to it. Last year, for example, the organization passed several amendments to its regulations on health emergencies. These include provisions on transparent reporting and coordinated financing.

“If the Trump administration tried to push for particular reforms for a year and then they were frustrated, I might find the reform line credible,” Moon said. “But to me, it’s a red herring.”

“I don’t buy the explanations,” Bernard said. “This is not an issue of money,” he added. “There is no rationale to withdraw from the WHO that makes sense, including our problems with China.”

Trump has accused the WHO of being complicit in China’s failure to openly investigate covid’s origin, which he alludes to in the executive order as “inappropriate political influence.”

“The World Health Organization disgracefully covered the tracks of the Chinese Communist Party every single step of the way,” Trump said in a video posted to social media in 2023.

On multiple occasions, the WHO has called for transparency from China. The agency doesn’t have the legal authority to force China, or any other country, to do what it says. This fact also repudiates Trump’s warnings that a pandemic treaty under negotiation at the WHO impinges on American sovereignty. Rather, the accord aims to lay out how countries can better cooperate in the next pandemic.

Trump’s executive order calls for the U.S. to “cease negotiations” on the pandemic agreement. This means the pharmaceutical industry may lose one of its staunchest defenders as discussions move forward.

In the negotiations so far, the U.S. and the European Union have sided with lobbying from the pharmaceutical industry to uphold strict patent rights on drugs and vaccines. They have opposed efforts from middle-income countries in Asia, Africa, and Latin America to include licensing agreements that would allow more companies to produce drugs and vaccines when supplies are short in a crisis. A study published in Nature Medicine estimated that more than a million lives would have been saved had covid vaccines been available around the world in 2021.

“Once the U.S. is absent — for better and for worse — there will be less pressure on certain positions,” Moon said. “In the pandemic agreement negotiations, we may see weakening opposition towards more public-health-oriented approaches to intellectual property.”

“This is a moment of geopolitical shift because the U.S. is making itself less relevant,” said Ayoade Alakija, chair of the Africa Union’s Vaccine Delivery Alliance. Alakija said countries in Asia and Africa with emerging economies might now put more money into the WHO, change policies, and set agendas that were previously opposed by the U.S. and European countries that are grappling with the war in Ukraine. “Power is shifting hands,” Alakija said. “Maybe that will give us a more equitable and fairer world in the long term.”

Echoes of Project 2025

In the near term, however, the WHO is unlikely to recoup its losses entirely, Moon said. Funds from the U.S. typically account for about 15% of its budget. Together with Trump’s executive order that pauses international aid for 90 days, a lack of money may keep many people from getting lifesaving treatments for HIV, malaria, and other diseases.

Another loss is the scientific collaboration that occurs via the WHO and at about 70 centers it hosts at U.S. institutions such as Columbia University and Johns Hopkins University. Through these networks, scientists share findings despite political feuds between countries.

A third executive order commands the secretary of state to ensure the department’s programs are “in line with an America First foreign policy.” It follows on the order to pause international aid while reviewing it for “consistency with United States foreign policy.” That order says that U.S. aid has served “to destabilize world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations.”

These and executive orders on climate policies track with policy agendas expressed by Project 2025. Although Trump and his new administration have distanced themselves from the Heritage Foundation playbook, CBS News reviewed the work histories of the 38 named primary authors of Project 2025 and found that at least 28 of them worked in Trump’s first administration. One of Project 2025’s chief architects was Russell Vought, who served as director of the Office of Management and Budget during Trump’s first term and has been nominated for it again. Multiple contributors to Project 2025 are from the America First Legal Foundation, a group headed by Trump adviser Stephen Miller that’s filed complaints against “woke corporations.”

Project 2025 recommends cutting international aid for programs and organizations focused on climate change and reproductive health care, and steering resources toward “strengthening the fundamentals of free markets,” lowering taxes, and deregulating businesses as a path to economic stability.

Several experts said the executive orders appear to be about ideological rather than strategic positioning.

The White House did not respond to questions about its executive orders on global health. Regarding the executive order saying U.S. aid serves “to destabilize world peace,” a spokesperson at USAID wrote in an email: “We refer you to the White House.”

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. 

In his first days in office, President Donald Trump signed an executive order on gender that affects transgender health care. The order aims to directly limit care for trans people incarcerated in federal prisons, but the broader implications on health aren’t clear-cut.

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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. 

A few years before the covid-19 pandemic, Dale Rice lost a toe to infection.

But because he was uninsured at the time, the surgery at a Reno, Nevada, hospital led to years of anguish. He said he owes the hospital more than $20,000 for the procedure and still gets calls from collection agencies.

“It can cause a lot of anxiety,” Rice said. “I can’t give you what I don’t have.”

Rice, 62, was born and has spent his life in Nevada. He said he fell through a gap in the tribal health care system because he lives 1,500 miles from the Prairie Band Potawatomi Nation home area in eastern Kansas, where he’s an enrolled member.

He receives primary care at the Reno-Sparks Indian Colony tribal health clinic in Nevada, but structural barriers in the federal Indian Health Service left him without coverage for specialty care outside of the clinic. Rice might have been eligible for specialty services referred by his tribe’s health system in Kansas, but he lives too far from the tribe’s delivery area to utilize the tribal health program that helps pay for services outside of the IHS.

“I shouldn’t need to move to Kansas City to be fully covered,” Rice said.

A new tribal sponsorship program rolled out last year in Nevada is aimed at getting tribal citizens like Rice covered and protecting them from incurring debt for uninsured care. It allows tribes to buy health insurance through the state’s Affordable Care Act marketplace for people living in their service area, including Native Americans from other tribes.

Tribal leaders and Nevada officials say the sponsorship model increases access to coverage and care for tribal citizens and their families by allowing them to seek medical care outside the tribal health care system.

A few dozen tribes have moved to set up the insurance programs since the ACA authorized them more than a decade ago.

“It’s not widespread,” said Yvonne Myers, an ACA and Medicaid consultant for Citizen Potawatomi Nation Health Services in Oklahoma.

Native American adults are enrolled in Medicaid at higher rates than their white counterparts and have long faced worse health outcomes, higher incidences of chronic disease, and shorter life expectancy. Many rely on the IHS, a division within the Department of Health and Human Services responsible for providing care to Native Americans, but the agency is chronically underfunded.

In Nevada, tribes can sponsor their community members’ health coverage through aggregated billing, a method for paying the premiums for multiple individuals in a single monthly payment to the insurer. Another part of the program includes collaboration between Nevada Health Link, the state health insurance marketplace, and tribes to certify staffers at tribal health clinics so they can enroll community members in health plans. Program officials also said they are committed to providing further education to tribes about the accommodations available to them under the ACA.

Health agencies in Washington state and Nevada have helped set up tribal sponsorship programs. Independently, tribes in Alaska, Wisconsin, Idaho, Michigan, Montana, and South Dakota have rolled out individual programs, as well.

It’s already making a difference for Native American patients in Nevada, said Angie Wilson, tribal health director for the Reno-Sparks Indian Colony and an enrolled member of the Pit River Tribe in California. Wilson said patients have shown up at her office in tears because they couldn’t afford services they needed outside of the tribal clinic and were not eligible for those services to be covered by the IHS Purchased/Referred Care program.

The Reno-Sparks Indian Colony, with more than 1,330 members in 2023, is one of two tribes that participate in Nevada’s tribal sponsorship program and aggregated billing. Russell Cook, executive director of Nevada Health Link, said he expects more tribes to come aboard as the agency works to build community trust in tribes often wary of government and corporate entities.

The Fort McDermitt Paiute and Shoshone Tribe, with a reservation that spans Nevada’s northwestern border, was the first tribe to pilot the program. There are about 125 households on the reservation.

As of December, 30 tribal members had been enrolled into qualified health plans through Nevada Health Link as part of the tribal sponsorship program, according to state officials, and more than 700 of those enrolled through the state marketplace self-reported American Indian and/or Alaska Native status for last year.

Through sponsorship, tribes may use their federal health care funding to pay the premium costs for each participating person. That, combined with cost-sharing protections in the ACA for American Indian and Alaska Natives enrolled in marketplace health plans, means beneficiaries face very low to no costs to receive care outside of tribal clinics. The American Rescue Plan also expanded eligibility for premium tax credits, making purchasing a health plan more affordable.

Because sponsorship in some tribes isn’t limited to enrolled tribal citizens, it can help the whole community, said Jim Roberts, senior executive liaison for intergovernmental affairs with the Alaska Native Tribal Health Consortium and an enrolled member of the Hopi Tribe in Arizona.

Since Alaska first allowed sponsorship in 2013, Roberts said, it has not only increased the access to care for Native Americans but also significantly lowered the costs of care, “which is equally as important, if not for some tribes more important.”

In Washington state, where sponsorship in ACA plans began in 2014, 12 of 29 tribes participate.

Cook said the state exchange is seeing interest in the part of the sponsorship program that trains staff at tribal clinics to become certified exchange representatives, a role similar to that of a navigator who helps inform people about health coverage options.

He said the agency is working on a marketing campaign to spread awareness among Native Americans in the state about the sponsorship program. It will include translating resource guides and other materials from the agency into Native languages spoken in the state, such as Northern and Southern Paiute, Washoe, and Western Shoshone.

Cook said he’s surprised more states haven’t taken the initiative to create sponsorship programs in collaboration with tribes.

Nevada Health Link patterned its approach by looking at Washington state’s program, Cook said. Since launching its own program, the Nevada agency has been approached by officials in California who are exploring the option.

But leaders like Wilson are concerned that under the Trump administration the enhanced tax credits for ACA marketplace enrollees implemented during the pandemic will end. The credits are set to expire at the end of this year if Congress doesn’t act to extend them. Without the credits, nearly all people enrolled through the marketplace will see steep increases in their premium payments next year.

If tribal citizens or other community members become ineligible for the premium tax credits, that could jeopardize the tribe’s financial ability to continue sponsoring health plans, Roberts said.

“Whatever side of the fence people fall on, it does not take away that there’s a federal trust responsibility by the United States of America to its First Nations people,” Wilson said.

Wilson, who has been an advocate for sponsorship since the ACA was approved in 2010 and led the effort to establish the program in Nevada, said she is happy with the tribal sponsorship program but wishes it would have happened sooner.

“We’ve lost so much in Indian Country over time,” she said. “How many more Indian people could have gotten access to care? How much more of a difference could that have made in sustaining health care for tribes?”

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

The second Trump presidency launched with a bang at the Department of Health and Human Services, where a traditional pause on public communications was expanded to an effective stoppage of scientific work, as health agencies were ordered to cancel meetings, travel, and efforts on outside publications. It is unclear how long the order will stay in effect; President Donald Trump’s nominee to run the department, Robert F. Kennedy Jr., won’t go before Senate committees for his confirmation hearings until the end of the month. 

Meanwhile, starting on his first day in office, the new president issued a raft of executive orders aimed at reversing Biden administration policy — but, notably, none directly addressing abortion, which has been a traditional focus every time the White House changes parties. 

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Roubein of The Washington Post, and Rachel Cohrs Zhang of Stat.

Among the takeaways from this week’s episode:

• The Trump administration took a very firm grip on federal agencies this week, sowing uncertainty with blanket cancellations of upcoming meetings and travel — as well as by implementing a broad pause on external communications. The cancellations reached deep into agencies’ core functions, affecting, for instance, meetings to review grant applications for federally funded research.
• Kennedy’s confirmation hearings to be Health and Human Services secretary are scheduled for Jan. 29 and 30. Yet questions remain about his nomination, including more recent revelations about conflicts of interest — such as his financial stake in ongoing litigation with Merck & Co. related to the HPV vaccine.
• Trump issued a slew of executive orders this week. (It is worth noting that executive orders largely instruct federal agencies to start making a change, rather than constituting the change themselves.) Of note on health, Trump’s orders instructed the removal of the U.S. from the World Health Organization; revoked a Biden administration order to reduce drug prices; and laid the groundwork to undermine health care for transgender people. Notably, though, none of the orders directly addressed abortion.

Also this week, Rovner interviews Rodney Whitlock, a consultant with McDermott+ and an adjunct faculty member at the George Washington University Milken Institute School of Public Health. Whitlock is a former House and Senate staffer and provides a primer on how Congress’ convoluted budget reconciliation process is supposed to work.

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

Julie Rovner: CNN’s “With Bird Flu Cases Rising, Certain Kinds of Pet Food May Be Risky for Animals — And People,” by Brenda Goodman.  

Rachel Roubein: The Washington Post’s “Antiabortion Advocates Look for Men To Report Their Partners’ Abortion,” by Caroline Kitchener.  

Rachel Cohrs Zhang: The Washington Post’s “In Florida, a Rebellion Against Fluoride Is Winning,” by Fenit Nirappil.  

Alice Ollstein: The Los Angeles Times’ “Now That You Can Return Home After the Fires, How Do You Clean Up Safely?” by Karen Garcia and Tony Briscoe. 

Also mentioned in this week’s podcast:

The Texas Tribune’s “Longtime Planned Parenthood President Cecile Richards Dies After Battle With Brain Cancer,” by Eleanor Klibanoff.

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. 

President Donald Trump’s early actions on health care signal his likely intention to wipe away some Biden-era programs to lower drug costs and expand coverage under public insurance programs.

The orders he issued soon after reentering the White House have policymakers, health care executives, and patient advocates trying to read the tea leaves to determine what’s to come. The directives, while less expansive than orders he issued at the beginning of his first term, provide a possible road map that health researchers say could increase the number of uninsured Americans and weaken safety net protections for low-income people.

However, Trump’s initial orders will have little immediate impact. His administration will have to take further regulatory steps to fully reverse Biden’s policies, and the actions left unclear the direction the new president aims to steer the U.S. health care system.

“Everyone is looking for signals on what Trump might do on a host of health issues. On the early EOs, Trump doesn’t show his cards,” said Larry Levitt, executive vice president for health policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

A flurry of executive orders and other actions Trump issued on his first day back in office included rescinding directives by his predecessor, former President Joe Biden, that had promoted lowering drug costs and expanding coverage under the Affordable Care Act and Medicaid.

Executive orders “as a general matter are nothing more than gussied up internal memoranda saying, ‘Hey, agency, could you do something?’” said Nicholas Bagley, a law professor at the University of Michigan. “There may be reason to be concerned, but it’s down the line.”

That’s because making changes to established law like the ACA or programs like Medicaid generally requires new rulemaking or congressional action, either of which could take months. Trump has yet to win Senate confirmation for any of his picks to lead federal health agencies, including Robert F. Kennedy Jr., the anti-vaccine activist and former Democratic presidential candidate he has nominated the lead the Department of Health and Human Services. On Monday, he appointed Dorothy Fink, a physician who directs the HHS Office on Women’s Health, as acting secretary for the department.

During Biden’s term, his administration did implement changes consistent with his health orders, including lengthening the enrollment period for the ACA, increasing funding for groups that help people enroll, and supporting the Inflation Reduction Act, which boosted subsidies to help people buy coverage. After falling during the Trump administration, enrollment in ACA plans soared under Biden, hitting record highs each year. More than 24 million people are enrolled in ACA plans for 2025.

The drug order Trump rescinded called on the Centers for Medicare & Medicaid Services to test ways to lower drug costs, such as setting a flat $2 copay for some generic drugs in Medicare, the health program for people 65 and older, and having states try to get better prices by banding together to buy certain expensive cell and gene therapies.

That might indicate Trump expects to do less on drug pricing this term or even roll back drug price negotiation in Medicare.

The White House did not respond to a request for comment.

Biden’s experiments in lowering drug prices didn’t fully get off the ground, said Joseph Antos of the American Enterprise Institute, a right-leaning research group. Antos said he’s a bit puzzled by Trump’s executive order ending the pilot programs, given that he has backed the idea of tying drug costs in the U.S. to lower prices paid by other nations.

“As you know, Trump is a big fan of that,” Antos said. “Lowering drug prices is an easy thing for people to identify with.”

In other moves, Trump also rescinded Biden orders on racial and gender equity and issued an order asserting that there are only two sexes, male and female. HHS under the Biden administration supported gender-affirming health care for transgender people and provided guidance on civil rights protections for transgender youths. Trump’s missive on gender has intensified concerns within the LGBTQ+ community that he will seek to restrict such care.

“The administration has forecast that it will fail to protect and will seek to discriminate against transgender people and anyone else it considers an ‘other,’” said Omar Gonzalez-Pagan, senior counsel and health care strategist at Lambda Legal, a civil rights advocacy group. “We stand ready to respond to the administration’s discriminatory acts, as we have previously done to much success, and to defend the ability of transgender people to access the care that they need, including through Medicaid and Medicare.”

Trump also halted new regulations that were under development until they are reviewed by the new administration. He could abandon some proposals that were yet to be finalized by the Biden administration, including expanded coverage of anti-obesity medications through Medicare and Medicaid and a rule that would limit nicotine levels in tobacco products, Katie Keith, a Georgetown University professor who was deputy director of the White House Gender Policy Council under Biden, wrote in an article for Health Affairs Forefront.

“Interestingly, he did not disturb President Biden’s three executive orders and a presidential memorandum on reproductive health care,” she wrote.

However, Trump instructed top brass in his administration to look for additional orders or memorandums to rescind. (He revoked the Biden order that created the Gender Policy Council.)

Democrats criticized Trump’s health actions. A spokesman for the Democratic National Committee, Alex Floyd, said in a statement that “Trump is again proving that he lied to the American people and doesn’t care about lowering costs — only what’s best for himself and his ultra-rich friends.”

Trump’s decision to end a Biden-era executive order aimed at improving the ACA and Medicaid probably portends coming cuts and changes to both programs, some policy experts say. His administration previously opened the door to work requirements in Medicaid — the federal-state program for low-income adults, children, and the disabled — and previously issued guidance enabling states to cap federal Medicaid funding. Medicaid and the related Children’s Health Insurance Program cover more than 79 million people.

“Medicaid will be a focus because it’s become so sprawling,” said Chris Pope, a senior fellow at the Manhattan Institute, a conservative policy group. “It’s grown after the pandemic. Provisions have expanded, such as using social determinants of health.”

The administration may reevaluate steps taken by the Biden administration to allow Medicaid to pay for everyday expenses some states have argued affect its beneficiaries’ health, including air conditioners, meals, and housing.

One of Trump’s directives orders agencies to deliver emergency price relief and “eliminate unnecessary administrative expenses and rent-seeking practices that increase healthcare costs.” (Rent-seeking is an economic concept describing efforts to exploit the political system for financial gain without creating other benefits for society.)

“It is not clear what this refers to, and it will be interesting to see how agencies respond,” Keith wrote in her Health Affairs article.

Policy experts like Edwin Park at Georgetown University have also noted that, separately, Republicans are working on budget proposals that could lead to large cuts in Medicaid funding, in part to pay for tax cuts.

Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning research group, also pointed to Congress: “On one hand, what we see coming from the executive orders by Trump is important because it shows us the direction they are going with policy changes. But the other track is that on the Hill, there are active conversations about what goes into budget legislation. They are considering some pretty huge cuts to Medicaid.”

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. 

California is advising health care providers not to write down patients’ immigration status on bills and medical records and telling them they don’t have to assist federal agents in arrests. Some Massachusetts hospitals and clinics are posting privacy rights in emergency and waiting rooms in Spanish and other languages.

Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization.

Donald Trump returned to the White House declaring a national emergency at the U.S.-Mexico border, suspending refugee admissions, and challenging birthright citizenship, or the policy of giving U.S. citizenship to anyone born in the U.S. As he begins carrying out the “largest deportation operation” in the nation’s history, states have offered starkly different guidelines to hospitals, community clinics, and other health facilities for immigrant patients.

Trump has also rescinded a long-standing policy not to arrest people without legal status at or near sensitive locations, including schools, churches, and hospitals. A proposal to formalize such protections died in Congress in 2023.

But no matter the guidelines that states issue, hospitals around the U.S. say patients won’t be turned away for care because of their immigration status. “None of this changes the care patients receive,” said Carrie Williams, a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. “We don’t want people to avoid care and worsen because they are concerned about immigration questions.”

During Trump’s first term, immigration agents arrested people receiving emergency care in hospitals and a child during an ambulance transfer. Immigration officers in Texas arrested a woman awaiting brain surgery in a hospital in Fort Worth. In Portland, Oregon, officers arrested a young man leaving a hospital, and in San Bernardino, California, a woman drove herself to the hospital to give birth after her husband was arrested at a gas station.

An estimated 11 million immigrants live in the United States without authorization, with the largest numbers in California, Texas, Florida, New York, New Jersey, and Illinois, according to Pew Research Center.

Half of immigrant adults likely without authorization are uninsured, compared with fewer than 1 in 10 citizens, according to the 2023 KFF-Los Angeles Times Survey of Immigrants, the largest nongovernmental survey of immigrants in the U.S. to date. While some states are highlighting health care expenses incurred by immigrants, a KFF brief noted that immigrants contribute more to the system through health insurance premiums and taxes than they use. Immigrants also have lower health care costs than citizens.

Some health care providers fear Immigration and Customs Enforcement agents will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. On Trump’s first day, the Republican president issued an executive order aimed at ending birthright citizenship for children born to a parent without legal authorization or on a visa, which could leave them ineligible for federal health and social programs. The order was immediately challenged by states and a civil rights group.

“You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need, who may not be able to get treatment for an ear infection or surgery,” said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

A recent survey conducted by the Im/migrant Well-Being Research Center at the University of South Florida found that 66% of noncitizens reported increased hesitation in seeking care after Florida Gov. Ron DeSantis signed a law in 2023 requiring hospitals that accept Medicaid to ask about a patient’s legal status. That’s compared with just 27% for citizens.

“That really was alarming to me to see how this law made people hesitant to go to the doctor, even in an emergency,” said Liz Ventura Molina, a co-author of the survey and report.

In signing the law, DeSantis touted it as “the most ambitious anti-illegal immigration” legislation in the nation. This month, the Republican governor called for a special session of the state legislature to help support Trump’s immigration agenda.

Jackson Health System, a public safety net provider in Miami, said in a statement that quarterly reports to the state don’t contain individual patient information. “We do adhere to all required cooperation with law enforcement agencies, including ICE, as part of any criminal investigations, understanding that privacy laws mandate we only release private patient information through a court-ordered warrant.”

In August, Texas Gov. Greg Abbott, a Republican, issued an executive order similar to Florida’s law to record health care costs incurred by immigrants without legal authorization. All hospitals that receive funding from Medicaid or the Children’s Health Insurance Program are expected to begin reporting the data to Texas Health and Human Services in March.

Even cities controlled by Democrats are walking a fine line. New York City Mayor Eric Adams met in December with Trump’s incoming “border czar,” Tom Homan, and pledged to remove immigrants who have been convicted of a major felony and lack legal status to remain in the country.

At the same time, Adams proposed an awareness campaign to let immigrants and asylum-seekers know they are safe to use the city’s hospital systems.

Some states are going further by advising health facilities to do all they can to protect immigrant patients.

In December, California Attorney General Rob Bonta released a 42-page document recommending providers avoid including patients’ immigration status in bills and medical records. The guidance also emphasized that while providers should not physically obstruct immigration agents, they are under no obligation to assist with an arrest.

According to the document, health care facilities should post information about patients’ right to remain silent and are encouraged to provide patients with contact information for legal-aid groups “in the event that a parent is taken into immigration custody.” If feasible, it says, the facility should designate an immigrant-affairs liaison to help train staff and provide nonlegal advice to families.

“We cannot let the Trump deportation machine create a culture of fear and mistrust that prevents immigrants from accessing vital public services,” said Bonta, a Democrat.

On Tuesday, the Trump administration directed the Department of Justice to investigate state and local officials who don’t cooperate with immigration enforcement. During Trump’s first term, California limited cooperation with federal authorities, citing public safety and community trust concerns. The department, then under Jeff Sessions, sued to block the law but the state won in federal court, arguing that states have the authority to decide whether local resources are used to enforce federal law. The Trump administration appealed, but the Supreme Court turned down the petition.

Under California law, state-run health care facilities are required to adopt policies to limit their participation in immigration enforcement, and private entities are encouraged to follow similar protocols. David Simon, a spokesperson for the California Hospital Association, which represents more than 400 hospitals, said members have incorporated such policies, ensuring patient privacy.

“Hospitals don’t call ICE about patients,” Simon said.

California is bracing for a new round of clashes with Trump. Gov. Gavin Newsom and fellow Democratic state leaders have agreed to set aside $50 million for litigation and grants to nonprofit immigrant groups.

Lawmakers in New Jersey are considering legislation to limit health care facilities from asking about a patient’s immigration status. The bill would also require the state attorney general to establish policies for hospitals and health care facilities for ensuring patient access.

In New York City, hospital administrators are directing staff to seek guidance from an “immigration liaison” if immigration authorities show up, and to take photos and videos of any enforcement actions if they can’t reach them first. They are also discouraging staff from actively helping a person hide from ICE. In Massachusetts, some clinics and hospitals are training staff on how to read ICE warrants and plan to require ICE agents to identify themselves and present a warrant if they want to enter a private area.

“You can’t be scrambling in the moment,” said Altaf Saadi, a neurologist who co-directs a clinic for asylum-seekers at the Massachusetts General Hospital. “We have to prepare for these worst-case scenarios, and we hope that they don’t happen, but we do need to be prepared.”