A customer enters a CVS store in October 2023 in Los Angeles. Pharmacies in Black and Latino neighborhoods and those with more residents on Medicaid are less likely to regularly dispense buprenorphine — one of the main medications used to treat opioid use disorder. (Photo by Mario Tama/Getty Images)

Pharmacies in Black and Latino neighborhoods are less likely to dispense buprenorphine — one of the main treatments for opioid use disorder — even though people of color are more likely to die from opioid overdoses.

The drug helps reduce cravings for opioids and the likelihood of a fatal overdose.

While the nation as a whole has seen decreases in opioid overdose deaths in recent years, overdose deaths among Black, Latino and Indigenous people have continued to increase.

Many medical and health policy experts fear the broad domestic policy law President Donald Trump signed in July will worsen the problem by increasing the number of people without health insurance. As a result of the law, the number of people without coverage will increase by about 10 million by 2034, according to the Congressional Budget Office.

About 7.5 million of the people who will lose coverage under the new law are covered by Medicaid. Shortly before Trump signed the bill into law, researchers from the University of Pennsylvania and Boston University estimated that roughly 156,000 Medicaid recipients will lose access to medications for opioid addiction because of the cuts, resulting in approximately 1,000 more overdose deaths annually.

Because Black and Hispanic people are overrepresented on the rolls, the Medicaid cuts will have a disproportionate effect on communities that already face higher barriers to getting medications to treat addiction.

From 2017 to 2023, the percentage of U.S. retail pharmacies regularly dispensing buprenorphine increased from 33% to 39%, according to a study published last week in Health Affairs.

But researchers found the drug was much less likely to be available in pharmacies in mostly Black (18% of pharmacies) and Hispanic neighborhoods (17%), compared with mostly white ones (46%).

In some states, the disparity was even worse. In California, for example, only about 9% of pharmacies in Black neighborhoods dispensed buprenorphine, compared with 52% in white neighborhoods.

The researchers found buprenorphine was least available in Black and Latino neighborhoods across nearly all states.

Barriers to treatment

Dr. Rebecca Trotzky-Sirr, a family physician who specializes in addiction medicine, said many communities of color are “pharmacy deserts.” Even the pharmacies that do exist in those neighborhoods tend to “have additional barriers to obtain buprenorphine and other controlled substances out of a concern for historic overuse of some treatments,” said Trotzky-Sirr, who wasn’t involved in the study.

In addition to its federal classification as a controlled substance, buprenorphine is also subject to state regulations to prevent illegal use. Pharmacies that carry it know that wholesalers and distributors audit their orders, which dissuades some from stocking or dispensing it.

Dima Qato, associate professor of clinical pharmacy at the University of Southern California and an author of the Health Affairs study, said that without changes in policy, Black and Hispanic people will continue to have an especially hard time getting buprenorphine.

“If you don’t address these dispensing regulations, or regulate buprenorphine from the aspect of pharmacy regulations, people are still going to encounter barriers accessing it,” she said.

In neighborhoods where at least a fifth of the population is on Medicaid, just 35% of pharmacies dispensed buprenorphine, Qato and her team found. But in neighborhoods with fewer residents on Medicaid, about 42% of pharmacies carried the drug.

Medicaid covers nearly half — 47% — of nonelderly adults who suffer from opioid use disorder. In states that expanded Medicaid under the Affordable Care Act, another recent study found an increase in people getting prescriptions for buprenorphine.

“Medicaid is the backbone of care for people struggling with opioid use disorder,” said Cherlette McCullough, a Florida-based mental health therapist. “We’re going to see people in relapse. We’re going to see more overdoses. We’re going to see more people in the ER.”

Qato said the shortage of pharmacies in minority communities is likely to get worse, as many independent pharmacists are already struggling to stay open.

“We know they’re more likely to close in neighborhoods of color, so there’s going to be even fewer pharmacies that carry it in the neighborhoods that really need it,” she said.

‘There needs to be urgency’

Qato and her colleagues say states and local governments should mandate that pharmacies carry a minimum stock of buprenorphine and dispense it to anyone coming in with a legitimate prescription. As examples, they point to a Philadelphia ordinance mandating that pharmacies carry the opioid overdose-reversal drug naloxone and similar emergency contraception requirements in Massachusetts.

“We need to create expectations. We need to encourage our pharmacies to carry this to make it accessible, same day, and there needs to be urgency,” said Arianna Campbell, a physician assistant and co-founder of the Bridge Center, a California-based organization that aims to help increase addiction treatment in emergency rooms.

“In many of the conversations I have with pharmacies, when I’m getting some pushback, I have to say: ‘Hey, this person’s at the highest risk of dying right now. They need this medication right now.’”

She said patients frequently become discouraged due to barriers they face in getting prescriptions filled. The Bridge Center has been expanding its patient navigator program across the state, and helping other states start their own. The program helps patients identify pharmacies where they can fill their prescription fastest.

“There’s a medication that can help you, but at every turn it’s really hard to get it,” she said, calling the disparities in access to medication treatment “unacceptable.”

Trotzky-Sirr, the California doctor, fears the looming Medicaid cuts will cause many of her patients to discontinue treatment and relapse. Many of her patients are covered by Medi-Cal, the state’s Medicaid program.

“A lot of our patients are able to obtain medications for treatment of addiction like buprenorphine, because of the state covering the cost of the medication,” said Trotzky-Sirr, who also is a regional coordinator at the Bridge Center.

“They don’t have the resources to pay for it, cash, out of pocket.”

Some low-income patients switch between multiple providers or clinics as they try to find care and coverage, she added. These could be interpreted as red flags to a pharmacy.

Trotzky-Sirr argued buprenorphine does not need to be monitored as carefully as opioids and other drugs that are easier to misuse or overuse.

“Buprenorphine does not have those features and really needs to be in a class by itself,” she said. “Unfortunately, it’s hard to explain that to a pharmacist in 30 seconds over the phone.”

More is known about the medication now than when it was placed on the controlled substances list about two decades ago, said Brendan Saloner, a Bloomberg Professor of American Health in Addiction and Overdose at Johns Hopkins University.

Pharmacies are fearful of regulatory scrutiny and don’t have “countervailing pressure” to ensure patients get the treatments, he said.

On top of that fear, Medicaid managed care plans’ prior authorization processes may also be adding to the pharmacy bottleneck, he said.

“Black and Latino communities have higher rates of Medicaid enrollment, so to the extent that Medicaid prior authorization techniques are a hassle to pharmacies, that may also kind of discourage them [pharmacies] from stocking buprenorphine,” he said.

In some states, buprenorphine is much more readily available. In Maine, New Hampshire, Oregon, Rhode Island, Utah and Vermont, more than 70% of pharmacies carried the drug, according to the study. Buprenorphine availability was highest in states such as Oregon that have the least restrictive regulations for dispensing it.

In contrast, less than a quarter of pharmacies in Iowa, North Dakota, Texas, Virginia and Washington, D.C., carried the medication.

“We’re going to see more people becoming unhoused, because without treatment, they’re going to go back to those old habits,” McCullough, the Florida therapist, said. “When we talk about marginalized communities, these are the populations that are going to suffer the most because they already have challenges with access to care.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

A health care worker fills a syringe with the MMR vaccine at a vaccine clinic in Texas in March. Florida announced plans to end all state vaccine mandates, while three Western states — California, Oregon and Washington — are forming an alliance to issue their own vaccine guidelines amid federal upheaval. (Photo by Jan Sonnenmair/Getty Images)

The Democratic governors of California, Oregon and Washington said Wednesday they are forming an alliance to coordinate vaccine recommendations for their states.

Meanwhile, Florida announced plans to become the first state to phase out all vaccine mandates, including ending requirements that kids be vaccinated against dangerous diseases before enrolling in schools.

Public health experts have relied on vaccines, including school mandates, for decades to limit the spread of communicable diseases and keep kids and adults safe.

The contrasting moves come amid turmoil at the U.S. Centers for Disease Control and Prevention, where several top leaders resigned last week to protest efforts by Health and Human Services Secretary Robert F. Kennedy Jr., a vaccine skeptic, to dismiss CDC Director Susan Monarez for pushing back against Kennedy’s vaccine policies.

Accompanied by Florida Republican Gov. Ron DeSantis, state Surgeon General Dr. Joseph A. Ladapo said at a news conference Wednesday that vaccine mandates are “wrong” and “immoral,” the Florida Phoenix reported.

“Your body is a gift from God. What you put into your body is because of your relationship with your body and your God,” Ladapo said.

“They do not have the right to tell you what you put in your body. They don’t have the right to tell you what your kids have to put in [their] body. They do not have the right. Do not give it to them. Take it away from them. And we’re going to be starting that here in Florida.”

The Florida Department of Health can eliminate some vaccine mandates on its own, Ladapo said, but the Florida legislature would have to scrap other ones. He did not mention specific vaccines, but repeated that his goal was to end “all of them. Every last one of them.”

“Every last one of them is wrong and drips with disdain and slavery,” Ladapo said.

The goal of the new West Coast Health Alliance, governors said, is to disseminate evidence-based recommendations about who should get immunized, as well as to provide vaccine education throughout the three states. In the coming weeks, the states will coordinate and finalize immunization guidelines that are in line with leading medical organizations.

In their announcements, California Gov. Gavin Newsom, Oregon Gov. Tina Kotek and Washington Gov. Bob Ferguson criticized recent Trump administration actions, including the firing of scientists and the upheaval at the CDC.

“When federal agencies abandon evidence-based recommendations in favor of ideology, we cannot continue down that same path,” Washington Secretary of Health Dennis Worsham said in a statement.

Worsham added that “public health at its core is about prevention — preventing illness, preventing the spread of disease, and preventing early, avoidable deaths.”

Last week, the U.S. Food and Drug Administration restricted access to updated COVID-19 shots. In June, Kennedy ousted all 17 members of the vaccine advisory committee at the CDC, replacing them with some members who are vaccine skeptics. Many states rely on the committee to form vaccination guidelines.

And in May, Kennedy rescinded recommendations for children and pregnant women to get vaccinated against COVID-19 — sidestepping the usual process for issuing official recommendations.

The three Western states said the “dismantling” of the CDC has created “a vacuum of clear, evidence-based vaccine guidance,” hampering health care providers, disrupting manufacturers’ production plans and creating uncertainty for families.

In 2020, at the start of the COVID-19 pandemic, the three states, along with Nevada, created a similar workgroup that emphasized the scientific rigor behind the Pfizer COVID-19 vaccine in an effort to boost confidence in the shot.

“President Donald Trump’s mass firing of CDC doctors and scientists — and his blatant politicization of the agency — is a direct assault on the health and safety of the American people,” the joint statement from the three governors’ offices said.

“The CDC has become a political tool that increasingly peddles ideology instead of science, ideology that will lead to severe health consequences. California, Oregon, and Washington will not allow the people of our states to be put at risk.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

A child gets an MMR vaccine at a clinic put on by Lubbock Public Health Department in Lubbock, Texas, in March. States have been reporting steady increases in vaccination exemption requests for kids. (Photo by Jan Sonnenmair/Getty Images)

Dr. Rana Alissa hears it daily in the clinic.

“It’s better for my kid to get the virus than get the vaccine.”

“The more you [doctors] vaccinate, the more money you get.”

“I did not vaccinate any of my kids, and I’m not going to vaccinate this one. So, please, don’t waste your time.”

The Jacksonville, Florida, pediatrician said on average, she’d hear vaccine skepticism from a couple of parents a month, at most, before the COVID-19 pandemic. “Now, it’s every day,” said Alissa, who is also president of the Florida Chapter of the American Academy of Pediatrics.

Medical experts say hesitancy is likely to increase further as a result of misinformation pouring from the Trump administration — and turmoil at the federal agency largely responsible for setting vaccine policy.

On Thursday, three top officials were escorted out of the Atlanta headquarters of the federal Centers for Disease Control and Prevention.

All three officials resigned to protest the effort by Secretary of Health and Human Services Robert F. Kennedy Jr. to dismiss CDC Director Susan Monarez for pushing back against Kennedy’s vaccine policies.

One of the officials, Dr. Demetre Daskalakis, director of the CDC’s National Center for Immunization and Respiratory Diseases, posted on X that he’s resigning because “the intentional eroding of trust in low-risk vaccines” will cause the nation to suffer.

Earlier this week, the U.S. Food and Drug Administration restricted access to updated COVID-19 shots. The new rules include limitations for young children that the American Academy of Pediatrics called “deeply troubling.” The FDA only approved COVID-19 vaccines for people who are 65 and older and those who are known to be at risk for a severe case. Consultation with a medical provider will be required before the shot is given to healthy children under 18, meaning parents can’t simply take their kids to a vaccination clinic or pharmacy.

In June, Kennedy ousted all 17 members of the vaccine advisory committee at the CDC, replacing them with some members who are vaccine skeptics. Many states use the committee’s recommendations to develop their vaccine requirements. And in May, Kennedy rescinded recommendations for kids to get vaccinated against COVID-19.

In his books, experts say, Kennedy appears to promote his own version of miasma theory, an obsolete belief dating back to ancient times that diseases are caused by vapors from rotting organic matter. Scientists have since proven that microbes, not bad air, cause infectious diseases.

Experts say Kennedy’s actions are likely to make vaccination rates worse, paving the way for more outbreaks.

“Every vaccine that we give prevents a serious and life-threatening disease,” New York pediatrician Dr. Jesse Hackell, chair of the Committee on Pediatric Workforce at the American Academy of Pediatrics, told Stateline. “I don’t want to force anybody, but I do want to make sure that the information they’re getting is quality information — and that’s not what is coming from HHS.”

Nonmedical exemptions

Every state requires kids to get certain shots to attend school. All states exempt children who can’t be immunized for medical reasons, but nonmedical exemptions for religious or personal reasons vary from state to state.

Vaccination rates among kids are declining. Flu vaccinations, for example, hit their lowest rate since 2019. And since the beginning of the pandemic, exemption requests have increased across the country.

Among kindergarteners, nonmedical exemptions have increased each year since 2020, from 1.9% in the first year of the pandemic to 3.4% in the 2024-25 school year, according to the latest data from the federal Centers for Disease Control and Prevention. Exemptions increased in 36 states and Washington, D.C. Seventeen states reported exemption rates over 5%.

The changes may seem small. But experts say even slight increases in exemptions and decreases in vaccinations make a big difference.

“With a disease that’s as infectious as measles … small increases in vaccination rates could really go a long way,” epidemiologist Sophia Newcomer, a University of Montana associate professor, said in a recent panel discussion hosted by Montana Families for Vaccines.

Alissa and other experts say rampant confusion around the shots, including federal officials casting doubt, is exacerbating the problem. Often, parents aren’t sure whom they can trust, finding conflicting information and unreliable sources, she said.

“[Parents] come to our clinic and the hospitals and they say, ‘We looked it up, and we just don’t want it,’” she said. “There’s different kinds of reasoning: the ingredients of the vaccine, the side effects of the vaccine, ‘vaccines don’t work.’”

But research consistently shows vaccines protect children from serious illness. Shots also protect the most vulnerable who can’t get vaccinated, such as babies who are too young, or children and adults who are immunocompromised. Babies up to age 2 are more likely to get very sick from COVID-19, making up the most hospitalizations among kids.

Ultimately, Alissa said, “We are endangering each other.”

In Florida, where Alissa practices, religious exemptions have increased monthly, according to a state report that tracked the numbers through April. Some counties have higher rates of children with religious exemptions than others, ranging from about 1.5% to 15%, the state department of health reported. Among kindergarteners in the state, the rate of nonmedical exemptions rose from 2.7% in the 2020-21 school year to 4.8% in the 2024-25 school year, CDC data shows.

Five states — California, Connecticut, Maine, New York and West Virginia — don’t allow nonmedical exemptions, according to the National Conference of State Legislatures. Two West Virginia families with immunocompromised kids brought lawsuits over Republican Gov. Patrick Morrisey’s January executive order mandating religious exemptions despite state law.

Kennedy defended religious exemptions and endorsed the governor’s order in a post on X. His agency also sent letters to West Virginia health departments warning of civil rights violations if they don’t allow such exemptions.

“There’s a ton of variability across states in how easy it is to not get vaccinated,” Newcomer, of the University of Montana, said. Some states require parental vaccine education as part of the exemption request while others don’t.

“Increased exemptions needs to be fought at every level — working to make sure there’s access, to make sure that there’s good information, and to make sure that there’s strong policy at the state level, so that people aren’t exploiting exemption loopholes,” Northe Saunders, American Families for Vaccines president, said during the panel discussion.

Other vaccines

Doctors are worried that other vaccines will be targeted by the Trump administration, such as those for whooping cough. By April, preliminary CDC data showed more than 9,000 cases this year, about twice as many compared with the same time last year and more than there were right before the pandemic. Whooping cough, or pertussis, can be deadly for babies. Vaccines help prevent severe whooping cough illness.

Hackell said that when he was training in the 1970s, there were no pneumococcal and haemophilus vaccines. Babies would come in with 104-degree fevers and they were immediately tested for the infections, he recalled. For babies under age 2, those bacterial infections can show up as only a high fever, but the infection can rapidly turn fatal without treatment, he told Stateline.

“When I trained, we didn’t have these vaccines, and these kids kept us up at night,” Hackell said. “I never want to practice in those days. I never want to go back to that. … To me, that is unacceptable to submit my patients to those risks that we’ve been able to reduce.”

This week the FDA removed one of the available COVID-19 vaccines for young children, limiting the Spikevax vaccine to only kids with at least one serious health issue. Moderna’s shot is still available for children 6 months and older. Pfizer’s shot is no longer available for kids under 5, as the FDA is ending its emergency use authorization for the age group.

But the American Academy of Pediatrics recommends COVID-19 shots for children 6 months to 2 years. It also recommends them for older children with underlying health issues. Healthy children whose parents want them to get the shot should also be offered them, the AAP says.

Hackell is concerned by the FDA’s new limitations on the shot.

“As a parent, as a grandparent and as a physician who takes care of vulnerable kids, it disgusts me,” Hackell said.

He’s also concerned about vulnerable kids who get their shots through the federal Vaccines for Children (VFC) Program, which covers shots if parents can’t afford them and follows federal vaccine advisory recommendations.

“If you’re covered by VFC, which is basically kids on Medicaid and a few other populations, then you’re out of luck,” Hackell said. “To me, that’s a huge inequity in access to care, which is indefensible.”

He added that the move breaks with the administration’s emphasis on individual decision-making, saying the new restrictions limit parental decisions.

‘Normalization’ of outbreaks

During the Montana panel discussion, Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, pointed to CDC data showing that over the past year alone, about 1 in 5 children and adolescents hospitalized with COVID-19 were put in the ICU. And between September 2023 and last August, 152 children died of COVID-19 and 213 children died of the flu.

While Texas officially declared its measles outbreak over — which means the state hasn’t reported a new case in six weeks — neighboring New Mexico continues to see new cases.

“What we’re going to see is, you know, sadly, a normalization of these outbreaks,” said Rekha Lakshmanan, chief strategy officer at The Immunization Partnership, a Texas-based vaccine education organization. “We need to make sure that kids are protected against the diseases that they can be protected against, because we truly are in a vulnerable state right now.”

Newcomer, the Montana epidemiologist, said that under-vaccination trends are usually due to disparities in access, such as challenges in reaching vaccine providers in rural communities. At rural health care centers lacking staff and technology, it’s harder to automate vaccination reminders for patients — which can increase the likelihood patients show up for appointments but require technical infrastructure, she explained.

Adding misinformation to the mix only makes matters worse, experts say.

“Parents are confused and understandably concerned,” Offit told Stateline. “It’s the most vulnerable among us that will suffer, and that will be our children.”

He added that he’s also wary about the federal administration’s removal of data, concerned that vaccination figures will be next.

“It’s nightmarish,” he said. “What worries me the most is we’re not going to know the degree that we’re suffering. We’re not, because the CDC is losing its capacity to do adequate surveillance across the country.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

In this photo illustration, a pharmacist holds a COVID-19 vaccine. States and clinicians are working on getting correct information on vaccines to vulnerable groups amid shifting federal guidance. (Photo illustration by Joe Raedle/Getty Images)

Heading into the respiratory illness season, states and clinicians are working to encourage pregnant patients to get COVID-19 vaccinations, even though the U.S. Department of Health and Human Services no longer recommends that they should.

Along with being older and having an underlying health condition, pregnancy itself is a risk factor. Pregnant women are more vulnerable to developing severe illness from COVID-19. They’re also at high risk for complications, including preterm labor and stillbirth. The vast majority of medical experts say getting the shot is safe and effective — much safer than having the illness.

But HHS Secretary Robert F. Kennedy Jr. announced in May that the agency would no longer recommend that pregnant women get the vaccine. Before testifying before Congress in June, Kennedy circulated a document on Capitol Hill claiming higher rates of fetal loss after vaccination. But the authors of those studies told Politico that their work had been misinterpreted.

Experts say the federal shift puts the onus on state health agencies to ramp up vaccine guidance and outreach. Clinicians and public health organizations are trying to dispel misinformation and make sure information reaches low-income people and people of color, who had higher maternal death rates during the pandemic. During the first two years of the pandemic, the virus contributed to a quarter of maternal deaths, according to federal data.

“We are severely disappointed,” said Dr. Neil Silverman, a professor of clinical obstetrics and gynecology at the University of California, Los Angeles David Geffen School of Medicine. He has studied vaccines and pregnancy for the past 15 years and specializes in high-risk pregnancies.

Silverman called the federal shift a “public health tragedy on a grand scale.”

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Vaccinations against COVID-19 help prevent severe illness in pregnant people as well as their newborns, who are too young to get vaccinated, Silverman said. In what’s called passive immunity, vaccinated mothers pass on antibodies to their babies through the placenta and through breast milk.

“State public health agencies are probably going to have to implement vaccine guidance that differs from the federal recommendations. And that’s going to be an interesting can of worms,” said OB-GYN Dr. Mark Turrentine, a professor of obstetrics and gynecology at the Baylor College of Medicine in Texas.

Turrentine serves on a board of the American College of Obstetricians and Gynecologists that focuses on immunization and infectious diseases. He said his recent pregnant patients who had COVID-19 hadn’t gotten the vaccine.

“The change in guidance on the federal level just really makes a lot of confusion, and it makes it very challenging to try to explain to individuals why all of a sudden the difference,” Turrentine said.

A slew of public health organizations have been making a concerted effort to dispel vaccine myths. They include the Society for Maternal-Fetal Medicine, a Washington, D.C.-based nonprofit organization of maternal-fetal experts. At a news briefing the society held this month, clinicians stressed the safety and long-standing science behind COVID-19 vaccines, as well as the shots for RSV and the flu. Cases of RSV and the flu tend to peak in the winter months, while in recent years COVID-19 cases have spiked in the summer and the winter.

Dr. Brenna Hughes, an OB-GYN who chairs the organization’s infectious diseases and emerging threats committee, pointed to survey data from the federal Centers for Disease Control and Prevention showing that less than a third of eligible pregnant patients received COVID-19 shots, and only 38% received RSV shots for the 2023 to 2024 season. Less than half — 47% — received flu shots, and 59% received TDAP (whooping cough) vaccines.

CDC data shows that for last year’s and this year’s season, only between 12% and 14% of pregnant patients got the COVID-19 vaccine.

“The complications from the infection are so much greater than the complications and the very few and typically minor adverse events that might occur from the vaccine,” said microbiologist Sabra Klein, a professor of molecular microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health.

In June, the American College of Obstetricians and Gynecologists and 30 other professional health organizations signed a letter urging insurers to continue covering the COVID-19 shot for pregnant women, and have continued to urge coverage since then.

CVS Caremark, one of the nation’s three major pharmacy benefit managers, told Stateline it will continue covering the vaccine for pregnant women. The Arizona, California and North Carolina state Medicaid agencies also told Stateline they are still currently covering COVID-19 vaccines for pregnant women.

Doulas, midwives and lawmakers challenge erasure of Black women in maternal health care

Dr. Kimberly Fortner, president-elect of the Infectious Diseases Society for Obstetrics and Gynecology, said during the maternal-fetal medicine briefing that she hopes medical groups’ joint messaging will bolster insurers.

“Hopefully by us linking arms, that can then help develop consistency so that insurers will continue to pay for the vaccine,” she said.

Exacerbating disparities

Dr. Ayanna Bennett, director of the District of Columbia Department of Health, said the federal government’s new stance has upended “a system that’s been stable for a very long time.”

Bennett said her agency used federal pandemic aid to shore up vaccine outreach efforts to communities of color. Now that flow of money is ending.

The changes in federal guidance and funding will “almost certainly exacerbate” maternal health disparities, said Marie Thoma, a perinatal epidemiologist and an associate professor in the University of Maryland Department of Family Science who researches pregnancy and COVID-19.

Black and Indigenous women died at higher rates. The virus exacerbated existing racial disparities in maternal health — and created new ones: Latina mothers, who generally see low rates of maternal mortality, saw deaths surge to 28 per 100,000 in 2021. Their rate was about 12 per 100,000 in 2018, according to federal data.

“We are going in with some exposure already that we didn’t have during the start of the pandemic. So, there will be some protection, but now that will erode,” said Thoma. “If we’re not getting vaccines, or if people are hesitant to take them, we could see some increase.”

Silverman said the administration’s efforts to strip mentions of race from government policies makes it difficult for institutions to reach populations at greatest risk. He called the dismissal of decades of data “saddening and infuriating.”

“The politicization of the vaccine process, or access to it, is what concerns me the most,” said Dr. Yvette Martas, a Connecticut OB-GYN who chairs the board of directors of the Hispanic Health Council.

Many women “are trying to navigate an economic system that’s not always in their favor in terms of also providing access to the kind of educational material that they need,” she said.

Not just COVID-19

In June, Kennedy ousted all 17 members of the CDC’s vaccine advisory committee, replacing them with some members who are vaccine skeptics.

The change is creating chaos. Some states have vaccine laws, such as mandates for kids and coverage statutes, that are specifically tied to the committee’s decisions.

The Vaccine Integrity Project at the University of Minnesota called on frontline health workers, health officials and professional societies to “counter the spread of inaccurate and confusing vaccine information.”

At a news briefing this month held by the Association of State and Territorial Health Officials, representatives from Alabama, Connecticut and Washington, D.C., said they will continue to recommend vaccines.

Alabama’s state health officer, Dr. Scott Harris, said clinicians will be instrumental in getting correct vaccination information to patients.

“We don’t think that we necessarily have the same authoritative voice that we might have had a decade ago in trying to guide people in what to do, but we do believe that people trust their health care providers in most cases and are certainly willing to listen to them,” he said at the briefing.

Bennett said she is hopeful that strong, consistent messaging from respected medical organizations will help combat confusion.

“Having established groups like the American Academy of Pediatrics or the American College of Obstetrics and Gynecology make very firm recommendations that keep us essentially not changed from where we have been, I think, should reassure families,” she said.

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

People listen to a sermon before being admitted to lunch at the Hope Center, which assists homeless and addicted residents in Hagerstown, Md. Experts say Medicaid cuts will exacerbate rural communities’ access to mental health care. (Photo by Spencer Platt/Getty Images)

Across the nation, Medicaid is the single largest payer for mental health care, and in rural America, residents disproportionately rely on the public insurance program.

But Medicaid cuts in the massive tax and spending bill signed into law earlier this month will worsen mental health disparities in those communities, experts say, as patients lose coverage and rural health centers are unable to remain open amid a loss of funds.

“The context to begin with is, even with no Medicaid cuts, the access to mental health services in rural communities is spotty at best, just very spotty at best — and in many communities, there’s literally no care,” said Ron Manderscheid, former executive director of the National Association of County Behavioral Health and Developmental Disability Directors.

Cuts over the next 10 years could force low-income rural families to pay for mental health care out of pocket on top of driving farther for care, experts say. Many will simply forgo care for depression, bipolar disorder and other illnesses that need consistent treatment.

“Not only do you have very few services available, but you don’t have the resources to pay for the services,” Manderscheid said. “That makes the problem even worse.”

Rural communities are already at higher risk of suicide, with rates almost doubling over the past two decades. Already, rural communities are grappling with a shortage in mental health professionals, making them more vulnerable to losses compared with more urban areas, experts say.

Paul Mackie, assistant director of the Center for Rural Behavioral Health at Minnesota State University, Mankato, studies rural mental health workforce shortages.

“If it [coverage] goes away, what would then be the person’s next option if they already don’t have the resources?” said Mackie, who grew up on a rural Michigan dairy farm. “You can have a rural psychologist or a rural clinical social worker working under a shingle, literally alone.”

Small rural hospitals often provide critical behavioral health care access, he said. One analysis found the cuts next year would leave 380 rural hospitals at risk of shutting down.

States such as Mackie’s Minnesota, which expanded Medicaid eligibility under the 2010 Affordable Care Act, would suffer significant slashes in federal matches as a result of President Donald Trump’s signature legislation. The law, which includes tax cuts that disproportionately benefit the wealthy, cuts the federal government’s 90% matching rate for enrollees covered under expansion to anywhere from 50% to 74%.

States will have to redetermine eligibility twice a year on millions enrolled under Medicaid expansion. Some Medicaid recipients also will have to prove work history. The new law creates work requirement exceptions for those with severe medical conditions — including mental disorders and substance use — but experts say proving those conditions may be convoluted. The exact qualifications and diagnoses for the exceptions haven’t been spelled out, according to a report by KFF, a health policy research organization.

“You can’t work when your mental illness is not treated,” said Dr. Heidi Alvey, an emergency and critical care medicine physician in Indiana. “It’s so counter to the reality of the situation.”

Alvey worked seven years at Baylor Scott & White Health’s hospital in Temple, Texas. As nearby rural critical access hospitals and other mental health centers shut down, the hospital became the only access point for people hours away, she said.

“People who just had absolutely no access to care were coming hours in to see us,” she said. Many had serious untreated mental health conditions, she said, and had to wait days or weeks in the emergency department until a care facility had an open bed.

She’s concerned that Medicaid cuts will only make those problems worse.

Jamie Freeny, director of the Center for School Behavioral Health at advocacy group Mental Health America of Greater Houston, worries for the rural families her center serves. The organization works with school districts across the state, including those in rural communities. Nearly 40% of the state’s more than 1,200 school districts are classified as rural.

She remembers one child whose family had to drive to another county for behavioral health. The family lost coverage during the Medicaid unwinding, as pandemic provisions for automatic re-reenrollment expired. The child stopped taking mental health medication and ended up dropping out of school.

“The child wasn’t getting the medicine that they needed, because their family couldn’t afford it,” Freeny said. “The catalyst for that was a lack of Medicaid. That’s just one family.

“Now, you’re multiplying that.”

Family medicine physician Dr. Ian Bennett sees Medicaid patients at the Vallejo Family Health Services Center of Solano County in California’s Bay Area. The community health clinic serves patients from across the area’s rural farm communities and combines primary care with mental health care services, Bennett said.

“When our patients lose Medicaid, which we expect that they will, then we’ll have to continue to take them, and that will be quite a strain on the finances of that system,” Bennett said. The center could even close, he said.

“The folks who are having the most difficulty managing their lives — and that’s made worse by having depression or substance use disorder — are going to be the folks most likely to drop off,” said Bennett, a University of Washington mental health services researcher. “The impacts down the road are clearly going to be much worse for society as we have less people able to function.”

The psychiatric care landscape across Michigan’s rural western lower peninsula is already scarce, said Joseph “Chip” Johnston. He’s the executive director of the Centra Wellness Network, a publicly funded community mental health care provider for Manistee and Benzie counties. The network serves Medicaid and uninsured patients from high-poverty communities.

“I used to have psychiatric units close by as an adjunct to my service,” he said. “And they’ve all closed. So, now the closest [psychiatric bed] for a child, for example, is at least two hours away.”

Those facilities are also expensive. A one-night stay in an inpatient psychiatric facility can be anywhere from $1,000 to $1,500 a night, he said.

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

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