Federal regulators are cracking down on the nonprofits responsible for coordinating organ donations, aiming to begin shutting down substandard groups by early next year.

New criteria will score the organizations on donation and transplantation rates and will decertify the bottom tier, meaning their contracts with the federal government will be revoked. Many professional medical groups welcome more stringent evaluations. But the nonprofits strongly oppose aspects of the criteria and have filed lawsuits, warning of potential disruptions in some states or regions.

More than 109,000 people are on waiting lists nationwide for organ procurement, according to federal data as of July. The majority of patients await kidneys. Each day on average, about a dozen patients die waiting for an organ. 

State- and region-based nonprofits known as organ procurement organizations recover organs from deceased donors and work with families and transplant centers to coordinate donations. The procurement organizations have faced heavy scrutiny in recent years, with media reports and research papers highlighting issues such as skipping over some transplant centers and sicker patients, which worsens racial and socioeconomic disparities in organ transplants. 

The feds have shut down at least two groups in the past two years, citing questionable practices and saying that there were cases in which workers ignored signs of consciousness in donors.

Changes have been in the works for years. The Centers for Medicare and Medicaid Services first announced the new evaluation framework in 2020, in response to an executive order from President Donald Trump. Earlier this year, CMS released proposed revisions to that rule. 

Aiming for better accountability, transparency and oversight of the groups, as well as increasing patient protections and organ recovery, CMS will score the nation’s 55 organ procurement organizations based on their donation and transplantation rates. 

It will rank them into three tiers: Top tier organizations — those calculated in the top 25% of organizations for donation and transplantation rates — would be automatically renewed for another four years. Those that fall in the second tier will have the opportunity to improve and reapply for certification, while those ranking in the bottom tier would be decertified entirely. Other nonprofits will then make bids to the federal government to take over their service areas, according to CMS.

The new evaluation method has stirred debate. Some medical and policy experts say better oversight of the nonprofits is long overdue, while organ procurement organizations say they will face logistical hurdles in coordinating lifesaving organs if some are shut down.

CMS hasn’t yet released which organization’s contracts will be renewed or dropped, but said in March that the process would begin sometime late this year. The current four-year contracts expire in January, but CMS has said it will issue extensions as needed to ensure organ transplants continue. 

CMS did not provide a specific date in response to Stateline’s request for information about when it would release certification decisions. The agency said it “is committed to a process that is transparent, data-driven, and focused on the goal of saving more lives through organ donation.”

But the Association of Organ Procurement Organizations, which represents the nonprofits, says nearly 42% of the 55 organizations could be ranked in the bottom tier, meaning they would face automatic decertification. The association says this may disrupt logistics around organ donation coordination.

Jeff Trageser, the association’s immediate past president, said the organization agrees that underperforming nonprofits should be held accountable. But he noted that many of the groups argue that outcomes such as transplant rates aren’t within their control and shouldn’t be considered in evaluations.

“Decertification needs to be a part of that. There has to be repercussions if there is just no improvement,” Trageser said. “Let’s measure the OPOs on what we actually do, and that is talking to families, advocating for donation, working to get organs allocated effectively to the right patients.”

The American Society of Transplant Surgeons said it supports “long-overdue” changes to how the nonprofits are evaluated and called the feds’ decertification last year of a Miami group a “powerful decision” that will strengthen the system. But it had also raised concerns about using transplant rates to grade the nonprofits.

Dr. Joel Adler, a transplant surgeon and assistant professor of surgery at Dell Medical School at The University of Texas at Austin, said some factors the organizations are responsible for can influence whether a transplant center accepts an organ or not, but that transplant centers’ own acceptance decisions matter too. He also said designing a quality measure for the complex process is difficult, but necessary. 

“At some point, there needed to be quality metrics attached to the whole system, so we can have different ways to measure it and work toward improvement,” Adler said.

Nonprofits have brought several lawsuits against CMS — most recently, in August, a nonprofit in Hawaii sued to block the rule, arguing that it would force organ procurement organizations to compete with each other for service areas.

A federal district court in Florida recently upheld the rule in a case brought by organizations serving California, Florida, Georgia, Iowa, Puerto Rico, Texas and Washington state that filed a lawsuit last year. The organizations appealed the ruling.

In some of the legal complaints, the nonprofits called the new evaluation method a competitive “Hunger Games” approach, arguing it would destabilize the nation’s organ donation system.

If a group shuts down, the trust that organizations have spent years building with its local communities could be fractured, particularly in communities of color that may have historic distrust in the medical system, said Dr. J. Thomas Rosenthal, board secretary of OneLegacy, the organ procurement nonprofit that serves Los Angeles and surrounding counties and is a plaintiff in one of the lawsuits. 

“Trust is the key factor in everything that we do,” said Rosenthal, former director of renal transplantation at the University of California, Los Angeles school of medicine.

But Greg Segal, founder and CEO of patient advocacy nonprofit Organize, said he questions the success of community relationships among lower-ranking organizations.

“There’s a lot of fearmongering. If an OPO is tier three, I am not impressed by the strength of the relationships they have built … because if you have done all the things right and built all the right relationships, you are going to have much better outcomes than being a tier three,” he said. “If you’ve been failing and failing and failing, you are not serving patients well.” 

Katie Ross-Driscoll, assistant professor of surgery at Indiana University’s school of medicine, researches disparities in access to care among liver transplant patients.  

“They (organ procurement organizations) serve an absolutely vital role in the system and in the community, and they are what makes the promise of transplantation possible for patients,” said Ross-Driscoll, who is also a researcher at health systems research organization, Regenstrief Institute and statistical editor for Liver Transplantation and Hepatology Communications. “At the same time, I think that objective measures that enable comparability across organizations are what helps us understand how we can do better.”

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

Urban hospitals are closing at roughly the same rate as rural ones, and the shuttered hospitals are more likely to have served communities with high poverty rates and fewer transportation options, according to a new study published Thursday in the journal JAMA.

Researchers at the Harvard T.H. Chan School of Public Health analyzed hospital closures and openings that occurred between 2010 and last year. They found that closures increased by 4% year over year, while new hospital openings decreased 3% year over year.

The study comes as health systems across the nation brace for the effects of the broad tax and spending measure passed by congressional Republicans and signed by President Donald Trump in July 2025. The so-called One Big Beautiful Bill Act is projected to cut federal Medicaid spending by an estimated $886.8 billion over the next decade, according to estimates by the Congressional Budget Office.

The law includes $50 billion in rural health grants to be distributed to states over five years, but the funds are for a wide variety of initiatives, with limitations on how much hospitals can benefit.

Public attention has mostly focused on struggling rural hospitals, but the Harvard researchers found that urban hospitals also have been vulnerable: The closure rate was 9.1% for urban hospitals and 8.3% for rural hospitals. Across both rural and urban areas, hospitals that were for-profit, small or safety-net, or served the most vulnerable counties — such as those with higher poverty rates or less access to transportation — were most likely to close.

Overall, 432 hospitals closed between 2010 and 2025 while 216 opened, leading to a net loss of over 24,000 beds. Rural areas were less likely to see a new hospital, as the new facilities were mostly urban, for-profit and small. Rural communities are more likely to have fewer doctors per capita and a lower overall number of patients.

Of the hospitals that closed, about 73% shut down completely, while the remaining retained outpatient care, including rural emergency hospital care.

The Midwest and the South saw the most closures overall, and there were more closures in states that didn’t expand Medicaid eligibility under the Affordable Care Act, according to the study.

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

Nearly 100 community-based organizations have lost their federal HIV-prevention grants this week as the Trump administration redirects dollars to state and local health departments.

The funding change represents a departure from the decades-old national HIV prevention strategy favored by most public health organizations.

President Donald Trump launched the Ending the HIV/AIDS Epidemic Initiative during his first term in office. Since 2021, the program has disbursed a total of nearly $240 million to 96 community-based organizations in 31 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands.

Those groups have used the money to pay for testing and pre-exposure prophylaxis (PrEP), a medication that people at high risk for HIV can take for protection during sex or injection drug use. Preventing new HIV infections and preserving access to treatment for those who have HIV helps prevent further transmission of the virus.

By prioritizing areas with the highest number of HIV diagnoses, the initiative sought to reduce HIV incidence by 75% in five years and by 90% by 2030. It continued under the Biden administration.

But now the Trump administration has shifted course.

Instead of granting money directly to community-based organizations, the administration is offering one-time grants to state and local health departments. It is encouraging the jurisdictions with the most HIV diagnoses to funnel at least 25% of the money to community groups, but there is no requirement that they do so. Health departments in areas with fewer diagnoses are being encouraged to send 10% of their money to community groups.

The state and local health agencies are required to spend whatever dollars they don’t pass on to community groups on HIV surveillance and PrEP access.

When the federal Centers for Disease Control and Prevention announced the availability of the original grants in 2020, it noted that since the late 1980s, it had partnered with community-based organizations to fight the spread of HIV because of “their accessibility, history and credibility in the community,” especially among Black and Hispanic people, gay and bisexual men and people who inject drugs.

“CDC has done this for a very long time, specifically because they know that community-based organizations are important players in the community,” said Lindsey Dawson, associate director for HIV policy at KFF, a nonprofit health research group.

“They’re a voice in the community that people trust, and these programs really are able to reach people who are at greatest vulnerability to HIV in a way that the state or federal or local government (would) not be able to do.”

When asked for an explanation of the change, the U.S. Department of Health and Human Services referred Stateline to the Office of Management and Budget. Neither OMB nor the White House press office responded to multiple requests for comment.

The National Alliance of State and Territorial AIDS Directors told Stateline that under the new grant program, the federal government will disburse approximately $90 million to state health departments through May 2027. Though that amount is nearly twice as much as the roughly $48 million per year that was handed out under the old grant program, community-based organizations are going to see less money, public health experts say.

In August, KFF estimated that overall, community-based organizations would need about 35% of the new money to match what they were getting before. The National Alliance of State and Territorial AIDS Directors estimates that percentage to be closer to 50%.

In Texas, health officials said the state plans to send about 23%, or about $1.2 million, of its $5.24 million grant to community-based organizations.

Jeffrey Campbell, chief executive officer of Allies in Hope — formerly called AIDS Foundation Houston — told Stateline that he expects his federal funding to be cut by $441,000, which could force him to lay off at least three staff members.

Under the old grant structure, half of all funding had been channeled to organizations in the South, which accounts for more than half of the nation’s HIV diagnoses.

But already, one organization in that region has announced it will have to shut down as a result of the funding change: PowerHouse Charlotte in North Carolina announced in August that it will close. For 16 years, that  organization has provided  free HIV and STD screenings, prevention services and community resources geared toward gay Black men.

In at least two states, Minnesota and Oregon, state health agencies wouldn’t be able to match the amount of money their community-based organizations were getting under the old system even if they gave 100% of their state grants to those groups, according to KFF.

“These community-based organizations are on the ground doing the work with the populations that need it,” said Carl Schmid, executive director at the HIV+Hepatitis Policy Institute, a public health nonprofit that tracks policies related to HIV prevention.

“Some states may have relationships with some of the existing grantees and may be fine, but others, they may not. And so there’s definitely going to be a lapse of funding.”

Emily Schreiber, senior director of policy at the National Alliance of State and Territorial AIDS Directors, said that under the new rules, states don’t have much time to establish new contracts with community-based organizations.

“(States) are trying to turn around things as fast as possible. But simply there (was) not enough time to get that funding through the contracting process and all of that by September 30th, which was really unfortunate,” she said.

“It’s not easy for a health department to create a whole new contracting process overnight. Even in the best-case scenario, this is not a perfect solution.”

Many health departments take between 45 and 90 days to scale new contracts and grants, said Toni Young, executive director and founder of Community Education Group, a nonprofit offering HIV community engagement, testing and outreach across rural West Virginia and the broader Appalachian region.

“We don’t have an infrastructure in many rural communities to address HIV,” she said.

Another challenge for community-based organizations is that because they won’t be getting money directly from the federal government, they will no longer be eligible for discounted drugs under the federal 340B program.

“When you took away this grant, you also took away their 340B status, which is the reason some have had to potentially close or at least stop this entire side of operations,” said Maximillian Boykin, manager of the Save HIV Funding Campaign.

“It leaves a lot of these places very fragile.”

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

Medicaid enrollees from five states and leading medical organizations filed a lawsuit Friday challenging new Medicaid work requirements.

The broad tax and spending law that President Donald Trump signed last summer, known as the One Big Beautiful Bill Act, established work, school or community service requirements for low-income adults who receive Medicaid under expansion provisions and waiver programs across 44 states. The law exempts people who are medically frail from work requirements, but the lawsuit argues a new administration rule severely restricts who qualifies.

Plaintiffs in the lawsuit filed in the U.S. District Court for the District of Maryland include Medicaid enrollees from five states — Kentucky, Illinois, Indiana, Missouri and North Carolina. 

They also include the American College of Physicians, the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, Doctors for America, the New Hampshire Medical Society, the New Hampshire Chapter of the American Academy of Pediatrics and the city of Columbus. The National Health Law Program and the Democracy Forward Foundation are representing the plaintiffs.

“Creating barriers to healthcare coverage for the most vulnerable needlessly puts people’s lives at risk and inevitably drives up the cost of care for everyone,” Columbus City Attorney Zach Klein said in a news release. “These are folks who should be focused on getting the help and care they desperately need, not overcoming even more obstacles.”

The federal government in June issued a rule that specifies “medical frailty” exemptions from the work requirements. Those include people who are blind or disabled, or have any physical or developmental disability that interferes with daily living; people with substance use disorders or disabling mental disorders; or those with “serious or complex” medical conditions. People who fall in these categories still must prove that their conditions hinder their ability to work or participate in community engagement.

Republicans argue that work requirements would push people into the workforce and allow them to come off government aid. Research shows the majority of Medicaid recipients already work or are in school.

The plaintiffs argue that the new designations are narrow and that work or exemption verification processes will create red tape that threatens Medicaid coverage for people with serious or chronic health conditions. Those who could be harmed under the new rule include people with cancer, diabetes, HIV, substance use disorders and other behavioral health conditions, the lawsuit argues. 

Individuals represented in the lawsuit have health conditions ranging from autism spectrum disorder, obsessive compulsive disorder, bipolar disorder, severe vision impairments, HIV and narcolepsy.

Work requirements will be costly for cities and localities that provide public health and emergency care services, the plaintiffs argue, as many people may lose coverage.

“When they (cities and localities) provide services for residents who lose their Medicaid coverage, they do so without compensation,” the lawsuit reads.

Medical groups are concerned the reporting burdens will cause interruptions in care and coverage for low-income, vulnerable adults.

“We should not and must not be implementing policies that place this already vulnerable population at increased risk of interrupted treatment, disrupted coverage, or losing healthcare access altogether,” said Dr. Jan K. Carney, president of the American College of Physicians.

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

Four in 10 pediatricians reported kids in immigrant families are avoiding coming in for healthcare out of concerns around immigration status, according to a new survey published Tuesday.

More than 1,600 pediatricians responded between April and June to the survey by American Academy of Pediatrics researchers.

In the survey, pediatricians were asked whether over the past year, their patients or the families they care for avoided seeking medical care for their child due to concerns around the immigration status of a household member. They were also asked the same about sending kids to school and about applying for safety net programs such as Medicaid, the Children’s Health Insurance Program or food stamps. 

On average, pediatricians reported that about a quarter of their patients are in immigrant families. Forty percent of pediatricians reported those families avoided seeking medical care for their child out of concern for the patient or family’s immigration status. 

Thirty-one percent of the surveyed physicians reported immigrant families avoided applying for government programs. Just over a fifth reported that families had avoided sending their child to school.

The American Academy of Pediatrics said the findings are likely an undercount and that more children are likely going without care.

Stateline reported this month that many clinicians are seeing more advanced illnesses among kids of immigrants, as well as skipped preventive care and forgone surgeries amid immigration status fears.

In the survey, answers varied across different service areas and subspecialities. For example, nearly 45% of pediatricians with subspecialities and almost half — 48% — of urban, inner city pediatricians said families retreated from seeking medical care for their child, versus 32% of rural pediatricians surveyed.

In January of last year, the Trump administration rescinded Biden- and Obama-era restrictions on places where immigration agents generally could not arrest people, such as hospitals, clinics and schools. 

In 2024, a quarter of children nationwide were in immigrant families with one or both parents born in another country, with the percentages varying by state, the researchers noted.

Healthcare professionals have also raised concerns about a new federal policy that goes into effect Friday. It broadens the discretion of immigration officers reviewing applications for green cards, certain visas or admissions into the U.S., allowing officers to consider enrollment in public benefits — such as housing and food assistance, Medicaid and the Children’s Health Insurance Program — as a “public charge,” which is grounds for inadmissibility under federal law. 

“Pediatricians have long spoken out against changes to the public charge policy because we know that it leaves families fearful of accessing programs and services that are critical for their health and well-being,” Dr. Sural Shah, chair of the academy’s Council on Immigrant Child and Family Health, said during a news conference on the policy last week.

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

States, cities and counties filed a pair of lawsuits Monday challenging new federal rules that will allow immigrants’ use of safety net resources to be taken into account for green cards and other applications to stay in or enter the country.

The new federal policy goes into effect Friday and broadens the discretion of immigration officers reviewing applications for green cards, certain visas or admissions into the U.S., allowing officers to consider enrollment in public benefits, such as housing and food assistance, Medicaid and the Children’s Health Insurance Program, as something called “public charge.” 

When officers determine a person could become dependent on government benefits, that “public charge” is a ground for inadmissibility under federal law. Such non-cash benefits were previously restricted from public charge consideration under the Biden administration. 

The Trump administration rescinded that 2022 policy, arguing that it is protecting taxpayer dollars and expects immigrants to be self-sufficient.

Both lawsuits were filed against the U.S. Department of Homeland Security and the U.S. Citizenship and Immigration Services in the U.S. District Court for the Southern District of New York. 

Many mixed-status households are expected to forgo benefits and disenroll from programs, causing U.S. citizen dependents, including children, to lose care and benefits for which they’re legally entitled to receive, experts and state officials say.

In their lawsuit, 22 states and the District of Columbia pointed to DHS estimates that say states nationwide may lose roughly $4.05 billion in annual federal transfer payments for Medicaid and CHIP programs alone. Of that nationwide total, the plaintiffs may stand to lose about $2.2 billion in reduced federal payments. 

The states include Colorado, Connecticut, California, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington and Wisconsin.

Due to disenrollments, states nationwide could lose about $1 billion in the Supplemental Nutrition Assistance Program (SNAP). Of that, the plaintiff states could lose $575 million in reduced federal payments.

The states argue that the new rules contain many ambiguities and will cause the states to“ultimately be forced to fill the breach” by funding gaps out of their own budgets, leading to “staggering” costs.

Along with losing federal funding due to disenrollments from state programs, public agencies will face administrative costs, the states argue, and as households forgo enrolling in benefits, such as preventative healthcare and nutritional assistance, including school lunches, public health will suffer, leading to an increase in disease prevalence and driving up the costs of medical care, they argue.

In a separate lawsuit, a coalition of cities and counties — New York City; Chicago; San Francisco; Santa Clara County, California; Seattle and King County, Washington — say the new rule is unlawful in reversing “longstanding limits on public charge determinations.” Roughly 1.3 million people, including 600,000 children, could lose care and coverage in those places, the suit argues.

New York City, which led the cities’ lawsuit, estimates it would see 6,000 fewer annual primary care visits. 

“The new public charge rule seeks to push immigrant families away from the programs that have kept people fed and healthy for decades,” New York City Mayor Zohran Kwame Mamdani said in a news release. “New Yorkers will be afraid to see a doctor or ask for help they are legally entitled to. That fear will not stop at the families that the federal government is targeting. Families who remain fully eligible for benefits will feel a chilling effect and all New Yorkers will pay for it.”

The coalition also argues that children would be forced to withdraw from free or low-cost education programs. It notes that about 19% of Seattle residents and 26% of King County residents rely on such programs.

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

New rules going into effect next week allow immigrants’ enrollment in safety net resources to be taken into account for lawful immigration status applications, the latest in the Trump administration’s immigration overhaul.

The rules will have wide implications for mixed-status households, as people without lawful status may forgo enrollment in public benefits for their U.S. citizen kids and other dependents out of fear. 

The new U.S. Citizenship and Immigration Services (USCIS) guidance goes into effect Sept. 18 and affects people applying for a green card, certain visas or admission into the United States. It rescinds the Biden administration’s 2022 public charge regulations, which restricted immigration officers from considering immigrants’ use of non-cash public benefits, including many benefits for low-income families such as Medicaid, housing programs and food stamps.

When an immigration officer determines a person could become dependent on government benefits, that “public charge” is a ground for inadmissibility under federal law.

Trump’s new policy broadens immigration officers’ discretion, allowing them to consider enrollment in non-cash public benefits as public charge. That includes Medicaid, Children’s Health Insurance Program (CHIP) and the Supplemental Nutrition Assistance Program, the country’s largest food assistance program.

Those subject to public charge consideration are immigrants seeking adjustment of immigration status to lawful permanent residency, and includes those who are spouses, siblings, parents and children of U.S. citizens; widowers and widows; foreign medical school graduates; U.S. armed forces personnel; certain workers such as those with advanced degrees, and others.

USCIS specifies certain immigrant groups and classifications that are not subject to public charge. Those include asylees, refugees, Afghani and Iraqi interpreters or such nationals who worked for the U.S. government, people seeking temporary protected status, human trafficking victims, self-petitioners under the Violence Against Women Act, Indigenous people born in Canada who aren’t U.S. citizens, among other groups.

Health research group KFF this summer estimated that between 1.4 million and 4.1 million Medicaid and CHIP enrollees living in a household with a noncitizen could disenroll due to the public charge rule or another immigration-related fear.

Last November, the U.S. Department of Homeland Security acknowledged this, saying that the rule would affect U.S. citizens in mixed-status households. The agency said that federal and state spending could be reduced by almost $9 billion annually “due to disenrollment or forgone enrollment in public benefits programs by members of households that include aliens who may be receiving public benefits.”

It also acknowledged “downstream and upstream” effects for states and their economies.

“For example, the rule might result in reduced revenues for healthcare providers, such as hospitals and nonprofits, participating in Medicaid, companies that manufacture medical supplies or pharmaceuticals, grocery retailers participating in SNAP, agricultural producers who grow foods that are eligible for purchase using SNAP benefits, or landlords participating in federally funded housing programs,” the agency wrote in its proposed guidance.

Previous studies found that under the first Trump administration’s public charge rules, families were less likely to apply for food assistance or seek healthcare, a point emphasized by the American Academy of Pediatrics this week.

“When a child is hungry, it can affect every aspect of their development and lead to chronic conditions like heart disease and diabetes, even into adulthood,” said Dr. Sural Shah, chair of the American Academy of Pediatrics’ Council on Immigrant Child and Family Health, during a news conference Thursday.

“Without accessing WIC, babies and young children will miss out on critical nutrition supports that are important for brain development in the first 1,000 days of life. Medicaid and CHIP are lifeline programs.”

In an executive order he signed a month after his inauguration, President Donald Trump wrote that his administration would “uphold the rule of law, defend against the waste of hard-earned taxpayer resources, and protect benefits for American citizens in need, including individuals with disabilities and veterans.” 

Health clinicians say immigration activity has been leading to fear and isolation among families, causing delayed care and illnesses to advance among children. They also say those with disabilities and complex needs will be among those hit hardest.

The Autism Self Advocacy Network, for example, said immigrants with disabilities will be disproportionately affected, as they tend to use public benefits more than other immigrants. 

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