A masked U.S. Immigration and Customs Enforcement agent knocks on a car window in Minnesota on Jan. 12. A new court ruling allows ICE to use Medicaid data, alarming some states and advocates who warn it could have a chilling effect on immigrant families accessing health care. (Photo by Nicole Neri/Minnesota Reformer)

In a win for President Donald Trump’s immigration crackdown, a recent court ruling has cleared the way for U.S. Immigration and Customs Enforcement to resume using states’ Medicaid data to find people who are in the country illegally.

The case is ongoing. But for now, immigrants — including those who are in the country legally — will have to weigh the benefits of gaining health coverage against the risk that enrolling in Medicaid could make them or their family members easier for ICE to find.

Last summer, 22 states and the District of Columbia sued the Trump administration to block information sharing between ICE and Medicaid, the state-federal health insurance program that primarily covers people with low incomes. But at the end of December, a federal judge ruled that ICE can pull some basic Medicaid data to use in its deportation proceedings, including addresses, phone numbers, birth dates and citizenship or immigration status.

The court ruled that in the states that sued, ICE is not allowed to collect information about lawful permanent residents or citizens, nor records about sensitive health information. In the 28 states that didn’t sue, however, the court did not place any limits on the Medicaid information ICE can access.

The U.S. District Court in San Francisco essentially said that government agencies can share some data, including basic identifying information. “That kind of data sharing is clearly authorized by statute,” the decision states.

But the court also ruled that agencies can’t share more sensitive data without adequately explaining why they need it. In his ruling, U.S. District Judge Vince Chhabria wrote that ICE and federal Medicaid information-sharing policies were “totally unclear and do not appear to be the product of a coherent decisionmaking process.” He said the states had shown they would “suffer irreparable harm from these vague and likely overbroad” policies.

By law, federal Medicaid money cannot be used to cover people who are in the country illegally.

But in recent years, nearly half of states, including some led by Republicans, have chosen to use their own Medicaid money to extend coverage to certain groups of people, such as children and pregnant women, regardless of immigration status.

Advocates for immigrants and some state officials worry that ICE’s use of Medicaid data will cause widespread fear among immigrant families, keeping them from seeking the health care that states have said they’re eligible to receive. California’s health department recently called the administration’s actions “a grave breach of public trust.”

“States have constantly reassured people that their health care information won’t be used against them, and that’s changed,” said Tanya Broder, senior counsel for health and economic justice policy at the National Immigration Law Center, an advocacy organization focused on immigrant rights.

Court filings in the lawsuit illustrate the potential impact of the ruling.

In Chicago, for example, a patient at an Esperanza Health Center delayed her first prenatal visit until her third trimester because she worried enrolling in Medicaid could put her husband at risk of deportation, the clinic reported in a December court filing. By the time she received care, she had complications that could have been addressed with earlier health visits. Another patient refused to apply for Medicaid for her child, a U.S. citizen, because she worried that seeking benefits would allow ICE to locate her.

“The expectation of privacy that we all have when we seek to enroll in a health care program has been compromised,” said Broder.

“Not only undocumented immigrants but people who live in families with immigrants and the broader community are going to feel less comfortable in applying for these health programs, over concerns their information is going to be weaponized against them or their family members.”

An about-face

Several months into Trump’s second term, ICE gained access to the personal data of 79 million Medicaid enrollees as part of its efforts to find people who may be living illegally in the United States.

Data on Medicaid enrollees is routinely exchanged between states and the feds, including to verify eligibility to receive federal funding. But the new agreement marked an about-face from past federal policies of not using such information for immigration enforcement.

The effort is unprecedented at the national level, said Medha Makhlouf, a law professor at Penn State Dickinson Law who specializes in health and immigration.

“Previously the federal government has balanced immigration enforcement interests with the protection of health-related interests,” she said. “Now they’re weighing much more heavily the interests of immigration enforcement.”

That puts the federal government at odds with states that have expanded health coverage as a matter of public health and economic policy, she said. Many states have extended coverage to a wider swath of people on the premise that broader coverage helps prevent the spread of disease, prioritizes preventive care over more costly emergency treatment and reduces economic losses when employees miss work because of illness.

The judge’s order will stand until the case is resolved, as the judge considers what kinds of data can be released for use in immigration enforcement.

California Attorney General Rob Bonta, a Democrat, said in a July statement that the Trump administration’s data-sharing move was illegal and “created a culture of fear that will lead to fewer people seeking vital emergency medical care.”

Federal officials say they’re allowed to use lawfully collected information for immigration enforcement purposes.

The Department of Homeland Security and ICE did not respond to requests for comment.

Broder, of the National Immigration Law Center, said it isn’t clear whether the limited information the court has allowed the Department of Homeland Security to use can be cleanly separated from data belonging to citizens and lawful permanent residents. The ruling says that if that basic data can’t be separated from data that’s still protected, Medicaid can’t share it with ICE.

California’s Department of Health Care Services, which administers the state’s Medicaid program, emphasized that concern in a statement updated earlier this month. The department said the feds haven’t provided any information about how they plan to implement the court’s order.

Meanwhile, some states are looking at their options for protecting their Medicaid data. Oregon Health Authority Director Dr. Sejal Hathi called the move to use Medicaid data for immigration enforcement “disappointing, to say the least” in a public board meeting earlier this month.

She said her agency is “committed to doing all that we can within our authority to protect the health privacy of our members” and is working with health providers to “ensure that Oregonians, no matter their background, can continue to seek and receive quick and responsive health care without worrying about the safety of their health information.”

States step up

In recent years, an increasing number of states have used their own money to extend health insurance coverage under their Medicaid programs to some noncitizens, such as people with green cards, refugees and those with temporary protected status.

For example, 14 states and the District of Columbia cover income-eligible children regardless of immigration status, while seven states and the district offer state-funded coverage to some adults with low incomes, regardless of immigration status. Nearly half of states — including a handful of red states — cover income-eligible pregnant women, regardless of their immigration status.

Makhlouf, of Penn State, directs a legal clinic at her law school where law students assist people who face legal barriers to getting health care and other public benefits. The students have fielded questions from parents — even those who are in the country legally — who have asked if applying for Medicaid for their children, who are U.S. citizens, jeopardizes their own legal status or exposes household members to scrutiny from ICE.

“We see the chilling effects directly,” Makhlouf said. “Folks have many more questions about the risks versus the benefits of applying for government programs. It should be an easy decision for families to accept help, but it’s not easy anymore.”

In the past year, the Trump administration also has ordered states to hand over personal data from sources including voter rolls and food stamps, even as it consolidates information held across federal agencies into a trove of information on people who live in the United States.

In November, a federal judge blocked the IRS from sharing taxpayer information for immigration purposes.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

Sarah Simmons, a midwife and co-owner of Maple Street Birth Center in rural Okanogan County, Wash., holds a newborn. Freestanding birth centers can address maternal health inequities, but many are facing mounting financial and regulatory pressures. (Photo courtesy of Sarah Simmons)

Dr. Heather Skanes opened Alabama’s first freestanding birth center in 2022 in her hometown of Birmingham. Skanes, an OB-GYN, wanted to improve access to maternal health care in a state that’s long had one of the nation’s highest rates of maternal and infant mortality.

Those rates are especially high among Black women and infants. Skanes’ Oasis Family Birthing Center opened in a majority-Black neighborhood, offering midwifery services as well as medical care.

But about six months after the center’s first delivery — a girl who was Alabama’s first baby born in a freestanding birth center — the state health department ordered Skanes to shut it down. A department representative informed her that by holding deliveries at the birth center, she was operating an “unlicensed hospital,” she said.

Hospital labor and delivery units are shuttering across the nation — including more than two dozen in 2025 alone. Freestanding birth centers like Skanes’ could help fill the gaps, but they too are struggling to stay open.

They face some of the same financial pressures that bedevil hospitals’ labor and delivery units, including payments from insurers that don’t cover the full cost of providing maternity care.

Birth center owners also must contend with arcane state rules and antipathy from politically powerful hospitals that view them as competition, especially in rural areas with few births.

Nationwide, the number of freestanding birth centers doubled between 2012 and 2022, but more recently the pressures have taken a toll: About two dozen centers have closed since 2023, bringing the total number down to about 395, according to the most recent data from the American Association of Birth Centers.

In November, Pennsylvania Lifecycle Wellness and Birth Center announced it would shut down birth center services, citing pressure from regulatory challenges and sharp surges in malpractice premiums. It had served Philadelphia for 47 years. And New Mexico’s longest-operating freestanding birth center stopped delivering babies in December.

“When a new business opens, within the first three to five years you expect a certain number will close,” said Kate Bauer, executive director of the American Association of Birth Centers. “But we’ve had several long-standing birth centers close [in 2025] and that hits particularly hard.”

In California, which has some of the strictest birth center licensing rules in the country, concern over the closure of at least 19 birth centers between 2020 and 2024 prompted the state legislature to pass a law in October to streamline birth center licensure.

An appealing alternative

Freestanding birth centers are not attached to hospitals and aim to provide a more homelike, less traditional medical setting. They employ midwives and focus on low-risk pregnancies and births. Some also have an OB-GYN or family medicine doctor on staff, and they often have partnerships with nearby hospitals and doctors if more specialized care is required.

Some Black and Indigenous midwives and doulas say birth centers can be helpful alternatives to their community members, many of whom have had experiences in more medicalized settings that left them feeling marginalized, dismissed or unsafe.

Midwife Jamarah Amani, executive director of Southern Birth Justice Network, runs a mobile midwifery clinic serving majority-Black and Latino neighborhoods in Miami-Dade County, Florida. The nonprofit, which aims to make midwife and doula care more accessible, recently bought a building for a freestanding birth center it aims to open in 2027.

“[Midwifery] presents like a luxury concierge-type of service, and our goal is to really change that and to bring it back to the community in a very grassroots way,” Amani said. She added that expanding access to prenatal care could help address inequities in maternal health, as maternal death rates among Black women are three times higher than those among white women.

Freestanding birth centers also can be a solution for communities without a hospital nearby.

The closest hospital to the Colville Indian Reservation, located in northern Washington state, is half an hour away, said Faith Zacherle-Tonasket, founder of the nonprofit xa?xa? Indigenous Birth Justice.

So far, the group has trained nearly a dozen tribal doulas and midwives to serve the area. In the next few years, it plans to open a freestanding birth center. Zacherle-Tonasket said Indigenous-run birth centers are crucial alternatives for tribal women, who also have some of the highest maternal mortality rates in the nation and often face prejudice in clinical settings.

“They don’t feel safe. So a lot of them just don’t get prenatal care,” said Zacherle-Tonasket. “Bringing traditional midwives that are from our own communities, that were born and raised in our communities, that know the families — we know that those babies will be birthed with love.”

Regulatory hurdles

When the Georgia legislature relaxed state health care regulations in 2024, it felt like a long-awaited win for Katie Chubb. A registered nurse and mother of three who’s worked in health and nonprofits, Chubb has spent years trying to open a birth center in Augusta.

The state denied her application to open the center in 2021. Georgia, like many states, requires health care providers to get state approval, called a certificate of need, before they can build a new facility or expand services. Rival providers, like other hospitals, can challenge an application, effectively vetoing their local competition.

That happened in Chubb’s case: Two local hospitals filed letters of opposition against her and refused to say they’d accept emergency transfers from her birth center, another requirement for opening.

Georgia currently has three freestanding birth centers, a fraction of the more than two dozen that operate in neighboring Florida.

“We’re seeing women giving birth in hospital hallways or at home unassisted, because there’s no in-between option like a birth center,” Chubb said. In October, Georgia lost another labor and delivery unit at a rural hospital two hours north of Augusta.

“Women are just left to figure things out.”

In Kentucky, the Republican-controlled legislature passed a bill in March that aimed to clear the way for freestanding birth centers by exempting them from the certificate of need process.

But Republican lawmakers attached a last-minute anti-abortion amendment to the bill, prompting Democratic Gov. Andy Beshear to veto it. The legislature eventually overrode his veto. Midwifery advocates hope the new law will help make it easier to open a birth center in the state.

Georgia legislators similarly revised Georgia’s certificate of need rules in 2024, exempting freestanding birth centers. Chubb, who championed the new law, hoped it would clear the path for herself and others.

But they hit another roadblock. The state still requires birth centers to secure a written agreement with a local hospital to accept transfers of clients in emergencies. Chubb and at least one other prospective birth center owner have been unable to get their local hospitals to sign such transfer agreements.

“We’re still fighting,” Chubb said. “Behind closed doors we’re still working very hard on getting legislation and regulations changed to make opening birth centers more equitable.”

Some hospitals view birth centers as a threat to the viability of their labor and delivery units, siphoning off patients and revenue from a service that’s already unprofitable for most hospitals.

Daniel Grigg, CEO of Wallowa Memorial Hospital, a 25-bed critical access hospital in northeast Oregon, said there aren’t enough births in the area for both hospitals and birth centers.

“When you’ve got a small-volume community like we have, every birth helps the providers keep their skills up and their competency,” he said. “When you’ve got a midwife taking, say, 10 patients out of that pool,” it can have an impact on physicians and hospitals.

Alabama lawsuit

After the Alabama Department of Public Health shut down Skanes’ birth center in 2023, she joined with two other women who had also been attempting to open birth centers in Alabama: Dr. Yashica Robinson, an OB-GYN in North Alabama, and Stephanie Mitchell, a licensed midwife in Alabama’s rural and economically disadvantaged Black Belt region. Together they sued the Alabama Department of Public Health over what they called a de facto ban on birth centers.

The state insisted its tighter regulations would ensure that birth center facilities are safe. The birth center owners said the state’s rules were overly burdensome and clinically unnecessary for the low-risk, nonsurgical births that are attended by midwives. And, they said, the rules prevented more families from accessing care where it’s desperately needed. The state has lost at least three hospital labor and delivery units since 2020.

“Entire swaths of the state are maternity care deserts without access to essential health care,” said Whitney White, a staff attorney with the American Civil Liberties Union, which is representing the birth center owners and their co-plaintiff, the Alabama affiliate of the American College of Nurse-Midwives.

“Hospital labor and delivery units are closing, and pregnant folks are reporting they’re really struggling to access the care they need, struggling to get appointments, struggling to find a provider,” White said.

Last May, an Alabama trial court permanently blocked the state from regulating freestanding birth centers as hospitals. Birth center staff are still overseen by state boards of midwifery and nursing.

All three Alabama centers are now open. But their licensed midwives are delivering babies under a cloud of uncertainty about the future.

The state appealed the ruling in November. The case is ongoing.

Struggles and solutions

Bauer, of the American Association of Birth Centers, said many centers face the same financial barriers. Uncomplicated births at freestanding birth centers cost less than they do at hospitals, but research has shown that insurers, including Medicaid, reimburse centers at lower rates. Some state Medicaid programs don’t cover some of the nonclinical services, such as lactation consultants and doulas, that birth centers may provide. And malpractice premiums are rising.

“We’re volunteering our time, essentially, to keep the birth center open as a service to the community,” said Sarah Simmons, co-owner of Maple Street Birth Center in rural Okanogan County, Washington. The center can’t afford to hire a front-desk staffer or another midwife, Simmons said. She added that on average, the center makes less than a third of what the local hospital makes for providing the same obstetric service.

But there may be solutions to some of these financial problems. For example, the Center for Healthcare Quality and Payment Reform, a national health care policy center, has recommended that health insurance plans, both Medicaid and commercial, pay hospitals and birth centers monthly or quarterly “standby capacity payments” per woman of childbearing age covered by that health plan in the facility’s service area. It also recommends that plans pay a separate delivery fee for each birth.

In 2024, Democratic U.S. senators proposed a bill to allow for a similar payment model.

Standby payments could help freestanding birth centers, especially those that fill gaps in maternity care deserts — but not unless centers receive payments that are comparable to those that hospitals get, said Simmons, whose center serves four sparsely populated counties along with the Colville tribal communities.

“This would be most beneficial to freestanding birth centers if pay parity laws were enforced, so rural freestanding birth centers were paid the same rates for the same services as rural hospitals, ” she said.

State grants also can help, but birth centers say a one-time infusion won’t be enough. In 2024, Washington opened grant applications for distressed hospital labor and delivery units and freestanding birth centers.

Ashley Jones, of True North Birth Center and president of the Washington chapter of the American Association of Birth Centers, said the grant has helped keep their doors open.

Meanwhile, Chubb, the Georgia nurse, recently had to take another job to support her family while her birth center remains in legal limbo.

“I’m just waiting until the government figures out what they’re doing.”

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org. Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.