WASHINGTON — State officials say they need more information from the Trump administration before they can fully implement new requirements for Medicaid, according to a survey released Thursday by KFF and the Georgetown University Center for Children and Families.

Republicans’ “big, beautiful” law made several changes to the state-federal health program for lower income people and some people with disabilities, including that enrollees between the ages of 19 and 65 work, participate in community service, or attend an education program for at least 80 hours a month.

The survey of Medicaid program officials from 43 states showed the people tasked with implementing the law have questions about how exactly they should determine if someone meets the new requirements or is exempt. 

“In addition to how to define medical frailty, states wanted additional direction in many areas including what qualifies as community service, how to calculate half-time school attendance, and what is considered a ‘significant relationship’ to qualify for the caregiver exemption,” the report states. “They also indicated they need guidance about what sources can be used for verification, whether self-attestation will be allowed if other sources are not available, and how long verification of exemptions remain valid.”

The law includes several additional carve-outs, including for Medicaid enrollees who are pregnant, have dependent children, are tribal community members or are in the foster care system, and for individuals released from incarceration in the last 90 days, among others.

The vast majority of state officials surveyed said they would implement the new requirement for work, education, or community service at the start of next year.

There are, however, a few states moving forward earlier. 

Nebraska plans to begin May 1, Montana on July 1 and Iowa officials said they will begin this year, though they haven’t provided a date, KFF said. Arkansas has planned a “soft launch” for July but won’t actually remove anyone from Medicaid for not meeting the new requirements until next year, according to the report.

Hardship exemptions

The KFF-Georgetown survey says that nearly all states will allow hardship exemptions for people in counties with higher unemployment; those who recently experienced a natural disaster; those who have been admitted to a hospital or nursing facility; or those who need to travel outside their community for medical care.

Indiana and Iowa are the only two states so far that don’t intend to allow any hardship exceptions from the requirement that Medicaid enrollees work, attend community service, or enroll in an education program, the report said. 

“Oklahoma is not adopting the exceptions for residents of counties with high unemployment or with a declared natural disaster while Missouri is not adopting the exception for residents of counties with high unemployment,” the report says. “New York is not planning to adopt the exception for individuals traveling outside their community for medical care. Twelve states had not made a decision.”

Look-back periods vary

Thirty-six states will look back one month when someone applies for Medicaid to determine whether they’re working, participating in community service, or enrolled in an education program. Indiana and Idaho will look back at the last three months before the person applied to determine whether they meet the new requirement. 

Thirty-four states will look back one month during the renewal process, which must happen at least every six months under the law. 

“Indiana and New Hampshire will check quarterly and at renewal to verify that enrollees meet the requirements every month between renewals,” according to the report. “Arkansas will also look back three months at renewal but is not planning quarterly checks. States that had not made a decision at the time of the survey included five states for application, six states for renewal, and seven states for more frequent checks.”

Three years after a miscarriage that caused a severe, nearly septic infection because a Tennessee hospital denied her an abortion, Katy Dulong was looking forward to telling her story in a trial that was scheduled to begin Monday.

But this week, the state appealed to a higher court based on a new law passed by the legislature in March, and the court put the trial on hold indefinitely. It will now be months before the lower court can proceed.

Dulong had complications that led to a miscarriage in November 2022 at 16 weeks of pregnancy, long before fetal viability. Under the state’s abortion ban, which had only been in place for a few months, the hospital sent her home to miscarry on her own. When that didn’t happen, severe infection started to set in 10 days later, when she was able to get doctors to agree to help. The experience left her with post-traumatic stress disorder.

Tennessee bill expands attorney general rights to appeal case rulings

The delay in the legal case feels like the state trying to silence her and the other plaintiffs, she said.

“It’s shocking to me that there’s anyone in this world that would have such opposing views to think that our voices don’t matter,” Dulong said in an interview. “How are they taking away our voice right now?”

In a motion to dismiss in February, the state argued it couldn’t be sued by the plaintiffs under a term called sovereign immunity, and in April, the Tennessee Legislature passed a law making it harder to sue the state on the constitutionality of a state or government action. Legislators passed another bill allowing the state to automatically appeal a decision related to sovereign immunity.

Nicolas Kabat, a staff attorney at the Center for Reproductive Rights who has been working on the case with the plaintiffs, said the state has tried to have the case dismissed four times without success, and said this is just the latest move to delay the trial. But he said the latest laws passed by the legislature allowing automatic appeals in the middle of a case, on the eve of a trial, make the situation unique.   

“There is nothing unusual about appealing an appealable order,” said Phil Buehler, press secretary for Tennessee Republican Attorney General Jonathan Skrmetti, in an email Thursday.

Similar lawsuits are ongoing or have already been resolved in several states with bans, including Texas and Idaho, where state residents have challenged the law based on their personal experiences. Plaintiffs in Idaho won their case in April 2025, when a judge said the near-total abortion ban does not mean a pregnant patient’s death has to be imminent or “assured” to perform an abortion. Complaints are also pending related to Texas hospitals allegedly not complying with federal law mandating emergency room treatment for a patient who needs an abortion as stabilizing care.

Women with serious pregnancy complications sue over state abortion bans

Allie Phillips, the lead plaintiff in Tennessee, joined several other women to sue the state in September 2023, alleging that the abortion ban put their health and lives in jeopardy when they were pregnant. They asked the state to clarify the law so that health is considered in an abortion decision, not just an immediate threat to a pregnant patient’s life. The way the law is written, attorneys argue, is too vague to allow for those exceptions.

Phillips and Nicole Blackmon, another plaintiff, had fetuses with anomalies related to the development of vital organs. Blackmon couldn’t afford to travel out of the state for an abortion, and eventually had to stop working because the pregnancy was affecting her health. She delivered a stillborn baby in her seventh month of pregnancy. Phillips raised enough money to seek an abortion in New York, only to find when she got there that the fetus had already died.

After the court granted a temporary block on the law as it relates to pregnancy complications, the state passed several laws that affected the case. The first bill, meant to clarify the state’s health exception for an abortion, was enacted in April 2025 but didn’t solve the issue, Kabat said. The language still wasn’t clear enough, and the court agreed and allowed the suit to continue.

Kabat said the legal team will continue its effort to clarify Tennessee’s laws so that stories like Dulong’s don’t happen to others.

“No matter how long this takes, we’re going to get the trial, we’re going to get these stories heard and we’re going to seek accountability from the state,” Kabat said.

Stateline reporter Kelcie Moseley-Morris can be reached at kmoseley@stateline.org. 

This report was updated at 1:35 p.m. 4/23/2026.

Employees of two Wisconsin clinics operated by Rogers Behavioral Health voted by large majorities in favor of union representation Wednesday after more than two months in which the mental health nonprofit had campaigned heavily against the union.

In West Allis, employees voted 53-4 in favor of joining the National Union of Healthcare Workers. In Madison, the vote to join the union was 26-4. The votes were supervised by National Labor Relations Board officials at both clinics.

Employees at the two clinics “are ready to negotiate contracts that would provide better pay, protections to ensure safe staffing levels and more time to care for individual patients, as Rogers workers secured in California after joining NUHW,” the union stated in a press release Thursday.

The union represents Rogers employees at three facilities in California, where contracts have been negotiated, and one in Philadelphia, Pennsylvania, where contract negotiations are underway. “While contract negotiations are still ongoing in Philadelphia, the contracts Rogers agreed to for workers based in the Bay Area, Los Angeles and San Diego are among the best in the industry,”  the union statement said. “They include strong raises, limits on caseloads, and guarantees that no jobs will be lost to new technologies, including artificial intelligence.”

Rogers, based in Oconomowoc, said in a statement released Thursday, “We acknowledge the union election outcomes in Madison and West Allis Lincoln Center. We are evaluating our next steps in support of our system of care. We are committed to our patients, our people, and the integrated care that has made Rogers a trusted provider across Wisconsin since 1907.”

The union said in its press release that during the West Allis election Wednesday, Rogers management “prohibited NUHW’s representative from entering the facility and then suspended a worker who had agreed to serve as the union’s observer.”

Federal labor law procedures call for representatives from management as well as the union to observe the vote count. The absence of a union observer “could have resulted in the ballots being impounded and not immediately counted,” the union press release stated.

A second Rogers employee volunteered to serve as the union observer for the count “over the objections of Rogers’ representatives,” the NUHW stated, adding that Rogers did not attempt to stop ballots from being counted at the Madison clinic.

The workers involved were among three employees fired shortly after workers announced their petition for a union. The union has filed unfair labor practice charges over the terminations, claiming that the three were fired in retaliation for their support for unionization, which is illegal under federal law.

Rogers has declined to explain the firings, citing employment confidentiality, but said that it has not violated any laws.

Rogers Behavioral Health issued a follow-up statement Thursday about the voting conflict in West Allis. According to the statement, “individuals who are no longer employeed by Rogers had illegally entered the facility,” and Rogers contacted local police.

The next step will be for the National Labor Relations Board to certify the results. But a federal lawsuit challenging the agency is still pending. In addition, Rogers said in public statements as well as in communications to the workers before the vote that the company would not begin bargaining with the union until all its appeals have been exhausted. 

The nonprofit campaigned actively against unionization, telling employees that a union would not have been in the interests of the staff, the patients or the organization. In a final letter distributed on Monday, Rogers urged employees to vote no and made statements that the organization had made mistakes and wanted to be given another chance to improve relationships with the staff without a union.

Union supporters welcomed the outcome of Wednesday’s votes.

“We are thrilled with the overwhelming victory,” said Stephani Lohman, a nurse practitioner who was among those active in the union organizing campaign and was one of the three fired employees. “Over the last few weeks Rogers has shown us exactly why we need a union by running an aggressive anti-worker campaign, trying everything in their toolbox to intimidate and demoralize us, but it failed spectacularly because it was so cruel and wicked that it drove everyone to support the union.”

According to union supporters, the union campaign began late last year after changes at Rogers that included clinicians being reclassified from salaried to hourly, which resulted in schedule changes that increased patient volumes for staff members and reduced individual patient care. The organization increased caseload caps, “forcing caregivers to be responsible for far more patients than previously,” the NUHW said in its statement.

This report has been updated with additional information and comments Thursday from both the National Union of Healthcare Workers and from Rogers Behavioral Health. 

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A federal judge in Milwaukee rejected a bid from Rogers Behavioral Health Tuesday to block a pair of union elections scheduled for Wednesday at Rogers mental health clinics in West Allis and Madison.

The decision sets the stage for votes to go forward at both clinics. About 35 employees at Rogers’ Madison clinic and about 68 at the West Allis clinic will vote Wednesday on whether to be represented by the National Union of Healthcare Workers.

Rogers, based in Oconomowoc, had argued that the union election should cover all 13 Rogers facilities in Wisconsin — not just the two where employees had actively organized. But in a direction of election issued April 14, the NLRB regional director whose jurisdiction includes Wisconsin said those two clinics alone were each appropriate bargaining units.

On Monday, Rogers lawyers filed a lawsuit to block both elections. U.S. District Judge Lynn Adelman denied the mental health nonprofit’s petition for a temporary restraining order Tuesday after an online hearing that ran a little more than 40 minutes.

“I don’t think that they’ve established unconstitutional irreparable harm,” Adelman said of Rogers’ lawyers.

The Rogers lawsuit echoed a recent line of legal challenges that have sought to unravel the National Labor Relations Board — the 91-year-old agency created under President Franklin Delano Roosevelt as part of his administration’s New Deal to secure rights for workers and help the U.S. recover from the Great Depression.

One of Rogers’ lawyers, Aron Karabel, argued that the members of the NLRB itself as well as the regional director who issued the union election order are unconstitutional because they aren’t subject to dismissal by the president, violating the separation of powers in the U.S. Constitution.

Similar arguments have been made by other businesses, including Amazon and SpaceX, but the U.S. Supreme Court has not endorsed the claim.

Karabel’s colleague, Hannah Fitzgerald, argued that under Wisconsin law, the NLRB regional director had engaged in “tortious interference” with existing employment contracts for some of the Rogers employees who would be included in the union election bargaining unit. For that reason as well as other reasons, the election could cause “irreparable harm” to Rogers, Fitzgerald asserted.

Representing the NLRB, lawyer Craig Ewasiuk said that a Supreme Court ruling 82 years ago established that individual contracts “may not be availed of or to defeat or delay the procedures prescribed by the National Labor Relations Act” to further collective bargaining.

“The Supreme Court has spoken unambiguously on this question, and you simply can’t bring tortious interference acts against the NLRB for running elections,” Ewasiuk said.

Karabel argued that Rogers’ case was not about collective bargaining — which would prevent the federal court from acting until after final action by the NLRB — and for that reason, the court was an immediately appropriate venue.

The NLRB lawyer rejected that argument. ‘’The employer is essentially trying to stop the board’s proceedings from resolving this underlying labor dispute,” Ewasiuk said.

Staunch resistance to the union

Rogers Behavioral Health has mental health clinics and hospitals in 10 states. Employees are already represented by the National Union of Healthcare Workers at four clinics — three in California and one in Philadelphia, Pa. — and at three of those, the union was recognized voluntarily.

But in its home state of Wisconsin, Rogers has taken a much different posture.

Three employees were fired shortly after the union campaigns went public, according to the union, and the NUHW has filed unfair labor practice charges claiming the firings were illegal retaliation for union support.

Rogers has declined to discuss the firings as confidential personnel decisions but has stated they were not in violation of any laws.

From when employees first notified Rogers management of their desire for union representation, however, Rogers has posted notices and issued statements declaring that the mental health nonprofit doesn’t want  union representation for the West Allis and Madison employees.

“Many of your colleagues, your leaders, and I strongly believe that this union is not in the best interests of you, your family or our patients,” said one notice, stating it was from clinic leaders but without a name attached, that was shared with the Wisconsin Examiner. “We believe you should vote no and allow our team the opportunity for positive and direct collaborations.”

In March, Rogers’ executive director of marketing and communications, Maureen Remmel, responded to a question from the Examiner about the difference between Rogers’ responses at its California and Pennsylvania clinics and its handling of the union campaigns in Wisconsin

“While we work in good faith with the NUHW in California and Pennsylvania, our integrated system in Wisconsin is different,” Remmel said in an email message  March 17. “A direct relationship with our Wisconsin team members best serves employees, patients, and the company.”

At an NLRB hearing in February to establish the appropriate bargaining units for the Wisconsin clinics, Rogers’ lawyer argued that flexibility across multiple facilities was important and necessitated allowing all 13 Wisconsin locations to vote on union membership.

A statement attributed to the organization as a whole that Remmel sent April 16, after the election order was issued, asserted, “A union is not right for Rogers Behavioral Health in Wisconsin because it jeopardizes our ability to work together to solve problems quickly and flexibly.”

Jennifer Hadsall, the NLRB regional director, wrote in her analysis that there was little evidence of “functional integration” across the system to overcome the presumption that the two facilities where employees had organized were by themselves appropriate bargaining units.

Hadsall also rejected Rogers’ argument that certain employees were supervisors and therefore not eligible to be part of their facility’s bargaining unit.

Professional consultants

Starting in early February, Rogers has hired consultants to assist in managing its response to the union campaigns, according to LaborLab, a nonprofit based in Helena, Montana. LaborLab monitors the industry of consultants who advise and assist employers in responding to union drives.

Under the federal Labor-Management Reporting and Disclosure Act, employers and the consultants they hire to persuade employees “directly or indirectly” about unionizing must regularly file reports with the federal government. Employers file LM-10 reports and consultants file LM-20 reports as well as LM-21 annual financial reports.

While advocates for greater disclosure complain that those reports are often late or incomplete, they offer some information about those businesses.

LaborLab has identified three consultants working for Rogers since early February, when pro-union employees in Madison and West Allis petitioned for voluntary recognition. Two were identified through their LM-20 reports and one was named by union supporters during a radio interview with WORT-FM, the listener-sponsored community radio station in Madison.

LaborLab has estimated the consultants’ fees total about $50,000 a week, or more than $325,000 through April 1. Those don’t include the cost of attorneys representing the business on legal matters connected with the union campaign or “internal costs” that LaborLab’s calculations impute to employees assigned to directly address the union organizing effort.

“It’s hard to be precise because there are a lot of variables in these campaigns,” said Teke Wiggin, LaborLab’s strategic coordinator. “But we think that workers should have some general sense of how much is being invested in these campaigns.”

Wiggin said in an interview that some consultants interact only with corporate managers and executives, while others hold meetings with employees themselves, an action that requires disclosure in federal reports.

“They take arguments that have been crafted by industrial psychologists to sow as much fear and doubt about the value of unionization as possible,” Wiggin said.

In a letter sent to Rogers Feb. 25, 20 local and state elected officials criticized the organization for having “hired union busters” and urged the organization’s CEO to “immediately stop wasting patient care dollars on union busters paid to try to intimidate workers from organizing.”

Rogers did not respond to a question from the Examiner about its use of consultants in the organizing campaign.

In a response to the elected officials that was signed by “Rogers Behavioral Health,” the organization said it has “retained consultants to better understand and address the concerns shared by our employees and to raise awareness about their rights and the election process.”

Messages to employees

In a media statement April 16 after the election was scheduled, Rogers reiterated the organization’s position that a union was not the right choice for its employees and its intention to appeal the regional director’s finding after the election.

The day before, Rogers management emailed employees with a similar message, stating, “We are disappointed and disagree with this decision and are appealing to the full NLRB in Washington, D.C.”

The final line of the message was, “Regardless of the election outcome, bargaining will not start with the union until all appeals have been exhausted.”

The Wisconsin Examiner was provided screenshots of the message.

Employees involved in the union campaigns said that shortly after it landed in their inboxes, that message was remotely deleted, possibly because it was recalled.

On Monday, Rogers distributed another letter at both the West Allis and Madison locations that took up about a page and a half.

“We want to be direct with you today: change is coming to Rogers,” states the letter, photos of which were shared with the Examiner. “You will see it. We are working on it. That is why we are asking you to vote no on Wednesday and allow leadership 12 months to demonstrate to you, your colleagues, patients and families our commitment to making Rogers better than ever.”

Under federal labor law, if a majority of employees vote against a union in a representation election, the employees must wait at least 12 months before seeking a union again.

The members of Rogers’ leadership team “have heard you,” the letter states. “We know that there are things we can do and must do better.”

The letter’s final paragraphs reiterated both the vow to improve relations and a plea to vote against the union.

“The leadership team is committed to doing better. Today we are asking you to please give us 12 months. Vote ‘no’ in the upcoming election and give us a chance to show our commitment in action. If we do not come through for you, the law gives you the right to hold another election. Rogers will honor your choice in that election.

“Please vote ‘no’ on April 22. Vote to hold Rogers leadership accountable.”

Federal court records show Rogers filed its lawsuit to block the vote the same day that employees received that letter.

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Elected leaders and public health officials in Milwaukee gathered at the Marcia P. Coggs Center for Health & Human Services building to announce that opioid overdose deaths in Wisconsin’s most populous county have declined for the fourth straight year in a row. 

According to data provided through the county’s overdose dashboard, there has been a 17.7% decrease in fatal overdoses and a 22.7% decrease in fatal opioid overdoses since 2024. There has been a 42.6% decline since 2022 in all forms of overdose death, with a 54.6% decline in opioid-related overdose deaths specifically.

Milwaukee County Executive David Crowley praised the use of opioid settlement funds to expand  treatment and harm reduction strategies. The funds originate from lawsuits against the producers and distributors of pain killers that triggered the opioid crisis. The nationwide epidemic of addiction and overdoses is also tied to the powerful synthetic opioid fentanyl which began spreading in  the mid-2010s, causing deaths on an unseen scale.

“As we acknowledge the progress we have made, we must also remember those we have lost,” said Crowley. “Their lives matter, and their stories remind us why this work is so critical. I am committed to continuing this work until every person in Milwaukee County has access to the care, support and second chances they deserve.” 

The latest data shows that 387 people in Milwaukee County still lost their lives to an overdose last year. “These are our neighbors, these are our loved ones, these are our family members,” said Crowley, “people who we care about that live in our own communities.” At a press conference Tuesday, Crowley said he has seen family and neighbors struggle with addiction as he grew up. “And I saw firsthand the barriers that they faced when trying to access treatment, but also continue to take those steps towards healing,” said Crowley. “Healing is a lifelong journey. So to me these aren’t just numbers on a dashboard. They’re people, and even one overdose death is one too many.” 

Milwaukee County will receive $111 million over the next 18 years through the opioid settlements. This represents the largest amount recovered by a local government in Wisconsin history, a county press release states. 

“Three years ago, we were losing a life to opioid overdose every 16 hours,” said Chief Health Policy Advisor Dr. Ben Weston, praising the sharp decline in deaths since then.

Weston recalled an April weekend three years ago when there were 16 overdose deaths in Milwaukee County. The scale of the epidemic was “unimaginable” Weston said, and it forced emergency management staff, firefighters, police and community members  to “say enough,” said Weston. 

Over the  last several years Milwaukee County adopted multiple harm reduction strategies. Narcan — the nasal spray used to revive someone from an opioid overdose — has been distributed in vast quantities to emergency responders and average citizens. There are also 27 free-to-use harm reduction vending machines around the county providing narcan, fentanyl testing strips and even gun locks. 

The vending machines were launched through a Department of Health and Human Services program called Harm Reduction MKE. Another program called Pull Up & Pick Up offers residents the opportunity to order free supplies and pick them up at the Coakley Brothers building (400 S. 5th St) on the third Friday every month. Vivent Health Depot has also partnered with Milwaukee County to provide free harm reduction supplies delivered right to people’s homes. 

“We’ve expanded community paramedicine programs and peer support to close the gaps in care and reach people who might never otherwise have entered into the system,” said Weston. “And we’ve partnered with the state using real-time overdose data and predictive learning and modeling to better understand who is at highest risk, and be able to intervene early.” 

Treatment centers have also worked to overcome zoning restrictions and stigma to open in new parts of Milwaukee. Treatment access has also been expanded for people both entering and leaving incarceration, a particularly dangerous time when people are more likely to overdose, Weston said. 

“At the Medical Examiner’s Office, we see firsthand the human toll of this crisis, and while the data shows progress, it also reminds us that this work is far from over,” said Dr. Wieslawa Tlomak, Chief Medical Examiner of Milwaukee County. ”

Tlomak said that it should concern everyone that every third or fourth death in Milwaukee County is due to drug overdose. She noted that usually overdose deaths are caused by multiple drugs. While Narcan can reverse an opioid overdose from fentanyl, there is no equivalent medication to reverse the effects of stimulants like cocaine or meth. “In other words, the landscape of overdose deaths has changed,” said Tlomak. “It is more complex, more unpredictable, and more difficult to treat.”

Tlomak said that of the 387 people who died of fatal drug overdoses last year, 263 involved opioids. 

Jeremey Triblett, Prevention Integration Manager at the Department of Health and Human Services, highlighted the importance of new campaigns in Milwaukee to continue to reduce overdose deaths. One program, dubbed “Better Ways To Cope,” provides residents with strategies to deal with life problems. 

On June 12, recognized as National Harm Reduction Day, the Department of Health and Human Services is inviting residents to participate in the 1,000 Doors Challenge, a neighborhood canvassing project aimed at spreading information and supplies to the people who need it. 

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Two right-wing organizations are taking aim at the ban on conversion therapy in Wisconsin’s professional code for social workers, citing a recent U.S. Supreme Court ruling.

But the head of a group that fought for the ban says professional standards are the central issue — and aren’t subject to free speech claims. 

In a joint letter Wisconsin Family Action and the Wisconsin Institute for Law & Liberty are demanding that Wisconsin repeal the ban. Conversion therapy is a widely discredited practice purporting to change sexual orientation or gender identity.

The Wisconsin Marriage and Family Therapy, Professional Counseling, and Social Work Examining Board included the ban in its updated professional code published in April 2024.

The code declares that it is “unprofessional conduct” for practitioners to use or promote “any intervention or method that has the purpose of attempting to change a person’s sexual orientation or gender identity, including attempting to change behaviors or expressions of self or to reduce sexual or romantic attractions or feelings toward individuals of the same gender.”

WILL has been at the center of many conflicts over trans-inclusive policies and gender identity. Wisconsin Family Action has also lobbied against including gender identity in state civil rights protections.

Their letter seeking the conversion therapy ban’s repeal cites a U.S. Supreme Court ruling March 31 in a lawsuit that challenges Colorado’s law banning conversion therapy on First Amendment grounds.

The high court ruling didn’t throw out the Colorado law directly. Instead, it instructed the federal court hearing the Colorado lawsuit to subject that law to “strict scrutiny” on First Amendment grounds because it seeks to “regulate speech based on viewpoint.”

The WILL-Wisconsin Family Action letter, first reported by Wisconsin Health News, was sent April 14 to Gov. Tony Evers, the Department of Safety and Professional Services and the chair of the social work examining board. 

The letter demands that the board stop enforcing the ban and start the process of repealing it. WILL represents a Christian counselor in a pending federal lawsuit to block a La Crosse city ordinance that bans conversion therapy.

Marc Herstand, executive director for the National Association of Social Workers’ Wisconsin chapter, said the U.S. Supreme Court ruling isn’t relevant to the Wisconsin rule.

“I don’t think it applies because we have a rule, and according to state statute, professional boards can create their own ethical standards,” Herstand told the Wisconsin Examiner. That is supported by both the general law that applies to the state’s licensing boards as well as specific provisions authorizing the social worker board, he said.

Herstand said rules against conversion therapy are to prevent harm. He compared the practice to an electrician’s bad advice that leads to a homeowner’s fatal electric shock or a health provider whose bad advice leads a patient with diabetes to lose a limb to nerve damage or the loss of circulation.

“That’s not free speech — that’s unprofessional conduct,” Herstand said. The electrician or health professional “would be held accountable by the [relevant professional] board. Conversion therapy is exactly the same thing.”

Republican lawmakers repeatedly blocked several previous attempts to update Wisconsin’s social work standards. In April 2024, after the Legislature’s session ended, the social work examining board updated its professional standards to restore the conversion therapy ban.

Then, in a landmark state Supreme Court ruling in July 2025, Chief Justice Jill Karofsky wrote that the statutes that state legislators had used to review and suspend administrative rules violated the Wisconsin Constitution. The examining board “exercised its statutory authority” when it revised its rules to ban conversion therapy, Karofsky wrote in the 4-3 decision.

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Employees of two Wisconsin mental health clinics, both part of a national mental health nonprofit based in Oconomowoc, will vote next week on whether to join a union after what has become a highly contested campaign.

Almost two months after a four-day National Labor Relations Board hearing, the NLRB’s Minneapolis-based regional director this week ordered the elections at the clinics, operated by Rogers Behavioral Health in West Allis and Madison.

In the April 14 order, Regional Director Jennifer A. Hadsall rejected Rogers’ position that the election should include all 13 Wisconsin Rogers locations. Hadsall instead directed elections at the West Allis and Madison clinics, where a majority of employees had signed up with the National Union of Healthcare Workers, according to the union.

Union supporters at the Wisconsin clinics have said they decided to seek union representation in response to increased caseloads, changes in how employee productivity was measured and a reduction in individual time that therapists and other providers could spend with patients.

“All of the changes were about increasing the number of patients that were coming into the building,” Stephani Lohman, a nurse practitioner, told the Wisconsin Examiner earlier this year. “It did not seem to have a cohesive plan and no plan would be communicated.”

The NUHW is based in California. After employees at a Rogers clinic in Walnut Creek, California, organized in 2023 and elected the union to represent them in 2023, they negotiated their first contract in 2024.

Employees at two other California clinics and at a clinic in Philadelphia also joined the union, which those three clinics voluntarily recognized.

Union supporters at the West Allis and Madison clinics each sought voluntary recognition of the union after organizing over the past year.

In Wisconsin, however, Rogers declined voluntary recognition, and the employees then filed petitions with the NLRB for union elections.

Lohman worked at the West Allis clinic, known as Lincoln Center, and was among those active in organizing the union. She said she and two other employees were fired after submitting the petition to be recognized. The union has filed unfair labor practice charges claiming that the three firings were in retaliation for union organizing, which is against the law.

In response to an inquiry in March about the firings, Maureen Remmel, Rogers’ executive director for marketing and communications, told the Wisconsin Examiner via email, “We do not comment on confidential personnel matters and have acted in compliance with applicable law.”

Hadsall held a hearing that took place Feb. 23 through Feb. 27 at the NLRB’s office in Milwaukee, where Rogers’ lawyers argued for a bargaining unit of 1,383 employees encompassing all Rogers locations in Wisconsin — three hospitals in the Milwaukee area and 10 outpatient clinics around the state.

Rogers had “a heavy burden” to overcome the presumption that a single facility is an appropriate bargaining unit, Hadsall wrote in her order this week, and she found that management had  failed to do so.

The evidence in how Rogers is organized and supervises its employees was insufficient to overcome a general presumption in U.S. labor law — that a union bargaining unit representing a single health care facility in a larger network or organization is considered appropriate.

Evidence in the case showed that neither of the two clinics had “lost their separate identity such that a single-facility union would be inappropriate,” Hadsall wrote.

Union elections for about 68 employees at the West Allis Lincoln Center clinic and about 35 at the Madison clinic are scheduled for Wednesday, April 22.

For employees at both clinics who have been seeking union representation, the decision was welcome news.

“I’m thrilled and beyond thrilled,” said Erin Quinlan, a behavioral health specialist at the Madison clinic. “It really just vindicated how firm our stance is and how confident we feel about organizing a union and doing so for the Madison clinic.”

Lohman said she and other West Allis employees who have been seeking union representation were pleased as well.

“I’ve just been feeling really overjoyed,” Lohman said Thursday. She and the other fired employees will be able to vote in the West Allis union election, she said.

Rogers Behavioral Health has announced the organization will appeal the order to the full NLRB in Washington, but that will not forestall next week’s voting.

“We are disappointed with the NLRB regional office’s decision to allow separate bargaining units given that Rogers Behavioral Health operates as one unified system across Wisconsin,”  Rogers said in a statement, which Remmel delivered via email. The statement asserted that patients “can move seamlessly between different levels of care, supported by providers who collaborate across locations.”

In her order, however, Hadsall found that there was not sufficient evidence of “functional integration” across the system to overcome the presumption that a single facility is appropriate for a bargaining unit.

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WASHINGTON — President Donald Trump on Thursday said he will nominate Erica Schwartz, who served in the president’s first administration, to lead the Centers for Disease Control and Prevention, a seat left vacant for months after his last director said she was ousted in a rift over childhood vaccines.

Trump announced his new pick on his social media platform, Truth Social, touting Schwartz’s career as a medical doctor with the U.S. armed forces.

“She is a STAR!” he wrote.

Schwartz was a deputy surgeon general during Trump’s first term, and previously served as the director of health, safety and work life while a rear admiral in the U.S. Coast Guard.

Trump’s previous CDC director, Susan Monarez, told U.S. senators under oath in September that Health and Human Services Secretary Robert F. Kennedy Jr. fired her for not agreeing to pre-approve changes to the childhood vaccine schedule, and for refusing to fire agency scientists without cause. 

Monarez held the position for just 29 days before she was ousted. She was confirmed by the U.S. Senate on a party-line vote in July.

The president also announced nominations of several other health officials to fill open spots at the CDC.

“I am also pleased to announce the appointment of Sean Slovenski as the CDC Deputy Director and Chief Operating Officer, Dr. Jennifer Shuford, MD, MPH, as the CDC Deputy Director and Chief Medical Officer, and Dr. Sara Brenner, MD, MPH, as Senior Counselor for Public Health to Secretary Robert F. Kennedy, Jr.,” Trump wrote.

“These Highly Respected Doctors of Medicine have the knowledge, experience, and TOP degrees to restore the GOLD STANDARD OF SCIENCE at the CDC, which was an absolute disaster focused on ‘mandates’ under Sleepy Joe,” he added.

The CDC’s vaccine advisory committee adjusted recommendations for childhood vaccines in September, withdrawing the agency’s recommendation that children receive the COVID-19 vaccine.

WASHINGTON — Health and Human Services Secretary Robert F. Kennedy, Jr. testified before Congress on Thursday that he’s not pleased with how spending cuts to programs that help lower-income Americans afford food will affect his efforts to bolster healthy eating habits. 

“Am I happy about the cuts? No, I’m not happy about the cuts,” Kennedy said during a lengthy hearing in front of the House Ways and Means Committee, one of several congressional panels he’ll testify before in the days ahead. 

Kennedy added that President Donald Trump and White House budget director Russ Vought also didn’t truly want to propose funding cuts to the Special Supplemental Nutrition Program for Women, Infants, and Children, often called WIC, and the Supplemental Nutrition Assistance Program, or SNAP. 

“Nobody wants to make the cuts. Russ Vought doesn’t want to make the cuts. President Trump doesn’t,” he said. “But we got a $39 trillion debt.”

Wisconsin Democratic Rep. Gwen Moore, who asked the questions, then referenced comments Kennedy made earlier in the hearing about Froot Loops, when he said it “isn’t even a food. It’s just poison.”

Moore noted the cereal is “a lot cheaper than good, healthy food.”

Froot Loops includes a corn flour blend, sugar, wheat flour, whole grain oat flour, modified food starch and other ingredients. 

Trump advocates reductions for HHS

The Trump administration’s budget request for the fiscal year set to begin on Oct. 1 proposes Congress increase defense spending by more than half a trillion dollars, accounting for a 43% boost, and that lawmakers cut domestic spending by 10%. 

It suggested Congress reduce spending at HHS by $15.8 billion, or 12.5%, to $111.1 billion, though lawmakers largely rejected proposed spending cuts to the department during last year’s government funding process. 

Vought testified earlier this week that the administration expects to ask Congress for additional defense spending for the war in Iran, though he said he couldn’t give lawmakers a ballpark estimate for how much that will add to the current request for $1.5 trillion in defense funding. 

Lawmakers questioned Kennedy about dozens of other issues throughout the hearing, including how he’s spoken about vaccines since being confirmed HHS secretary, the rise in measles cases throughout the country and comments Kennedy and Trump made about the possible causes of autism. 

Utah Republican Rep. Blake Moore, after sharing that his 10-year-old is on the autism spectrum, said he was “underwhelmed” by what the administration has released so far about possible causes. 

He also said that his wife was hurt by claims from Trump and Kennedy that women who take Tylenol when pregnant could increase the risk their children are later diagnosed with autism. 

“We don’t even know if she took Tylenol during her pregnancy, but that was a hurtful moment for her,” Blake Moore said. “And I just want to encourage the administration and your team to keep at it. And I think there’s more we can do here with low expectations.”

Medical experts say that decades of research shows autism is the result of a combination of genetic and environmental factors.  

Measles death

California Democratic Rep. Linda T. Sánchez questioned Kennedy about comments he made during his Senate confirmation hearing on vaccines, arguing that he hasn’t stuck to the commitments he made during that process. 

She then asked him if the measles vaccine could have prevented a boy from dying of the disease in Texas. 

“It’s possible, certainly,” Kennedy said. 

But, he repeatedly declined to answer a question from Sánchez about whether Trump approved the Centers for Disease Control and Prevention’s decision to remove a messaging campaign to encourage vaccination, even as she asked it several times. 

Sánchez then displayed a poster showing a photograph of Kennedy and Kid Rock to illustrate her discontent with his work so far as HHS Secretary. 

“Now, one thing that I find incredible is that you suspended this pro-vaccine messaging campaign. But somehow you’re spending taxpayer dollars to drink milk shirtless in a hot tub with Kid Rock,” she said. “And somehow you think that’s a better public health message than informing the public about the importance of vaccines.”

Day care, Medicaid, Black maternal health

Illinois Democratic Rep. Danny K. Davis pressed Kennedy about whether he agrees with a statement Trump made earlier this month when the president said, “We can’t take care of day care. It’s not possible for us to take care of day care. Medicaid, Medicare, all of these individual things. They can do it on a state basis. You can’t do it on a federal. We have to take care of one thing, military protection.” 

Kennedy responded that he was “told to make a 12% cut across our department” because the national debt, which has accumulated over decades, has reached $39 trillion. 

“We’re now having to tighten our belt,” Kennedy said. 

Davis also questioned Kennedy on funding and initiatives to reduce Black maternal mortality, saying “the Trump administration is undermining Black maternal health from all sides.”

“The GOP slashed over a trillion dollars from Medicaid, which pays for over 40% of births in the United States. President Trump just proposed cutting maternal and child health programs by over $800 million,” he said. “DOGE canceled funds for several research projects that could save countless Black mothers, like the Morehouse School of Medicine research on improving the health of Black pregnant and postpartum women.”

Kennedy responded by arguing that he and others in the Trump administration are “doing more to advance maternal health than any other administration in history.”

“There was tremendous duplication in the departments. We had 42 different maternal health services in our department,” Kennedy said. “And we cut some of those and consolidated them. Right now, we are investing huge amounts of money in maternal health.”

At Family Planning Associates in Chicago, in the office where staff take phone calls from potential abortion patients, a U.S. map colored in with red and green dry-erase markers notes the latest status of abortion access in every state. The map can change at any time.

In the center of the map’s biggest sea of red is Illinois, outlined in green — showing it’s a state with strong abortion access — surrounded by several states that ban or severely restrict abortion. Illinois is the destination for nearly 1 in 4 people traveling to another state for abortion care, according to a report from the Guttmacher Institute, an advocacy and research organization that supports abortion access and tracks data nationwide.

“Illinois really became kind of a haven state for the Midwest and much of the South immediately post-Dobbs,” said Megan Jeyifo, executive director of the Chicago Abortion Fund, which provides logistical and financial support to people who need abortions.

The state’s geography explains part of its popularity; in five of the six border states, abortion is either banned or largely inaccessible. But Illinois also is among the states that have put in place new policies — along with millions of dollars — to welcome patients who aren’t their residents. Advocates and providers say other safe-haven states should replicate the investments.

That’s happened most recently in Maine and Washington state, where governors approved funding to support family planning and abortion care, including for out-of-state patients.

Since the U.S. Supreme Court’s 2022 Dobbs v. Jackson Women’s Health Organization decision that overturned the constitutional right to abortion and allowed states to regulate the procedure, 13 states have implemented near-total abortion bans, and seven others have bans after six to 12 weeks. Although about one-quarter of people who need an abortion now obtain medication by telemedicine, many who live in states with bans still have to travel elsewhere for various reasons, including fear of prosecution.

Guttmacher’s data showed that fewer people traveled for care in the past two years than the peak of 170,000 who traveled in 2023, the year after Dobbs.

That number fell to about 155,000 in 2024, including 35,000 who went to Illinois, the data showed. Last year, an estimated 142,000 abortion patients traveled out of state, with a fairly consistent number, about 32,000, going to Illinois.

The next-highest destination after Illinois was North Carolina, followed by New Mexico and Kansas.

Guttmacher and other advocates attribute part of that decrease in the national numbers to wider availability of telehealth access to abortion medication that can be mailed to patients in other states. There were an estimated 1.1 million abortions across the United States in 2025, about the same amount as 2024 but the highest number since 2009, according to Guttmacher.

Shield laws protect health care providers in many states, including California, Illinois and New York. Those laws have prevented Republican attorneys general in other states, such as Texas and Louisiana, from trying to punish providers who prescribe the drugs.

Louisiana has unsuccessfully tried to charge and extradite doctors from California and New York, and is also suing the federal government to remove the provision that allows abortion medication to be prescribed by telehealth. A federal judge put the case on hold for now as the U.S. Food and Drug Administration completes a safety review.

Policy changes in Illinois

Illinois’ “haven” status is derided by anti-abortion groups, who call the state’s policies extreme.

“The abortion industry in Illinois is the wild west, which is clear by these numbers,” said Mary Kate Zander, president and CEO of Illinois Right to Life, to the Chicago Sun-Times, speaking about the Guttmacher report.

One state changing its laws to restrict abortion access can lead to a significant influx of patients traveling to clinics in other states. Dr. Allison Cowett, chief medical and advocacy officer for Family Planning Associates, said when six-week abortion bans went into effect in Florida and Georgia in May and October of 2024, respectively, many more patients from the South started coming to Chicago.

“Within the first few months after Dobbs, we had more than 1 in 3 patients coming from outside Illinois, and that has maintained for those three, almost four years,” Cowett said.

Illinois also borders Indiana, which has a near-total abortion ban in place. Cowett said Indiana residents were the largest percentage of out-of-state abortion patients at her clinic before 2022, and it has stayed that way.

Restricting, cutting Medicaid funding shifts more reproductive health care to telemedicine

Jeyifo said when she started as a volunteer with the Chicago Abortion Fund in 2016, the organization couldn’t financially support large numbers of out-of-state patients because Illinois didn’t invest in access the way it does now. The biggest change came in 2018, when Illinois allowed its state Medicaid program to cover abortion procedures.

“We would not have been able to expand our support outside of Illinois residents without that coverage,” Jeyifo said.

Nineteen other states allow their Medicaid program to cover abortion procedures, according to KFF, a health policy research group.

In 2023, Democratic lawmakers in Illinois allocated $10 million from the state health department to establish the Complex Abortion Regional Line for Access, known as CARLA, a hotline for the Chicago Abortion Fund and four area hospitals to help coordinate care. Jeyifo said more than 1,000 people have received assistance through that hotline in the years since.

The state has also helped fill in lost Medicaid funding after Congress passed a provision blocking federal Medicaid payments to certain abortion providers, mainly targeting Planned Parenthood, and it has helped pay for training and other programs that help connect people with care.

In January, the state launched a new partnership with the Chicago-based Michael Reese Health Trust to establish the Prairie State Access Fund, which will provide aid to out-of-state patients in need of reproductive and gender-affirming health care.

“(Illinois) is this model for other receiving states around the country to take up and learn about, because the proximity on a map is important, but the resources that are available once you get to a place are so much more important,” Jeyifo said.

Finding nearby states

The Guttmacher report showed 62,000 of the 142,000 people who traveled came from states with near-total bans, more than double the number who traveled from those states before 2022. But it has declined over the past year, down from 74,000 who traveled from those states in 2024.

The next-highest state for travelers, North Carolina, is relatively close to Georgia and Florida. The number of out-of-state travelers has remained steady there since 2024, even though North Carolina has a 12-week ban and a three-day waiting period for abortions.

In New Mexico and Kansas, about two-thirds of all abortions provided were for people traveling from outside the state, but those numbers are going down. New Mexico is often a destination for people from Texas, and Kansas borders Oklahoma, two states with strict bans. Kansas also borders Missouri; voters in 2024 passed a constitutional amendment legalizing abortion, but access has not returned, and lawmakers are trying to reverse the amendment in this year’s midterm elections.

Family Planning Associates is one of the largest independent abortion clinics in Illinois. It expanded its staff — including doctors, nurses and front desk workers — during the first year after Dobbs from about 40 people to more than 70 to handle the new patient volume, Cowett said. The clinic also expanded its physical space by about two-thirds.

Many of those who come from the South have never left their home state, Cowett said, and it can be overwhelming for them to come to a big city during an already emotional event. The abortion fund and others help supply a closet in the clinic that is stocked with toiletries, basic clothing, shoes and other items to assemble care packages for patients.

The state has also provided security infrastructure grants to nonprofits to protect against potential attacks, such as a clinic firebombing in Peoria, Illinois, in 2023, two days after Democratic Gov. JB Pritzker signed abortion protections into law. No one was in the building at the time.

Such aid was especially important for the Choices: Center for Reproductive Health clinic in Carbondale, a city at the southern tip of Illinois and the intersection of neighboring states with strong anti-abortion laws: Arkansas, Kentucky and Tennessee.

It’s a much shorter drive to Carbondale for people in those states than it is to Chicago, said Jennifer Pepper, Choices president and CEO, and it’s a more familiar, smaller area.

The state grant allowed them to harden the physical security of the clinic in Carbondale, Pepper said, which is something they haven’t been able to do for their sister location in Memphis, Tennessee. That clinic provides birth control, wellness exams and midwifery services, but receives no state support.

“We’ve never had state support in all of our 52 years in Tennessee,” Pepper said.

State assistance

Other states with Democratic leadership and protective abortion laws are starting to approve more funding to support reproductive health care.

Maine Gov. Janet Mills signed a budget bill Friday that includes funding for lost Medicaid reimbursements and creates an ongoing $5 million annual appropriation for family planning services. Washington Gov. Bob Ferguson signed a law in late March establishing a new revenue source for abortion care by implementing a tax on health insurance companies that is expected to generate about $10 million in the first year and about $2 million in each subsequent year.

Jeyifo, of the Chicago Abortion Fund, said she hopes to see more of those efforts in other states with laws that are supportive of reproductive health care, including ones with Democratic leadership that could be doing more to expand clinic availability and rescind waiting periods, such as the 24-hour waiting requirement that still exists in Wisconsin before a patient can get an abortion.

“So many states in our region could be doing more just for their own residents, let alone people traveling,” Jeyifo said.

Stateline reporter Kelcie Moseley-Morris can be reached at kmoseley@stateline.org.

Some anti-abortion state lawmakers are pushing to revise the definition of “abortion” so abortion bans don’t apply to cases in which the death of an “unborn child” is the result of medical care provided to the pregnant woman.

In the four years since the U.S. Supreme Court allowed states to ban abortion, stories continue to emerge of women with doomed pregnancies who developed life-threatening infections, had to travel to another state, or even died because doctors were afraid to provide what was once considered standard pregnancy-loss care.

Thirteen states have abortion bans, and all of them include a medical exception that allows abortions to protect the life of the pregnant woman. Some, but not all, of the bans also have exceptions to protect the health of the woman.

But patients and providers have argued in lawsuits challenging the bans that such exceptions are too ill defined to give doctors and hospitals the confidence to provide timely care. As a result, they say, providers end up denying care until the woman’s condition deteriorates to a point where the exceptions definitely apply, jeopardizing her health and future fertility.

Last year, states including Texas, Kentucky and Tennessee enacted laws designed to provide additional clarity. Confusion persists in those states and others, however, and research has linked abortion restrictions to higher rates of maternal death and injury.

The latest measures, crafted and promoted by national anti-abortion groups, would redefine “abortion” as the intentional ending of the life of the “unborn child.” Supporters say they would clear the way for doctors to manage miscarriages, ectopic pregnancies and other pregnancy-related emergencies.

“No one wants a physician to hesitate or pause and further endanger the life of the mother,” said Ingrid Duran, director of state legislation for the National Right to Life Committee, which has advocated for all of the measures, in a written statement. “This is why providing clearer language in defining terms can be beneficial.”

But reproductive rights advocates and many OB-GYNs say the real purpose of the bills is to fortify abortion bans that are broadly unpopular, even in states with full bans, and under legal challenge in multiple states. They argue the new measures are still too vague because they hang on the intentions of individual physicians, and many of the same procedures and medicines used in abortions are used to treat miscarriages.

They also say the language in the bills could grant embryos legal rights, thereby making some fertility treatments illegal.

“If you’re trying to define what is and is not an abortion, and you’re creating really specific, narrow guidelines, it could really unintentionally classify some pregnancy-related procedures as abortion care, and therefore within the law not medically necessary,” said Elias Schmidt, state legislative counsel for the Center for Reproductive Rights, an advocacy group.

South Dakota is first

In March, South Dakota became the first state to enact such a law. Its measure states that the state’s abortion ban only applies to “the intentional termination of the life of a human being in the uterus,” and not to medical treatment that results in “the accidental or unintentional death of the unborn child,” treatment to resolve a miscarriage or ectopic pregnancy, “the removal from the uterus of a deceased unborn child,” or a medical procedure that aims to save the fetus.

To the concern of fertility-treatment advocates, the law also defines “human being” as “an individual living member of the species of Homo sapiens, including the unborn human being during the entire embryonic and fetal ages from fertilization to full gestation.”

A similar bill introduced in Missouri defines abortion as “the act of using or prescribing any instrument, device, medicine, drug, or any other means or substance with the intent to destroy the life of an embryo or fetus in his or her mother’s womb.” It explicitly exempts miscarriage management and treatment for ectopic pregnancies from the definition.

And a bill in Utah, where abortion is still legal up to 18 weeks’ gestation, would regulate how an abortion procedure is recorded in a patient’s chart, distinguishing between an elective abortion and a medically indicated abortion. It defines the latter as an abortion “to remove a deceased fetus,” resolve an ectopic pregnancy, or to avert the death or “serious physical risk of substantial impairment of a major bodily function of a woman.”

Wisconsin’s legislature recently voted not to advance a similar bill this past legislative session.

Blame for the confusion

Anti-abortion groups blame doctors and abortion-rights advocates for creating the confusion around the medical exceptions in abortion bans, insisting it is clear what is a medically indicated abortion and what is purely elective.

“The fact that we’re in a place now that states actually have to define (abortion) is a result of my field, particularly (the American College of Obstetricians and Gynecologists) not clarifying it,” said Dr. Susan Bane, vice chair of the board of the American Association of Pro-Life Obstetricians and Gynecologists, which is made up of about 7,500 physicians and other medical professionals who oppose abortion.

The organization has launched a medical education and messaging campaign arguing that abortion bans do not prevent necessary health care.

According to Bane, the main difference between an induced abortion and medically indicated termination is that in the first case, “you want a dead baby at the end of whatever you do.”

The author of the South Dakota law, Republican state Rep. Leslie Heinemann, said he sponsored the measure to quell some of the criticism that the medical exceptions in his state’s ban were ill defined. He admitted he underestimated how difficult it would be to codify in law when care for a miscarriage is necessary.

“Even the medical community had trouble with helping define some of the issues,” he said.

The version of the bill that became law names only a few conditions and leaves the rest up to the discretion of physicians, who must exercise “appropriate and reasonable medical judgment that performance of an abortion is necessary to preserve the life of the pregnant female” to avoid felony charges.

Heinemann insisted his measure would not restrict fertility treatments or birth control. But reproductive health and legal experts say that by defining the beginning of human life as “the entire embryonic and fetal ages from fertilization to full gestation,” it could have that effect.

“Embedding personhood language into state laws does really bring up concern around contraceptive access and IVF access,” said Kimya Forouzan, principal state policy adviser for the Guttmacher Institute, a think tank that supports abortion rights.

“As personhood provisions grow in the state code, it brings up the question: At what point are we granting the legal rights of a person and placing those rights above the individual themselves?”

Dr. Amy Kelley, an OB-GYN in Sioux Falls, South Dakota, who was the chair of the South Dakota chapter of the American College of Obstetricians and Gynecologists from 2023 to 2025, said lawmakers ignored her and other doctors’ concerns that the amended abortion ban is still too vague.

“The whole point of medicine is to prevent people from becoming on the brink of death, right? So are they expecting us to wait until that?” Kelley said. “It’s still not very clear, and the definition for miscarriage and ectopic is also not the one we wanted. It’s just not helpful.”

Kelley said that since her state enacted an abortion ban, she often waits longer to terminate a pregnancy for medical reasons, and will sometimes send patients out of state for care. She noted that the new law doesn’t explain what level of risk to the pregnant woman justifies terminating a pregnancy.

“They want to say elective abortions are not allowed. But what do they consider elective?” she said. “Let’s say they have a heart condition and their risk of dying in pregnancy is 40%. Is that an elective abortion because their risk is not 100%?”

Stateline reporter Sofia Resnick can be reached at sresnick@stateline.org

In the eight states that expanded Medicaid after 2018, the number of people receiving prescriptions for the opioid addiction treatment medication buprenorphine increased dramatically, according to a paper that researchers will present next month.

The states that expanded Medicaid before that period also saw gains, but they were generally smaller. That’s because other changes, aside from Medicaid expansion, made buprenorphine easier to get after 2018.

The researchers found that among all patients — those covered by Medicaid, other insurers and the uninsured — the number of buprenorphine prescriptions increased in the eight most recent Medicaid expansion states (Idaho, Maine, Missouri, North Carolina, Oklahoma, South Dakota, Utah and Virginia) by more than 21% between 2019 and 2023. Maine, Oklahoma and Virginia saw the most dramatic increases.

Among the states that expanded Medicaid in 2018 or before, Kentucky, Vermont and West Virginia experienced the largest boosts. The study, published in February in JAMA Network Open, was conducted by researchers from Rutgers University and Indiana University, based on pharmacy claims data from retailers across the country.

Stephen Crystal, director of the Center for Health Services Research at Rutgers University and one of the authors, explained that buprenorphine became more accessible after 2018 as the federal government loosened various prescribing rules, including allowing prescribing via telehealth.

“Longer-term tracking shows that expansion, whether early or later, provides essential financial access and supports the growth of a provider network that improves population-level treatment rates,” Crystal told Stateline.

Experts warn that looming Medicaid cuts could cut off buprenorphine access to thousands of patients. The broad tax and spending law President Donald Trump signed last summer is projected to cut federal Medicaid spending by an estimated $886.8 billion over the next decade, largely because new work requirements will push people off the rolls, according to estimates by the Congressional Budget Office. CBO estimates that it could increase the number of people without health insurance by 7.5 million in 2034.

Opioid overdose deaths in the U.S. peaked during the COVID-19 pandemic, reaching a high of 81,806 deaths in 2022. They’ve fallen sharply since then, to 79,358 in 2023 and 54,045 in 2024.

Medicaid is  the largest payer of opioid use disorder treatment, and in 2023 it covered nearly half of all non-elderly adults in the U.S. with opioid use disorder in 2023, said Robin Rudowitz, a senior vice president at KFF, a health policy research group.

“Having health insurance is the main way for people to have consistent access to health care services, and also particularly for Medicaid, as most people are low income, and it provides protections against financial burdens,” Rudowitz said.

“And for (opioid use disorder) specifically, research shows that when people discontinue treatment, mortality risk increases. And for discontinuation of Medicaid, specifically, when coverage lapses, mortality rate increases.”

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

Under a bill signed Wednesday by Gov. Tony Evers, Wisconsin will seek health care coverage from the federal government for certain services for incarcerated people. 

A statement from Evers’ office said that AB 604 — now Wisconsin Act 233 — aims to improve health outcomes and reduce disruptions in care and rates of people committing new crimes. 

As people with substance use disorders return to the community from jail or prison, they are especially vulnerable to dying from an overdose. Supporters of the new law hope it will aid them.

A federal “inmate exclusion policy” limits incarcerated people’s ability to use Medicaid, but under the new law the state will apply for a waiver, taking advantage of an exception outlined by the federal government. 

The Wisconsin Department of Health Services will submit a request for a waiver to conduct a demonstration project to provide incarcerated people with health care coverage for certain services for up to 90 days before release. 

The department will request coverage for case management services, medication-assisted treatment for all types of substance use disorders and a 30-day supply of prescription medications. If the waiver is approved, incarcerated people would have to be otherwise eligible for coverage under the Medical Assistance program in order to qualify. 

As of Nov. 21, 19 states have approved waivers and nine states including Washington D.C. have pending waivers. 

The Wisconsin Department of Health Services must submit the waiver request by Jan. 1, 2027. The department told the Examiner in November that it needed the authority that the bill would provide before it starts work on putting together the details of the waiver. 

‘The care they need to live’

Rep. Shelia Stubbs (D-Madison), one of the lawmakers who introduced AB 604, said in a statement Wednesday that the bill gives incarcerated people “a greater chance of maintaining sobriety, preventing overdose, and remaining healthy after they rejoin the community.” 

The criminal justice advocacy organization WISDOM was among groups that expressed support for the bill. Tom Denk, the co-president of one of WISDOM’s affiliates, said in an emailed statement that this law is very personal to him and called it “a step forward.”

Denk, who was released from prison to extended supervision in 2022, said he’s had friends in and out of facilities and had too many die because of a lack of services. 

He said that “my own struggles, the trauma, and the deaths of some of my best friends are what motivated me to get involved in advocating for a better system.”

“Medications, and access to medical care, will literally save lives,” Denk said. “Too many people don’t have either, when they’ve left facilities.” 

Denk also emailed the Examiner a statement signed by Bev Kelley-Miller, who wrote that she lost her 22-year-old daughter, Megan Kelley, to a preventable heroin overdose. Kelley-Miller wrote that her daughter had an ankle bracelet “but that didn’t stop her from using.” 

Kelley-Miller, who expressed support for AB 604, wrote that substance use disorder is a medical condition and that using substances is not a choice once you are addicted. 

“I wish Megan was still here,” Kelley-Miller wrote. “Since she’s not, I advocate for others to receive the care they need to live.”

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Democrats seeking the party’s nomination for governor talk about many of the same goals when it comes to Wisconsin’s health care system: expanding access, reducing costs and ensuring quality.

Some of their proposals to those ends are almost identical. But key details vary. 

“If there’s one thing that’s a certainty, the context will change between now and when one of us takes office and has a Legislature that hopefully is going to work with us,” said Joel Brennan, former secretary of the Department of Administration, at a forum Wednesday conducted by Wisconsin Health News. “That context will change in the next nine to 10 months and we better be ready to change with it too.”

Brennan said his campaign’s health care policy will rest on four principles: broadening access to health care, particularly in rural areas; reducing costs; fostering a pathway to increase the health care workforce; and ensuring that mental health is “a basic part of health care.”

Other candidates have issued more detailed plans.

Former Wisconsin Economic Development Corp. CEO Missy Hughes announced a list of 10 proposals Wednesday.

“I’m really wanting to make sure that we’re addressing a very, very complicated problem in every different way,” Hughes said at the Wednesday forum.

Expanding Medicaid

Almost all of the seven major Democratic hopefuls have endorsed expanding Medicaid under the Affordable Care Act — opening up the health insurance plan for low-income Americans to people with incomes up to 138% of the federal poverty guideline.  When the ACA was enacted the federal government paid states that accepted expansion 90% of the additional cost.

Democratic Gov. Tony Evers made repeated attempts to enact expansion after he took office in 2019, but couldn’t do it without the support of the Republican majority in the state Legislature because of a law passed the month before Evers was sworn in.

Former Lt. Gov. Mandela Barnes has made Medicaid expansion the central focus of his health care policy pitch. He has promised to veto the state budget if it doesn’t include Medicaid expansion.

“The fact that so many folks aren’t covered right now is a problem for everybody,” Barnes said at a forum Monday, because health care providers pass the cost of uncompensated care on to other patients or their insurance companies. The Monday forum was conducted by ABC for Health, a nonprofit law firm that assists low-income Wisconsinites trying to navigate health care coverage and medical debt.

Hughes also lists expanding Medicaid — referred to as BadgerCare in Wisconsin — among her 10 proposals. She would connect BadgerCare expansion to the creation of a public option health insurance plan that Wisconsinites could purchase through the ACA marketplace, HealthCare.gov.

Milwaukee County Executive David Crowley also favors combining expanded Medicaid with a public option for people to buy into the plan. “We already have the BadgerCare infrastructure that is already in place,” Crowley said at the Wednesday forum. “So I think it’s our responsibility to expand the people’s ability to actually pay into a BadgerCare public option.”

Lt. Gov. Sara Rodriguez favors BadgerCare expansion as well as a public option health plan. Rather than combining them, however, she lists them as two of three health care initiatives she would pursue as governor. The third initiative is to institute a stabilization fund program to support struggling rural providers.  

The public option plan, to be sold on the ACA marketplace, “would be able to put downward pressure on costs across Wisconsin and have some price transparency within that,” Rodriguez said at the Monday forum. She pointed to examples in other states, including Colorado, where a public option health plan is also required to reduce its premium costs by 5% each year.

“Secondly, I do think that we should expand Medicaid in the state of Wisconsin,” Rodriguez said, noting Wisconsin is one of just 10 states that have not done so.

Rodriguez also observed that the 2025 “big, beautiful” tax and spending bill enacted by the Republican majority in Congress and signed by President Donald Trump on July 4, 2025, “makes it a little harder” for the state to expand Medicaid.

State Rep. Francesca Hong also included BadgerCare expansion and “a robust public option” health plan in a longer list of priorities during the Monday forum. Along with those, she called for lowering prescription drug costs, acting to “crack down on private insurers,” among other goals.

A Medicaid expansion dissent

An exception on Medicaid expansion is Sen. Kelda Roys. Although she has advocated Medicaid expansion going back to her years in the Assembly a decade ago, she argues now that it’s no longer practical.

An August 28 memo from the Wisconsin Department of Health Services declares that the 2025 tax and spending law includes “several traps making it cost and policy prohibitive for Wisconsin to expand Medicaid.”

The law requires Medicaid participants to prove they’re eligible every six months instead of annually as now — which advocates argue will lead more qualified recipients to be kicked out of the program. In addition, a $1.3 billion boost that Wisconsin would get for expanding Medicaid will end Dec. 31.

Expansion “is not feasible given the changes that the Trump administration has made right now,” Roys said Wednesday.

Instead, she has proposed allowing the general public to buy into the state health insurance plan that covers state employees. Wisconsin employers could buy into the plan to cover their workers, or individual Wisconsin residents could buy into it as an alternative to other private health insurance plans.

“We can lower costs, reduce uncompensated care, expand access to coverage, especially for small businesses,” Roys said.

Brennan has also proposed opening the state plan to the public, because it has broad participation as well as higher reimbursement rates for health providers, he said Wednesday. 

But he added that he thinks details on the public option should wait until the next governor takes office, so that experts in the state as well as from other states that have instituted a public option “can be part of that conversation.”

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Doula services aren’t covered by Wisconsin Medicaid – known as BadgerCare – as of April 2026.

Doulas provide emotional support and education around childbirth. Unlike midwives (which are covered), they don’t perform medical tasks.

A Wisconsin Department of Health Services spokesperson confirmed doulas aren’t covered as a stand-alone benefit for Medicaid recipients. 

State law requires the health department to get legislative approval before making changes to Medicaid. Doula coverage has been proposed by Gov. Tony Evers and Democratic lawmakers but has not come to pass.

According to the National Health Law Program, 26 states and Washington, D.C., are actively reimbursing for Medicaid coverage of doula care. Seven more are in the process of doing so.

A 2024 study from the American Journal of Public Health found Medicaid recipients with doulas had a 47% lower risk of cesarean delivery and a 29% lower risk of preterm birth than those without.

This fact brief is responsive to conversations such as this one.

Sources

• DONA International: What is a doula?
• Harvard Medical School: What does a doula do?
• Wisconsin Department of Health Services: Email with Elizabeth Goodsitt, communications specialist
• Wisconsin Legislature: 2017 Wisconsin Act 370
• Department of Administration: State of Wisconsin Executive Budget, February 2025
• Wisconsin Legislature: 2025 Assembly Bill 1085
• National Health Law Program: Doula Medicaid Project
• American Journal of Public Health: Role of Doulas in Improving Maternal Health and Health Equity Among Medicaid Enrollees, 2014‒2023

Are doula services covered under Wisconsin Medicaid? is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.

MIAMI — Midwife Sheila Simms Watson leaned to gently press on the pregnant woman’s belly. Me’Asia Taylor lay on a bed fitted with tie-dyed purple printed sheets in the corner of the RV.

Far from a typical camper, this RV houses a mobile midwifery clinic for prenatal, postpartum and women’s general health care.

“Roll when you’re getting up, and we can help you. You can sit there for a moment, all right, so you’re not lightheaded, not dizzy,” said Watson, whom patients and doulas call “Mama Sheila.”

Calm and slow, led by Watson’s soothing and attentive demeanor, the appointments are unrushed.

Run by the Southern Birth Justice Network, the mobile midwifery clinic brings care to majority-Black and Latino neighborhoods across Miami-Dade County several times a month. The clinic aims to offer a more relaxed setting, where women are comfortable and heard, their cultures are integrated, and they can connect with doulas from diverse backgrounds.

On the half-moon bench inside the RV, Watson, a doula and a midwife in training sit with patients. They take blood pressures and draw blood. They ask the women about their lives: How is their mental health and sleep? Do they have support at home? Do they want to give birth at a hospital or birth center with a midwife?

Taylor said pre-eclampsia, a dangerous pregnancy condition, runs in her family. She wanted to make sure she had space and time to express her concerns about her first pregnancy.

Taylor said she wants a midwife for her delivery. Many women of color have reported feeling marginalized or dismissed in medical settings. “I’ve just seen too many people have bad experiences,” Taylor told Watson.

The U.S. has markedly higher maternal mortality and infant mortality rates compared with other high-income countries, and women and babies of color fare the worst. Black women’s maternal death rates are three times higher than those of white women, and American Indian and Alaska Native women’s rates are twice that of white women. Researchers point to implicit bias, less regular access to prenatal care and higher rates of poverty.

OB-GYN shortages and labor and delivery units closing continue to make getting care harder. Last year, more than two dozen hospital labor and delivery units across the nation closed, including some in South Florida. And pregnant patients living miles away, or feeling uneasy about going to the doctor, may even forgo care.

Midwives can help fill gaps, maternal health equity advocates say, and mobile clinics can meet patients where they are.

“It really helps to disrupt this idea that patients must navigate these complex systems to receive care — and instead, (mobile midwifery) reimagines care as something that should be responsive to the needs of patients and should be community-centered,” said Tufts University professor and maternal health scholar Ndidiamaka Amutah-Onukagha.

But mobile units are not as common for midwifery as they are for other areas of care, such as dentistry or family medicine, the American College of Nurse-Midwives told Stateline. Other prenatal mobile outreach efforts in the state include an OB-GYN-run mobile unit by the University of Florida that serves areas around north-central Alachua County and an operation called The Midwife Bus in Central Florida.

To increase access to care, maternal health advocates are also pushing states to change regulations that restrict midwifery. The American College of Nurse-Midwives recently filed a lawsuit against Mississippi for requiring nurse-midwives to have agreements with physicians in order to practice. This week, Jamarah Amani, a midwife and the executive director of the Southern Birth Justice Network, joined other plaintiffs in filing a lawsuit against Georgia over its restrictions. But supporters of the rules say they are meant to protect patients and foster communication between clinicians.

Offering culturally centered prenatal care that women are more inclined to use can help address inequities in maternal health, Amani said. The group trains doulas, offers telehealth, provides referrals such as to mental health therapists, and advocates for equitable policies across the South.

Most of the mobile clinic’s clients — about 70% — are on Medicaid or uninsured, and the clinic is funded through federal and university grants, as well as donations.

“(Midwifery) presents like a luxury concierge-type of service,” Amani said. “Our goal is to really change that and to bring it back to the community in a very grassroots way.”

Preserving tradition

The Southern Birth Justice Network keeps a small drum on a table at a nearby booth. It represents the heartbeat, and ancestral reverence, Amani said. Drums are a universal language, and the instrument is meant to symbolize culture.

For doulas and many midwives like Amani and Watson, bringing their profession to communities today is the continuation of a significant part of Black American heritage.

Throughout history, Black midwives were venerated in their communities. Many practices were rooted in West African traditions. These midwives were the keepers of Black ancestral records, and delivered many white women’s babies. Enslaved women who were midwives traveled for deliveries. Some routes, long and traversed by foot, were dangerous in the deep rural South. During the Jim Crow era, Black Americans were denied care at hospitals or given inferior care.

“They only had protection if someone would send a carriage for them if they were going to deliver a white woman’s baby. But to care for the Black families, they often had to go in the middle of the night, alone,” Amani said. “We talk about the legacy of Black midwives as health care providers, but also as social pillars, as community leaders, as resistors of oppression.”

In the 20th century, medical institutions began to oppose midwifery, sometimes using racist and sexist campaigns to target the practice. They argued it was unhygienic and lobbied across states to dismantle midwifery. At the same time, while developing the field of obstetrics, doctors conducted gynecological experiments on Black women. The American College of Obstetricians and Gynecologists has acknowledged this history and said it’s committed to fighting racism and inequities.

Dr. Jamila Perritt, an OB-GYN and president and CEO of Physicians for Reproductive Health, said that in order to address structural barriers and close gaps, policies have to prioritize access to care, such as allowing midwives to expand their practices. Throughout the South especially, states still restrict midwives from practicing independently, despite widespread maternal health care deserts. She also pointed to research showing midwifery is associated with fewer C-sections, less preterm labor and better patient satisfaction.

“Expanding access to midwifery care, and expanding collaborations between physicians and midwives, only improves outcomes,” Perritt said.

Cultivating trust

On a recent breezy and brisk Saturday morning, the Southern Birth Justice Network’s midwives and doulas were stationed in the parking lot of the Freedom Lab, a local community center that hosts food and clothing distribution and a free urgent care center.

At the booth by the mobile clinic, under the shade of a royal-purple awning, meditation music, low-key and mellow, reverberated from a small speaker. There was a cooler filled with oranges, water and other snacks for the clinic’s pregnant patients.

“I’m going to keep giving you food. You need to eat enough,” one doula told a patient, handing her an orange and a liter of spring water.

Staff had surveys to help assess a new patient’s needs, and Florida-specific pamphlets on pregnant patients’ rights. The group is working on other state-specific guides for Louisiana, Massachusetts, Tennessee and Texas.

The table also held a portrait of the late midwife Ada “Becky” Sprouse, who started the mobile midwife clinic around 2008. She’d drive it to the city of Homestead, an agricultural hub in Miami-Dade County. There, she offered free midwifery care to migrant farmworkers, many of whom couldn’t afford care throughout their pregnancies.

Sprouse passed the clinic on to Amani, who relaunched the mobile unit and broadened the scope of the Southern Birth Justice Network.

Patients told Stateline trust was one of the main reasons they sought out the clinic. One patient said she spent 2 1/2 hours on public transit that day so that she could see the team.

For now, deliveries take place at hospitals or neighboring birth centers, where some of the group’s midwives also work. But the organization recently bought a building to open its own freestanding birth center, aiming for next year, along with a larger RV.

One patient, Isis Daaga, turned to Amani to deliver her other children after her first birth at a hospital. Despite the pressure she felt and her need to push during labor, Daaga recalled, hospital staff prevented her from delivering.

“They literally held my knees together,” Daaga said. “They were like, ‘the doctor’s not here yet,’ and the nurses were scared to deliver the baby.” In many hospitals, protocol is to wait for the doctor in case an emergency occurs.

By the time the doctor came, Daaga had a severe perineal tear, and she delivered the baby in one push. She had been in labor for 15 hours.

“I was in pain, I was upset,” said Daaga, a mental health therapist who is 35 weeks pregnant.

At the mobile clinic and with the midwives, Daaga said she feels supported.

“They make me feel the way I try to make my clients feel, like, it’s a safe space. You’re not judged here. I have a lot going on,” she said. “If I’m MIA or something, most of them will call and text me and (say), ‘Girl, you need to come in.’”

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

CINCINNATI — For four years, Kimberly Dudley has worked on the front line of the Affordable Care Act as a navigator, helping Ohioans solve the puzzle of buying private insurance on the federal HealthCare.gov marketplace.

But the job is harder now, the answers scarcer. In one of its first acts, the second Trump administration cut annual funding for navigators by 90%, from $100 million to $10 million, arguing the program was wasteful. Under the ACA, better known as Obamacare, navigators help educate and enroll people — especially those living in hard-to-reach communities. They were paid through a user fee on monthly premiums.

In January 2025, 50 navigators served Ohio’s 88 counties, toting their laptops to meet Ohioans at rural libraries and suburban food courts to help them search for a health care plan on the marketplace. But by the Nov. 1 start of open enrollment, the busiest time of year, only five navigators remained. Dudley, of Cincinnati, is one of them.

Married with a child, she was hired in 2022 at Cincinnati’s Freestore Foodbank and found “such a joy from helping people, although it’s been hard this year.” The hotline, for example, is in Dudley’s hands now. The other navigators who worked calls were laid off.

The administration did not respond to requests last week to discuss the navigator program cut. But in announcing the cuts last year, an administration statement said: “Navigators are not enrolling nearly enough people to justify the substantial amount of federal dollars previously spent on the program. This reduction will ensure funding is focused on meeting the statutory goals of the program more efficiently and effectively.”

Dudley’s task got even tougher at the end of last year, when the Trump administration and Congress allowed certain pandemic-era subsidies to expire, and policy premiums rose sharply, often to more than many Ohioans can pay.

She hears the stories every day on her own phone, which doubles as Ohio’s ACA hotline. People call when they are ruled ineligible for Medicaid, usually because their incomes are too high. In early March, Dudley heard from Tonya Horn, 59, of Cleveland Heights, who needed help.

All her working life, said Horn, she felt lucky to have employer-paid health benefits up to her most recent job, working remotely for Empower, a Colorado financial services company, as a talent acquisition diversity program manager. But last year, her job at Empower felt less secure. Her pink slip came in January.

Helping Horn, Dudley spotted a plan on HealthCare.gov that with an income-based subsidy would cost $450 a month with no deductible. But then Dudley discovered that Horn’s doctor does not accept that insurance plan.

“I don’t know if this works for you,” Dudley said, “but getting insurance could involve switching doctors.”

Horn sighed. “Can we keep looking?”

Drop in enrollment

This year, Ohio’s enrollment in the HealthCare.gov marketplace fell by 20%, the second-largest decline among the 50 states. The overall national enrollment slid 5%.

Experts in Ohio said a few factors depressed enrollment. Some people aged into Medicare. Others found jobs with health benefits. But one certain force was the Dec. 31 expiration of the pandemic-era subsidies on most marketplace plans.

The ACA does provide premium subsidies based on income, but the federal government began offering additional help in 2021 as temporary pandemic relief. The “enhanced” subsidies cut many people’s monthly premiums by hundreds of dollars.

They also helped boost the number of people buying health coverage from the insurance marketplaces, from 11.4 million people in 2020 to 24.3 million last year.

Americans who had the enhanced subsidies got warnings from their insurers about the Dec. 31 expiration. As of March 26, the number of Americans with marketplace coverage dropped by about 1.2 million compared with 2025, according to the Centers for Medicare & Medicaid Services.

Last week, a spokesperson for U.S. Sen. Jon Husted, an Ohio Republican, said that Husted proposed to extend the subsidies two more years, with new restrictions to prevent fraud in marketplace plans. Democrats rejected the idea, said Joshua Eck, Husted’s deputy chief of staff. “But had they supported the bill, or been willing to discuss it, it’s likely this problem would have been solved in December.”

In Ohio, the Columbus nonprofit research group Health Policy Institute of Ohio found that of the more than 580,000 Ohioans with 2025 HealthCare.gov plans, nearly 90% used the temporary subsidies.

California and at least nine other states that run their own health insurance marketplaces have used state money to help residents absorb the expiration price shock, though only New Mexico is completely filling the gap. Ohio could not dip into its budget that way because it uses the federal marketplace.

In January, the Health Policy Institute of Ohio estimated that 2026 premiums for Ohio marketplace plans would surge by 114% on average. Said institute analyst Brian O’Rourke: “It’s reasonable to expect that (the enrollment drop is) because of the expiration of the subsidies.”

On the statewide ACA hotline call with Horn, Kimberly Dudley said her own mother got a notice from her insurance company that her $40-a-month premium would increase to $400. “I was able to help her figure out a plan, but her premium still went up some,” Dudley said. “We’re going to find a way forward for you.”

“I hope so,” Horn said.

Ohio expands the ACA

Ohio’s industrial base collapsed in the 1990s, and hundreds of thousands of workers lost employer-paid coverage. Young people left Ohio for work, and the insurance pool shrank as it rapidly aged. Numerous studies found Ohio’s health declining, in no small part because nearly 1.5 million Ohioans, more than 10% of the population, had zero health insurance.

The ACA also allowed states to expand Medicaid to adults with incomes up to 138% of the poverty level, although some Republican-led states have refused the expansion. In Ohio, GOP Gov. John Kasich pushed the Republican-led state legislature to approve the expansion in 2013; 40 states and the District of Columbia have expanded their programs. Ohio’s participation in the federal marketplace grew until 2025, when enrollment hit a record high.

The speed of the retreat in Ohio of the ACA brought swift consequences. The Columbus nonprofit group UHCAN Ohio “has been helping people since the law’s inception,” said Executive Director Charlotte Rudolph. Then last fall, “If we saw five people, maybe one enrolled. They’re making that tough decision to say, ‘I hope I don’t get sick.’”

“We are now going through our archives, asking ourselves, how did we help people back in the day when they didn’t have coverage?”

Further complicating Ohio’s health care horizon are Trump administration cuts to Medicaid. More than 3 million Ohioans use the health program for low-income residents. But under the broad tax and spending measure President Donald Trump signed last summer, as many as 1 in 10 of those Ohioans could be found ineligible through new work requirements and other hurdles.

Horn, on the hotline phone call, said her weekly $624 unemployment payments had put her over the Medicaid threshold. Dudley nodded as she tapped on her keyboard. “I hear that a lot,” she said.

What the future holds

While the immediate problems are stressing the system, experts say they are anxious for what is to come in Ohio’s health care.

Uninsured people often use emergency departments for primary care, straining hospitals still under pandemic duress and understaffed. Many Ohioans on Medicaid live in its rural spaces, where the safety net has long been fraying. The trade group the Ohio Hospital Association told the state legislature last year that more than 70% of the state’s rural hospitals have been running in the red for years.

“My fears,” said Grace Wagner of the Ohio Association of Foodbanks, “are that as these changes continue to come, decision-makers aren’t aware or prepared to respond.”

Dudley and Horn spent another 30 minutes on the ACA hotline, but none of the HealthCare.gov options clicked. Finally, Horn said she would call back.

“Sure, it’s a lot to think about,” Dudley said, and ended the call. Then she sat looking at her laptop screen full of HealthCare.gov. She doesn’t like to leave a puzzle unsolved for someone who came to her for help.

“I love what I do. Being able to do this work is fantastic, even in the midst of all this stuff happening,” she said. “But there are times when I feel a little overwhelmed.”

States are paying contractors such as Deloitte, Accenture, and Optum millions of dollars to help them comply with the One Big Beautiful Bill Act — a law that will strip safety-net health and food benefits from millions.

State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a KFF Health News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat — or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price — both in the cost to taxpayers and coverage losses — according to state documents obtained by KFF Health News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause 7.5 million people to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly 2.4 million people will lose access to monthly cash assistance for food, including those with children.

In five states alone, company estimates developed for state officials and reviewed by KFF Health News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting company Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will cost nearly $6 million. Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which Deloitte drafted for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, according to an estimate prepared by Accenture, a consulting company that operates the state’s eligibility system.

Optum — which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act — estimated that it could cost roughly $1.8 million to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, have cost the state $1.6 million. And in Illinois, Deloitte estimated modifications will cost at least $12 million.

A historic mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules — nearly half of those enrolled.

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements — about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was worth $125.6 million as of October.

Nearly two-thirds of adult Medicaid enrollees nationally are already working, according to KFF. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the CBO reported.

In Wisconsin, state officials estimate roughly 63,000 adults could lose coverage after work requirements take effect. Not covering those people would save $532.6 million in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP — known as CARES — was implemented statewide in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New hurdles for vets and homeless people

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults — doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year contract worth more than $157 million. According to documents obtained by KFF Health News, initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government — that is, taxpayers — covers 90% of state costs to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems — as D.C. is —­ I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to KFF Health News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” KFF Health News found that Deloitte, a global consultancy that generated $70.5 billion in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 million bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a contract worth more than $60 million.

Adding the ability to verify work status would cost up to $7 million, an Accenture estimate from March 2025 showed. By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions skyrocketed to roughly $20.3 million. Accenture’s analysis said the federal law necessitated additional changes to Iowa’s system. Making employment a condition of Medicaid benefits could cause an estimated 32,000 Iowans to lose coverage, according to a 2025 state document.

Cutting 32,000 people from coverage could save $183 million in one year, a fraction of the $8.9 billion Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level — currently $33,000 for a family of four.

“There is no benefit to this population,” Lock said.

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that most of the work detailed in one of Deloitte’s estimates — priced at $12 million — is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have promised to offer discounts and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” said Daniel Brillman, the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum pledged to offer discounts for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time — supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 — Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License. 

When an Alabama clinic’s only OB-GYN left the state to provide abortion care in Colorado, the head of operations thought the facility would have to close.

But Robin Marty, executive director at WAWC Healthcare in Tuscaloosa, hired a doctor in August who she called a “unicorn” — someone who’s from Alabama and, after training outside of the state, returned home to practice medicine.

Marty said Alabama’s near-total abortion ban could cause physicians to practice elsewhere after they finish their residencies.

“Doctors don’t want to worry about surveillance, potential arrests and other legal issues,” she said.

A study published in March found that applications to medical residency programs in states with abortion restrictions have declined compared to states where abortion remained mostly legal. The findings are an “early signal” that the U.S. Supreme Court’s decision nearly four years ago overturning federal abortion rights protections may exacerbate health care shortages, said lead author Dr. Anisha Ganguly.

A majority of doctors end up practicing medicine in states where they trained. Obstetrician and gynecology training programs typically take four years to complete, so the full scope of how abortion restrictions affect where physicians work after they complete their residencies remains to be seen.

Still, experts said the findings could spell trouble for the future of the reproductive health care workforce in states with abortion restrictions, some of which are already plagued with maternity care deserts.

Doctors say bans limit training, standards of care

OB-GYNs affiliated with Physicians for Reproductive Health who either trained or work in states with abortion bans told States Newsroom that restrictions after the Supreme Court decision hamstrung their ability to offer reproductive care and affected the education of medical residents.

Dr. Neha Ali grew up in Texas and trained there, too. But by the end of her OB-GYN residency’s second year, the state enacted SB 8, a six-week abortion ban that allowed residents in the state to sue providers or anyone who helped someone terminate a pregnancy. After the Dobbs decision in June 2022, a near-total abortion ban took effect in Texas.

“I knew I wanted to be an abortion provider before I started OB-GYN residency, and I chose to be in Texas for my residency training because I wanted to experience what that’s like in a state with barriers. But ultimately, the barriers became too large,” Ali said.

After she finished residency in 2024, Ali moved to Colorado, a state with strong abortion-rights protections, where she practices complex family planning.

Ali said she talks to medical students about her experience training in Texas, where she was not able to perform any dilation and evacuations — a second-trimester abortion procedure — during residency.

“I do think it’s very valuable to see what it’s like to be in a restrictive state and understand what that is like to be a provider there, but that doesn’t sell people on a residency for four years,” she said.

OB-GYN Dr. Louis Monnig trained in Kentucky before the state banned abortion.

“Making it difficult or putting up barriers to that training just limits the abilities of any doctor who provides reproductive care to have opportunities to get exposure and experience, and just get better at what they’re doing,” he said.

Monnig completed his residency in June 2023 and moved back to his home state of Louisiana because of his connections to the region and its health care disparities. “It felt like it was worth it to come back,” he said.

In October 2024, a Louisiana law classifying mifepristone and misoprostol as controlled dangerous substances took effect.

“It made me lose faith that lawmakers were doing any of these things to actually protect patients or patient safety,” he said.

The medications are used not only for abortions, but miscarriages and other conditions, too. The law has sowed confusion among health care providers and led some to practice emergency drills to access the drugs during obstetric emergencies, Louisiana Illuminator reported. Monnig said the law has “changed some of the day-to-day operational workflow for patient care,” especially for situations where misoprostol is used, such as labor induction and postpartum hemorrhaging.

Patients have faced issues when trying to get prescriptions filled: Pharmacists have called Monnig’s office to make sure a patient wasn’t having an abortion after he prescribed misoprostol for conditions such as cervical stenosis — when it’s difficult to insert a medical instrument in the cervical canal.

Drop in applications to ban states’ residency programs

Out of more than 22 million applications to 4,315 residency programs across the U.S., 67% were submitted to programs in states without abortion restrictions between 2018 and 2023, the new research showed. Thirty-three percent went to programs in states with restrictions.

Fewer women than men applied to train in states with abortion restrictions before the Supreme Court’s landmark abortion ruling, according to the study, and that disparity widened after more than a dozen states enacted abortion bans. The number of men applying to residency programs in states with abortion restrictions — mostly in the South and the Midwest — also decreased significantly.

“When there’s a decreased level of interest in these states, it suggests to us that there’s an evolving health care workforce shortage in these states,” said Ganguly, an internal medicine physician and an assistant professor at University of North Carolina’s Division of General Medicine and Epidemiology.

Many states with abortion bans — Idaho, Iowa and Georgia, for example — are also facing labor and delivery unit closures, particularly in rural areas where hospitals struggle with provider recruitment. Health officials in these states listed improvements to maternal health as a priority in their applications to the federal Rural Health Care Transformation Program, but solutions will take years to implement.

Shortages affect more than one specialty. Ganguly said OB-GYNs have historically offered the bulk of abortion-related care in the U.S., but it’s increasingly important in emergency medicine, family medicine and internal medicine. Primary care providers and emergency medicine doctors often diagnose pregnancy complications such as miscarriages, and internists help women who have chronic disease manage and plan for pregnancy.

Dr. Hector Chapa, an OB-GYN who teaches obstetrics and gynecology at Texas A&M University and is a member of the American Association of Pro–Life Obstetricians and Gynecologists, took issue with the study’s approach.

“It’s essential to understand that this study is not specific to OB‑GYN residency programs, and by grouping OB‑GYN with family medicine, internal medicine and emergency medicine, the study assumes that all specialties are affected equally, despite their very different levels of involvement in abortion. This broad grouping risks introducing bias into the results,” he said in a statement.

Ganguly said her team did examine applications to OB-GYN residency programs in isolation to affirm findings of a decline among applicants in abortion-restricted states. Looking at other specialties, too, was meant to provide clarity about how bans affect the health care workforce more broadly.

OB-GYN education and the maternal health care workforce

The latest study adds to a body of research examining how the Supreme Court’s decision on abortion in 2022 affected training after medical school, particularly for those specializing in reproductive health care.

In the 2023-2024 application cycle, the number of applicants to training programs in states with abortion bans decreased by 4.2% compared to the previous cycle, while there was less than a 1% decrease in applications to residency programs in states where abortion is legal, according to the American Association of Medical Colleges.

In some states, abortion bans have definitively led to an exodus of OB-GYNs and maternal fetal medicine specialists. Idaho lost 35% of its doctors who provide obstetrics between August 2022 and December 2024, according to a study published in July.

Having reproductive health providers flee states with abortion bans is “devastating,” according to Pamela Merritt, the executive director of Medical Students for Choice.

“It’s a public health disaster that we’re going to see the consequences of decades to come,” she said.

Merritt’s organization has chapters at several medical schools in states with abortion bans. She said students are not getting adequate training, and some are even discouraged from discussing abortion.

In February, Texas Tech University Health Sciences Center canceled a Medical Students for Choice chapter’s talk with an OB-GYN who wrote a book about providing abortion care later in pregnancy. School officials told The Texas Tribune hosting the event on campus was not in the university’s best interests.

“Everybody who graduates from medical school in Texas should know that there’s this thing called third-trimester abortion, that when the life of the mother is at risk, you legally can provide this care,” Merritt said.

Republican Gov. Greg Abbott signed legislation last year clarifying that doctors can offer pregnant women abortions during medical emergencies. The Texas Medical Board released guidelines for the abortion law this year, nearly half a decade after the state banned most abortions and at least four Texans died after being denied prompt abortion care, ProPublica reported.

Program helps residents in restrictive states get abortion care training

“Every single physician, nurse and health care provider needs to be educated about abortion care,” said Dr. Jody Steinauer, an OB-GYN and the director of the Bixby Center for Global Reproductive Health at the University of California in San Francisco. “This is a huge crisis in OB-GYN specifically: All OB-GYNs must have the competence and the skill to safely empty the uterus. Even if the individual is personally uncomfortable providing abortion care, they have to be able to empty the uterus to save someone’s life in an emergency.”

Steinauer leads the Ryan Residency Training Program, which works with OB-GYN residencies across the country to ensure comprehensive abortion and family planning rotations. Nearly a dozen states lack Ryan programs, and most of them have near-total abortion bans.

She said residencies in states with abortion bans are struggling to make sure their students have the skills to provide abortion: “We’re at risk of having a whole generation of OB-GYN graduates who are not skilled to provide the care they need to provide.”

To remedy this issue, the Ryan Program has helped to establish 20 partnerships with schools in abortion-restrictive states to train OB-GYN medical residents in states with reproductive rights protections.

Steinauer said the rotations are between two to four weeks and complicated to plan, but they help doctors learn procedural skills, how to manage medication abortions and counseling.

The rotations also help OB-GYNs navigate pain management during obstetric procedures, communicate effectively with abortion patients and familiarize themselves with ultrasounds, she said. These skills are important for providing the full spectrum of reproductive health care, from inserting IUDs to treating miscarriages, the doctor said.

“It’s such a refreshing experience for them to be working in a state without a ban, and they get to see abortion as normal health care,” she said.

Stateline reporter Elisha Brown can be reached at ebrown@stateline.org.

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For many families across the Midwest, discussing end-of-life planning is about as comfortable as a January blizzard on Highway 175. However, proactive planning is a final act of care that prevents legal headaches and ensures a legacy stays within the family. In Wisconsin, specific statutes — ranging from marital property laws to unique transfer-on-death rules — make it essential to use the right tools. Whether you are a young parent or assisting aging parents, these are the legal and financial cornerstones for a solid plan.

Write a will and consider a living trust

A last will and testament is the traditional bedrock of any plan. In Wisconsin, a will allows you to name an executor (the person who will manage your estate) and a guardian for minor children. Without a will, a state judge — not your family — decides who raises your kids and how your assets are split.

For many Wisconsin families, a revocable living trust is a powerful alternative or supplement.

Benefit: Unlike a will, which must go through the public, often costly probate court process, a trust allows assets to pass privately and immediately to heirs.

Midwest reality: If you own property in multiple states (like a cabin in Michigan’s Upper Peninsula or a farm in Iowa), a trust can prevent your family from having to open probate cases in every state where you own land.

Assign power of attorney: health care and finances

Control is often lost not at death, but during a period of incapacity. Wisconsin law recognizes two distinct roles:

• Financial power of attorney: This grants a “trusted agent” the authority to pay your mortgage, manage your taxes and handle your bank accounts. Under Wisconsin Chapter 244, these are “durable” by default, meaning they remain valid even if you lose mental capacity.
• Health care power of attorney: This allows someone to make medical decisions if you cannot. In Wisconsin, your spouse is not automatically authorized to make all medical decisions for you without this document. It requires two witnesses who are not related to you or responsible for your health care costs.

Create an advance directive (living will)

While a health care power of attorney names who makes decisions, an advance directive (often called a “declaration to physicians” in Wisconsin) tells them what those decisions should be. This document outlines your wishes regarding life-sustaining treatments, such as ventilators or feeding tubes, specifically if you are in a terminal condition or a persistent vegetative state.

For Wisconsin residents, the Department of Health Services provides standard forms that are legally recognized across all state health systems.

Name beneficiaries for accounts and insurance

One of the most common mistakes is assuming a will covers everything. In reality, beneficiary designations on life insurance policies, 401(k)s and IRAs “trump” what is written in a will. If your will says your estate goes to your children, but your 20-year-old life insurance policy still lists an ex-spouse, that money will likely go to the ex-spouse.

To keep things simple, many Wisconsin banks offer payable-on-death (POD) options for checking and savings accounts, which keeps that cash out of the probate court’s hands.

Transfer-on-death deeds

Wisconsin is one of the states that allow a transfer-on-death (TOD) deed for real estate. This is a game changer for the “family home.”

How it works: You file a TOD deed with your local register of deeds (such as the one in Juneau for Dodge County). It names who inherits your home, but it has no effect while you are alive. You can still sell the house or change your mind at any time.

The catch: Because Wisconsin is a marital property state, if you are married, your spouse generally must sign the TOD deed even if the spouse’s name isn’t on the original title.

Note: For small estates, Wisconsin offers a “transfer by affidavit” process for estates valued under $50,000. This allows heirs to collect assets without a full court proceeding, provided they follow strict notification rules for the state’s Medicaid Estate Recovery Program.

This story is published in collaboration with Multi-Media Channels. It originally appeared in Multi-Media Channels’ print “Dignity in Care” publication.

Don’t leave a mess: What Wisconsin families should know about wills, trusts and end-of-life planning is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.