A pharmacy advertises COVID-19 testing and vaccinations on Sept. 4 in the Brooklyn borough of New York City. Several states, including New York, are breaking with restrictive eligibility policies the U.S. Food and Drug Administration has imposed on newly approved COVID-19 vaccines for the fall season. (Photo by Spencer Platt/Getty Images)

Several states, including Colorado, Massachusetts, New Mexico, New York and Pennsylvania, announced this week that they would be breaking with restrictive eligibility policies unveiled last week by the U.S. Food and Drug Administration on the newly approved COVID-19 vaccines for the fall season.

In New York, Democratic Gov. Kathy Hochul signed an executive order Friday morning to authorize pharmacists to provide the shot to anyone who desires it for the next 30 days, which can be renewed.

“When they said that they are not going to be requiring COVID shots and other vaccinations for our families, I said, ‘No, here in New York we will make parents have the option.’ If you want your child to have a COVID shot, it should be available to you and it should be covered by insurance,” Hochul said during a news conference Friday morning, where she signed the order.

“So what I’m doing now is signing an executive order, because extreme times call for extreme measures. And this is the power I have to use in the interim until we are able to have the legislature get back in January and pass legislation that mandates this.”

Previous FDA policy recommended that COVID-19 vaccine booster shots be made available to anyone 6 months or older regardless of their health status. But in August, the federal agency announced restrictions for the new shot.

The FDA limited access to the vaccines to people who are 65 and older and to younger people with at least one underlying health condition, such as asthma or obesity, that would put them at risk of developing a severe illness without a booster shot. Children are eligible only if a medical provider is consulted. Additionally, the Pfizer vaccine, one of the three that were approved, will no longer be available for any child under 5.

“The American people demanded science, safety, and common sense. This framework delivers all three,” U.S. Health and Human Services Secretary Robert F. Kennedy Jr. wrote on social media platform X on Aug. 27.

Other states are also taking measures to ensure more people can get access to the vaccines.

On Thursday, Massachusetts Democratic Gov. Maura Healey ordered health insurers in the state to continue covering the vaccine. The state also issued an order to allow pharmacies to continue providing shots to residents above the age of 5.

Massachusetts is “leading efforts to create a public health collaboration with states in New England and across the Northeast committed to safeguarding public health as the federal government backs away from its responsibilities,” the governor’s office said in a release.

This week, the State Board of Pharmacy in Pennsylvania held a special meeting to vote to bypass federal vaccine recommendations and allow pharmacists to continue administering COVID-19 vaccines.

“Health care decisions should be up to individuals — not the federal government and certainly not RFK Jr. My Administration will continue to protect health care access for all Pennsylvanians,” Pennsylvania Democratic Gov. Josh Shapiro said.

Colorado and New Mexico took similar steps this week, with state officials signing public health orders asking state agencies to take steps necessary to require insurers to cover the vaccines and instructing pharmacists to provide the shots without a doctor’s note.

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

A man waits for health care at a temporary health clinic in Terre Haute, Ind. President Donald Trump’s new tax and spending law will likely force more than half the states to reduce payments to doctors and hospitals that treat Medicaid patients, a change critics warn could reduce health care options for people in rural areas. (Photo by Spencer Platt/Getty Images)

President Donald Trump’s new tax and spending law will likely force more than half the states to reduce payments to doctors and hospitals that treat Medicaid patients, a change critics warn will be particularly harmful to rural hospitals struggling to stay afloat.

Medicaid, the joint state-federal health insurance program for low-income people, reimburses doctors, hospitals and nursing facilities for treating enrollees. But in many cases, the program doesn’t fully cover the cost of care, straining providers that serve a large share of Medicaid patients.

To help providers cover losses and continue to serve poorer populations, the federal government allows the 41 states, plus the District of Columbia, that have contracted with Medicaid managed care organizations (MCOs) to run their Medicaid programs to direct them to pay providers more — in some cases, as much as commercial plans.

Ultimately, taxpayers cover the costs of these so-called state directed payments — and those costs are growing. As of August 2024, the higher payments were projected to add $110.2 billion per year to Medicaid spending, nearly 60% more than the previous year’s projection.

That higher spending attracted the attention of conservatives on Capitol Hill.

Beginning in 2028, the One Big Beautiful Bill Act will cap the payments, forcing state Medicaid programs to reduce reimbursement rates by 10 percentage points each year until they reach either 100% or 110% of what Medicare pays. States that expanded Medicaid under the Affordable Care Act would be capped at the lower rate.

The new law will reduce Medicaid spending by $149 billion over the next decade, according to the Congressional Budget Office, and reduce Medicaid provider payments in as many as 31 states, according to KFF, a health policy research group. A separate analysis by The Commonwealth Fund, another research group, found that Medicaid payments to hospitals would drop by at least 20% in 19 of the 25 states that had publicly available data.

Critics say the change could be disastrous for hospitals, many of them in rural areas, that see a large share of Medicaid patients.

“This is all on top of an already pretty strained financial situation for rural hospitals,” Alexa McKinley Abel, director of government affairs and policy at the National Rural Health Association, a group representing rural health care providers, said in an interview. “We are worried about seeing service line closures at hospitals in an environment where OB-GYN and chemotherapy service lines are already being cut.”

Covering the cost of care

Supporters of the change say the extra payments inflate federal spending on the Medicaid program, giving hospitals “windfall profits.”

“Not only do these programs sidestep the truly needy on Medicaid and favor special interests instead, but all this is financed by growing the federal debt, leading to inflation and higher interest rates for all Americans,” the Paragon Health Institute, a conservative think tank that helped draft the bill, stated in a policy brief.

Hospital leaders dispute that. Earlier this year, the American Hospital Association asserted that without the extra payments, Medicaid managed care organizations in 2023 only covered about two-thirds of the actual cost of care.

Cindy Samuelson, senior vice president of the Kansas Hospital Association, said the additional payments are especially critical in a rural state such as Kansas, where some researchers have found that 87% of rural hospitals are in the red. Kansas is one of 10 states that did not expand Medicaid, and like other nonexpansion states, it will have to begin reducing direct payments to 110% of what Medicare pays starting in 2028.

“Over time, commercial payers are paying less and less,” Samuelson said. “Many hospitals in our state are at risk of closure.”

Samuelson said that in rural areas, health care providers see fewer patients, which makes it hard to spread out the cost of care and make up for losses that come from serving underinsured, Medicaid and Medicare patients. One result is that rural hospitals are trimming services. A report published this year by Chartis, a health care consulting firm, found that between 2011 and 2023, nearly 300 rural hospitals across the country stopped offering obstetrics care, and 424 rural hospitals ceased chemotherapy services.

In Hutchinson, Kansas, Benjamin Anderson, CEO of the rural and community-owned Hutchinson Regional Health System, said his hospital barely broke even this year, and lower Medicaid payments will take a toll. The 190-bed hospital serves more than 65,000 people in the central Kansas region, and sees a lot of patients who are struggling with mental health issues and substance use disorders.

“We are closely managing our workforce expenses. We’re going to be relying more heavily on philanthropy,” Anderson said, adding that the hospital wouldn’t lay off staff but would reduce the number of workers by not filling open positions.

He said his hospital has some cash reserves that should enable it to keep going, but that many other rural hospitals lack such a cushion.

“When we think about the cuts to Medicaid, it isn’t simply about cutting services to the poor. It’s threatening services to everyone, because in a rural community, we all get care in the same place,” he said. “If we cut out the safety net that’s sustaining these hospitals, everyone’s health care is threatened.”

Searching for answers

Three hours northeast of Hutchinson is the rural town of Holton, where about 3,400 people live. Holton Community Hospital is a 14-bed critical access hospital, meaning that it provides emergency care around the clock for a rural community. For the past two years, it has been struggling, according to Carrie Lutz, the hospital’s CEO.

Lutz said the hospital is not part of a broader health care group, and it relies on philanthropy and local taxes. Due to financial strains, it’s in the process of selling off its home and hospice services to another health care facility. The cap on extra payments will be an additional barrier, she said.

Samuelson said Kansas is applying for money under the five-year, $50 billion Rural Health Transformation Program, which Congress added to the One Big Beautiful Bill Act amid concerns about its impact on rural hospitals. She expects Kansas to get at least $500 million between 2026 and 2030.

Rural hospitals in Mississippi also hope to tap into those funds. The Mississippi Hospital Association, which is advising state leaders on their application, said it expects Mississippi to get at least $500 million over the next five years.

Like Kansas, Mississippi did not expand Medicaid under the Affordable Care, a decision that deprived it of additional Medicaid patients and thus extra revenue.

“A few years ago, we had several rural hospitals that were facing some imminent closure challenges, and so our enhanced supplemental payment based on the average commercial rate has been a lifeline,” said Richard Roberson, president and CEO of the Mississippi Hospital Association.

“What we’re concerned about is that when those payments start to decrease, then we’re going to be right back to where we were in 2022, with concerns about rural hospitals again.”

Roberson said Medicaid, with the additional payments, had become “one of the best payers, if not the best payer, for our hospitals over the last two years,” and helped a lot of hospitals stay out of the red.

He said the new rural health care fund is promising, but noted that Mississippi will decide where to spend any money it gets, and some rural hospitals might miss out.

“We want to make sure we’re working with the state to provide sustainable solutions, not one-time fixes,” Roberson said. “The big wild card is the Rural Health Transformation fund and what the state chooses to do with that money.”

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

Darryl Chavis, 62, served in the U.S. Army for two years as a watercraft operator. He stands outside the Borden Avenue Veterans Residence, a short-term housing facility in the Long Island City neighborhood of Queens, N.Y., where he lives. Chavis relies on the Supplemental Nutrition Assistance Program (SNAP) and is worried about new work requirements for the program, commonly known as food stamps. (Photo by Shalina Chatlani/Stateline)

NEW YORK — After a year in the U.S. Navy, Loceny Kamara said he was discharged in 2023, because while on base he had developed mental health issues, including severe anxiety and nightmares, and had fallen into alcoholism.

Kamara, 23, went to rehab and managed to get sober for some time while living with family in the Bronx, he said. But after he lost his job as a security guard in December, Kamara was kicked out of his home. Now he lives at a veterans homeless shelter in Long Island City, a neighborhood in Queens, New York, and he relies on the Supplemental Nutrition Assistance Program — commonly known as food stamps — and odd jobs to make ends meet.

Each month, nearly 42 million people receive SNAP benefits to help supplement their grocery budgets. Able-bodied SNAP recipients who are between 18 and 54 and don’t have children have always been required to work. Veterans, however, have been exempt from those rules — but that’s about to change.

The giant domestic policy measure that President Donald Trump signed on July 4 eliminates that exemption. Beginning in 2026, veterans will have to prove they are working, volunteering, participating in job training, or looking for work for at least 80 hours a month to keep their food stamps beyond three months, unless they qualify for another exemption, such as having certain disabilities.

Republicans in Congress and conservatives who helped formulate the law say these eligibility changes are necessary to stop people who could be working from abusing the system. But critics say the change fails to take into account the barriers many veterans face, and that the new work rules will cause thousands of veterans to go hungry.

“I’m pissed. I mean, I cannot get a job. Nowhere to live,” said Kamara. As he spoke, Kamara pointed to his collared shirt, noting that he had just dressed up to interview for a job as a security guard. He learned that morning he hadn’t gotten the job.

“I’ve been out of work for eight months,” Kamara told Stateline. “It’s hard to get a job right now for everybody.”

Veterans depend on SNAP

Nationally, around 1.2 million veterans with lower incomes, or about 8% of the total veteran population of 16.2 million, rely on food stamps for themselves and their families, according to the Center on Budget and Policy Priorities, a left-leaning research group.

An analysis by the group found veterans tend to have lower rates of employment because they are more likely to have health conditions, such as traumatic brain injuries, that make it difficult for them to work. They also tend to have less formal education, though many have specialized skills from their time in the military.

There has been a work requirement for most SNAP recipients since 1996. But Robert Rector, a senior research fellow at The Heritage Foundation, a conservative think tank, said the rules have “never really been enforced.” Rector argued that able-bodied people who have been exempt from the work requirement, such as veterans and homeless people, create an unnecessary burden on the system if they are capable of working but don’t.

“Most of the people that are in this category live in households with other people that have incomes, and so there really isn’t a chronic food shortage here,” Rector said in an interview. “We have tens of thousands of free food banks that people can go to. So it’s just a requirement to nudge these people in the proper direction, and it should no longer go unenforced.”

Darryl Chavis, 62, said that view ignores the difficulties that many veterans face. When Chavis left the U.S. Army at 21 after two years of service, he said, he was “severely depressed.”

“Nobody even came to help me,” said Chavis, who served as a watercraft operator, responsible for operating and maintaining tugboats, barges and other landing craft.

Chavis said he was diagnosed with post-traumatic stress disorder, which has made it difficult for him to keep a job. He just moved back to New York from Virginia after leaving a relationship. He’s been at the housing shelter in Long Island City since January.

“What I’m trying to do is get settled in to, you know, stabilize into an apartment. I have the credentials to get a job. So it’s not like I’m not gonna look for a job. I have to work. I’m in transition, and the obstacles don’t make it easy,” Chavis said.

The new SNAP work rules apply to all able-bodied adults between 55 and 64 who don’t have dependents, and parents with children above the age of 14. Some groups, such as asylum-seekers and refugees, are no longer eligible for the program.

Barbara Guinn, commissioner of the New York State Office of Temporary and Disability Assistance, estimates that around 300,000 New Yorkers could lose SNAP benefits due to work requirements. Of those, around 22,000 are veterans, homeless or aging out of foster care, she said. Almost 3 million New Yorkers relied on SNAP as of March 2025.

Veterans in other states are in a similar situation. In California, an estimated 115,000 veterans receive SNAP benefits, according to a study by the Center on Budget and Policy Priorities. The number is nearly 100,000 in Florida and Texas, and 49,000 in Georgia.

Between 2015 and 2019 about 11% of veterans between the ages of 18 and 64 lived in food insecure households, meaning they had limited or uncertain access to food, according to the U.S. Department of Agriculture, which oversees SNAP.

“We know that SNAP is the best way to help address hunger. It gets benefits directly to individuals,” Guinn said. “There are other ways that people can get assistance if they need it, through food banks or other charitable organizations, but we do not think that those organizations will have the capacity to pick up the needs.”

A greater burden on states

In addition to the work rule changes, the new law reduces federal funding for SNAP by about $186 billion through 2034 — a cut of roughly 20%, according to the Congressional Budget Office, an independent research arm of Congress. The federal government expects the new work requirements to reduce SNAP spending by $69 billion as people who don’t comply are dropped from the rolls.

SNAP has historically been funded by the federal government, with states picking up part of the cost of administering the program. Under the new law, states will have to cover between 5% and 15% of SNAP costs starting in fiscal year 2028, depending on how accurately they distribute benefits to people who are eligible for the program.

“This has been a strategic agenda to dismantle SNAP and to blame states for doing so, because they knew they are making it so incredibly burdensome to run and operate and unaffordable,” said Gina Plata-Nino, SNAP deputy director at the Food Research & Action Center, a poverty and hunger advocacy group.

“States are going to have to cut something, because there’s no surplus. There are no unlimited resources that states may have in order to be able to offset the harm.”

Guinn said New York expects to see a new cost burden of at least $1.4 billion each year. In California, new state costs could total as much as $3.7 billion annually, according to the California Department of Social Services.

Kaitlynne Yancy, director of membership programs at Iraq and Afghanistan Veterans of America, said many veterans with disabilities will not be able to fulfill the work requirements or find resources elsewhere. And it’s unclear whether states will be able to provide their own relief to people who are no longer exempted from work requirements or will be excluded from the program.

“It is a frustrating thing to see, especially for those that have been willing to put everything on the line and sacrifice everything for this country if their country called them to do so,” she said.

Yancy, 35, served in the U.S. Navy from 2010 to 2014. She began to use food stamps and the Medicaid program, the public health insurance program for people with lower incomes, as she navigated life’s challenges. They included going back to school to pursue her bachelor’s degree, becoming a single mother, and a leukemia diagnosis for one of her children. Frequent trips to the hospital made it hard for her to work steadily or attend school for 20 hours each week, she said.

Guinn said the new rules will create significant administrative challenges, too; even SNAP recipients who are working will struggle to prove it.

“Maybe they’re working one month, they have a job, and then their employer cuts their hours the next month,” Guinn told Stateline. “There are mechanisms for people to upload documentation as needed to demonstrate compliance with the program, but from an administrative standpoint, right now, we don’t have any super-high-tech automated way of doing this.”

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

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

A medical worker prepares to vaccinate people at a pop-up COVID-19 vaccination clinic in a rural Delta community in April 2021 in Leland, Miss. The Mississippi State Department of Health, like other state health departments, is concerned about the potential loss of federal funding. (Photo by Spencer Platt/Getty Images)

Between 2016 and 2022, as congenital syphilis cases rose nationally and especially in the South, Mississippi saw a one thousand percent increase — from 10 to 110 — in the number of newborn babies who were hospitalized after contracting the disease, known to cause developmental issues, intellectual disabilities, and even death.

So in 2023, the state Department of Health mandated that all medical practitioners screen for the disease in pregnant mothers, and it has been running advertisements to spread awareness.

Annual congenital syphilis cases in Mississippi rose from 62 in 2021 to 132 in 2023, according to state data. The number fell to 114 last year. There have been 33 cases so far this year.

That work won’t stop despite potential budget cuts, Dr. Daniel Edney, Mississippi’s state health officer, said in an interview. “We’re going to keep doing what we have to do, you know, to keep it under control.”

State by state, public health departments take a similar approach: They monitor, treat and try to stem preventable diseases, alongside their host of other duties. But in the coming year, health department officials — with their agencies already strapped for cash — fear they’ll find it much more difficult to do their jobs.

President Donald Trump’s budget proposal for fiscal year 2026 would cut the federal Centers for Disease Control and Prevention budget by more than half, from $9.3 billion to $4.2 billion. The proposal serves as a wish list from the administration, a blueprint for the Republican-controlled Congress as it works through upcoming spending legislation.

If lawmakers hew to Trump’s vision, then state and county public health departments would be hit hard. States contribute to their own health departments, but a lot of them rely heavily on federal funding.

And around half of local public health department funding comes from federal sources, primarily the CDC, as noted in a 2022 report from the National Association of County & City Health Officials.

Medicaid cuts are likely to worsen mental health care in rural America

“The federal government provides a lot of funding, but the actual implementation of public health programs happens at the state and local level,” said Josh Michaud, associate director of global health policy at KFF, a health policy research group. “Each state has its own approach, in many ways, to how public health programs are overseen, how they’re funded, how they are implemented.”

In announcing his department’s share of the proposed budget, U.S. Health and Human Services Secretary Robert F. Kennedy Jr. said Trump’s goals align with “new priorities in reversing the chronic disease epidemic.”

But many local health leaders point to the longtime mission of state public health departments in preventing the spread of disease.

“Local public health is on the front lines preventing communicable disease, operating programs to prevent chronic disease, ensuring our septic and well water systems are safe,” said Dr. Kelly Kimple, acting director of North Carolina’s Division of Public Health within the Department of Health and Human Services.

“I’m very concerned,” Kimple said, “especially given the magnitude of funding that we’re talking about, as we can’t keep doing more with less.”

Clawing back COVID-era grants

Other federal budget cuts also have states worried.

Many state public health departments grew alarmed when the Trump administration announced in March that it would be clawing back $11.4 billion in COVID-era funding for grants that were slated to extend into 2026.

Twenty-three states and the District of Columbia sued. A federal district court in Rhode Island temporarily blocked the cuts, and the case remains tied up in court.

The court’s preliminary injunction may not protect temporary staff or contractors, though. Public health departments have been laying off staff, cutting lab capacity and reducing immunization clinics, said Dr. Susan Kansagra, chief medical officer for the Association of State and Territorial Health Officials.

Historically, public health departments receive funding in “boom and bust” cycles, meaning they tend to get more federal support during emergencies, said Michaud, of KFF. But “since the Great Recession of 2008, there was a general decline in public health support funding until the COVID pandemic.”

For example, KHN and The Associated Press reported that between 2010 and 2019, spending on state public health departments declined by 16% per capita and spending for local health departments fell by 18%.

Nationally, syphilis cases reached historic lows in the 2000s, thanks to robust prevention efforts and education from public health officials. By 2022, however, cases reached their highest numbers nationally since the 1950s.

“In the wake of the COVID emergency, you’ve seen a sort of backlash to what people had been calling the overreach of public health and imposing vaccination requirements and lockdowns and other public health measures,” Michaud told Stateline.

Smallpox, cholera and typhoid

Public health departments and officials go back to the 19th century, when there was a greater emphasis on sanitation efforts to prevent spread of diseases such as smallpox, cholera and typhoid, which were rampant at the time.

By the end of the century, 40 states had established health departments, which to this day are responsible for water sanitation, tracking the spread of disease, administering vaccinations, furnishing health education, providing screenings for infants and some prenatal care for moms at local clinics, offering family planning services, and tracking and treating sexually transmitted infections, among other things.

Kimple pointed to measles as a current example of a disease that’s spreading fast. When North Carolina’s health department detected a case in the state, she said, the department “identified and contacted everyone who might have been exposed, helped people get tested, worked with doctors to make sure they knew how to respond.”

That’s the legacy of local public health, Michaud said.

“The federal government cannot decide, ‘This public health program will happen in this state, but not that state,’ that kind of thing. And cannot declare a national lockdown. The COVID pandemic tested a lot of those boundaries. It really is a state and local responsibility to protect public health. And that’s always been the case, since the beginning of our country,” Michaud said.

“And what we’re seeing now is a complete upheaval of the funding going into public health.”

A major cut in services

Kimple said she’s seen recent progress in her state in the support for funding public health.

“North Carolinians viewed our work as highly important to improving health and well-being in the state, and appreciated the local presence, the reliable information, the role in prevention and efforts to protect, in particular, vulnerable communities,” she said.

Similarly, Edney said that Mississippi state lawmakers were showing more support, despite some setbacks in 2016 and 2017. New federal cuts could throw a wrench in the health department’s economic plans and its ability to reach small communities.

“Now the federal rug is being pulled out from under us,” he said.

Edney said he expects the federal share of his department’s public health funding to fall from its current 65% to around 50%.

Edney said he’s been trying to strengthen Mississippi health department’s longevity by diversifying its revenue streams by, for example, accepting private donations.

The state will not stop doing its “core” work, he said, regardless of federal funding.

“We’re not going to cut back on services at the county health department, because what we do now is all mission critical,” Edney said.

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

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