Nurses at St. Mary’s Hospital in Madison have filed official charges with the National Labor Relations Board against the hospital’s parent company, SSM Health, for allegedly violating federal law by refusing to negotiate a contract with the recently established nurses’ union. 

The hospital’s nurses voted by a landslide earlier this summer to establish a union — a result that SSM fought to prevent the NLRB from recognizing. The efforts of management to prevent the union recognition were rebuffed by federal officials. 

In a news release on Tuesday, the nurses argued that hospital administration is wasting time engaging in anti-union activities when instead negotiations on a labor contract should be getting underway. 

The nurses have complained that the hospital administration has reduced staffing to unsafe levels, putting patient safety at risk. Staffing levels at St. Mary’s are the lowest of Madison’s seven hospitals. 

“SSM should be investing in staffing, support and retention of nurses, not wasting time and resources fighting our union, which is our voice to speak up for our patients,” St. Mary’s nurse Hannah Joers said in a statement released by the union. “Our number one goal is to win a contract which better takes patients’ level of sickness into account for staffing, and makes sure that we keep nurses by the bedside. SSM executives in St. Louis are abusing our empathy, making us do more and more with less and less. We’ve had enough, and the time has come to transform the system so that our patients’ needs come first. We will never back down and we are 1,000% determined to win a strong contract to provide the highest quality patient care.”

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Note: This is the first story in the Cap Times series Deadly Divide, investigating Wisconsin’s ongoing Black infant mortality crisis. This reporting is supported through a National Fellowship from the USC Annenberg Center for Health Journalism. 

Click here to read highlights from the story

• Wisconsin’s Black infant mortality rate was 12.5 deaths per 1,000 live births in 2024, compared with 4.8 for white babies; nearly 850 Black babies died before age 1 from 2015 through 2024.
• Preterm birth and low birth weight are the leading causes of death among Black infants, and Black mothers in Wisconsin are 50% more likely to give birth early than white mothers.
• Experts say income, education and health care access alone do not explain the disparity, pointing instead to the lasting health effects of systemic racism, chronic stress, segregation and generational trauma.
• State health leaders say improving outcomes will require support before and beyond pregnancy — including more time and trust in health care settings, culturally informed care and efforts to address housing, child care and other stressors.

For generations, Black families in Wisconsin have buried babies at rates far higher than their white neighbors — a disparity that has withstood medical advances, public health initiatives and decades of promises to close the gap.

The numbers have remained stubbornly consistent, with Wisconsin regularly ranking the worst in the nation when it comes to the rate at which Black babies die before reaching age 1. In 2024, the most recent year for which the Wisconsin Department of Health Services has publicized data, the state had an infant mortality rate of 12.5 deaths for every 1,000 live births among Black babies. For white babies, that rate was 4.8. 

Between 2015 and 2024 nearly 850 Black babies died in Wisconsin before turning 1, according to state data. Over the first half of that decade, nearly 25% of the deaths of Black infants were caused by being born into this world too early and too small to survive. 

Researchers and health experts say the crisis cannot be explained by lack of access to quality health care alone. They point to the cumulative effects of systemic racism, chronic stress and generational trauma that shape maternal health long before pregnancy begins and influence birth outcomes from one generation to the next. 

That these disparities transcend socioeconomic factors like income or level of educational attainment show the root cause lies elsewhere. Black babies are dying at higher rates even when their parents make a decent living. Black babies are dying at higher rates even when their moms are well-educated.

For Dr. Jasmine Zapata, Wisconsin’s state epidemiologist for maternal and child health and chronic diseases, the numbers have never just been numbers. 

Every chart tracking premature births, every report on infant death and every statewide trend carries the memory of her own pregnancy, when she unexpectedly delivered her daughter at just 25 weeks. 

As a second-year medical student at the time, she knew something wasn’t right when she felt sharp pain in her lower abdomen. Her due date was not until Jan. 2. It was Sept. 20. 

Zapata’s pain was repeatedly dismissed by doctors as Braxton Hicks contractions — a type of contraction that typically takes place earlier in a pregnancy and doesn’t result in cervical dilation or labor.

“I called about two, three times and I was just brushed off,” Zapata said.

But when Zapata began bleeding, she rushed to the hospital where providers found her cervix was already 10 centimeters dilated, the threshold typically required to give birth. 

“They told me ‘You’re going to meet your daughter today,’” Zapata said.

Though she was nearly 15 weeks out from her due date and her baby was barely beyond the point of viability, Zapata gave birth to her little girl. 

“When my baby came out, she was not crying. It was quiet, because her little lungs were too fragile to even breathe,” Zapata said. “I knew that complications of prematurity, this little baby fighting for her life … I was right there at the verge of being one of the infant mortality statistics.”

Zapata’s experience with preterm birth, even though her pregnancy was not categorized as high-risk, is common in Wisconsin, where Black mothers are 50% more likely to give birth before their due dates than white women. 

Preterm birth and low birth weight are the leading causes of death among Black infants, defined as younger than age 1. 

National experts on health and development say there’s a painful and deep-rooted reason these statistics persist despite medical advancements. 

‘This is the world you’ll be born into’ 

Dr. Tony Iton, a nationally recognized public health leader and advocate for health equity, has spent much of his career studying how chronic stress related to discrimination puts people’s health at risk. Iton is the CEO of The Health Trust in California.

Decades of research, he said, shows that living in a society built on a legacy of structural racism can result in consistently elevated levels of cortisol, the body’s stress hormone. Those levels increase the risk of pregnancy complications like preeclampsia (pregnancy-related high blood pressure) and early labor. 

“We don’t have a preterm crisis, we have a chronic stress crisis,” he said in an interview with the Cap Times. 

Those effects don’t disappear when a pregnancy ends. They accumulate over a lifespan and, in many cases, across generations. 

Research has shown that prolonged exposure to adversity can influence fetal development through changes in the mother’s body and health, said Nicole Bush, a clinical psychologist and director of the Division of Developmental Medicine at the University of California San Francisco. 

The science, she said, increasingly shows that a mother’s environment and experiences across her lifespan can affect a child’s health before birth, with consequences that can then extend into that child’s adulthood.

Those intergenerational effects can happen through epigenetic changes. Different from genetic mutations, epigenetic changes don’t alter core DNA sequences but instead perform like chemical switches that can turn specific genes on or off, Bush said. That switch affects how genes activate processes in someone’s body.  

“Our epigenetic marks can be influenced by nutrition. They can be influenced by sleep. They can be influenced by social experience,” Bush said. “Epigenetic changes related to experience can be stable for a long time after they’ve been changed, and so major stressors can have a long-standing impact on our bodies. They can affect our perceptions, our brain chemistry, our physiology.”

As a result, trauma and stress that someone experiences as a child can alter how their body responds later in life and, during pregnancy, influence how a fetus develops and preemptively trains an infant in utero to expect more stress in life. 

“In addition to placing the mother and her uterus and her pregnancy functions at immediate risk for challenges such as preterm birth or postpartum depression, it can also send certain chemicals and signals to the baby in utero that then program that baby to come out ready for a strong fight or flight and reactive immune system,” Bush said, “because the mom’s biology is trying to communicate to the baby ‘This is the world you’ll be born into, come out as prepared as you can.’”

Where Wisconsin stands

Nationally, the Black infant mortality rate is 11 per 1,000 live births, according to 2024 data from the National Center for Health Statistics, an agency that is part of the U.S. Centers for Disease Control and Prevention. 

The national infant mortality rate for white babies that same year was 4.4 deaths per 1,000 births. 

Also that same year, Wisconsin health data showed Black women were five times more likely than white women to die from pregnancy-related complications.

According to a 2025 study published in the Annals of Internal Medicine, Americans are living longer than ever and the difference in mortality between Black and white Americans has shrunk over the last half century, except when it comes to infants, where the disparity in mortality between Black and white babies has grown. 

That Wisconsin ranks so poorly for Black infant and maternal mortality is not new. In 2009, Black babies were almost four times more likely to die within their first year of life than white babies. 

The year before that, Dr. Richard Allan Aronson submitted a white paper to the University of Wisconsin School of Medicine and Public Health highlighting racial disparities in the state’s birth outcomes. Aronson served as medical consultant and chief medical officer for family and community health at the Wisconsin Division of Public Health from 1988 to 2002.

The Wisconsin Department of Health Services publicizes infant mortality statistics going back to 1985. In the four decades since, the mortality rate among white babies has consistently decreased in line with medical advancement. The rate among Black babies has remained largely stagnant, with the state having a higher rate of mortality among Black infants in 2023 than it did in 1991.

In his 2008 paper, Aronson identified segregation and disparate access to services as key factors in the racial gap in birth outcomes. 

“Since infant mortality is a sentinel indicator of a community’s overall well being, the factors that contribute to racial and ethnic birth outcome disparities relate to all sectors of society. The neighborhoods in Wisconsin with the highest rates of black infant mortality are characterized by hypersegregation, unemployment, economic hardship, and inadequate housing,” Aronson wrote. “Systems that serve children and families in these communities are often fragmented, burdensome, culturally and linguistically disrespectful, and deficit-based.”

Aronson’s assessment of the situation in Wisconsin is as true today as it was nearly two decades ago. And from the year he issued his report to 2024, nearly 1,500 Black babies in Wisconsin died before their first birthday, according to data from the Wisconsin health department. 

Had the rate been the same as it was for white babies, more than 970 of them would have survived.

Gaps in access to care and a lack of culturally competent medical services still play a key role in how Black Wisconsinites interact with the health care system, particularly during and after pregnancy, Zapata said. 

Wisconsin’s largest cities still carry the spectre of racial segregation and redlining, policies that separated whole populations from necessary services.

Milwaukee, Wisconsin’s largest city with the highest population of Black residents and the highest total annual number of Black infant deaths, has also been consistently ranked as one of the most segregated cities in America. 

Madison, which has a far lower population of Black residents, also faces notable racial and subsequently connected socioeconomic segregation. 

“If you were going to design a strategy to adversely impact the well-being of a population, you couldn’t come up with a better policy than racial residential segregation. It’s actually brilliantly evil in its manifestations,” Iton, with The Health Trust in California, said.

‘It shouts racism’

Poor health outcomes are often explained away by poverty or low educational achievement, Iton said. But disparities in maternal and infant health outcomes for Black women and babies are shown to transcend both of these factors. This shows that something else is at work, he said.

National data shows Black mothers with a college degree still have higher infant mortality rates than white women who drop out of high school. 

“It shouts racism,” Iton said. “If you’re not protected by income and social status from this outcome, that suggests that it’s not just material poverty or lack of resources, but it’s also your situatedness in society and what you perceive to be essentially a pervasive, large-scale devaluation of you as a human being.”

Those effects become clearer looking at data that show Black immigrants have better health outcomes when they come to the United States but exhibit poorer health outcomes the longer they are here, Iton said.

“The birth outcomes are so much better in the African immigrant women, and then as they acculturate, spend more time in America, their birth outcomes get worse,” he explained. “So the suggestion is that it’s really something in the environment in the United States.”

‘Preventing the fire in the first place’

Zapata, Wisconsin’s state specialist in child and maternal health, said she wants more focus on preventing the problems that hurt people in the first place. 

“There’s always so much focus on just when you get pregnant and right after. It’s kind of like a house is on fire and it’s burning, and then you’re always just focusing on how can the fire truck get there faster,” she said. “Let’s focus on preventing the fire in the first place.”

That means addressing stressors faced by Black Wisconsinites across their lifespan. 

“It’s like once you’re pregnant, you can qualify for all these services. But sadly, from a physiological and biological standpoint, a lot of times it’s too late,” Zapata said. “Because that birthing person — what happened to them all the way into their childhood, and even what was going on with their parents, and when they were in utero, the environment, the stress that their parents were having — that impacts them, that impacts their birth outcomes.”

Zapata said reducing Wisconsin’s Black infant mortality rate will require more than improving medical care. It will require confronting the centuries of systemic racism and inequity that have shaped Black women’s experiences with health care, government and other institutions — and rebuilding trust that has been eroded over generations.

“We’re not going to be able to undo some of the things that got us here in just five years,” she said.

She pointed to a history of exclusion and abuse that is not as distant as it can seem. Less than a century ago, Black people were barred from medical schools, she said, while unethical government and medical practices against people of color have contributed to generations of distrust.

“All of that accumulated harm plays a role into what we’re seeing today,” Zapata said.

That history is reflected in the health care system Black women encounter today, she said. Even when women have access to a doctor or hospital, that doesn’t necessarily mean they feel heard, respected or safe enough to fully engage with the system.

“We’re working within a system that’s just not designed to provide equitable care to all people in all backgrounds,” Zapata said. “We want to look around and see that it reflects the diversity of our community, or just come in and see someone that looks like me.”

Building that trust, she said, requires something the current health care system often does not give providers or patients: time.

Providers can be expected to see dozens of patients a day, while appointments designed to take an hour are squeezed into 15-minute slots. Long waitlists can make it difficult for patients to establish relationships with providers in the first place.

For Black women who already approach the health care system with distrust, those constraints can be especially consequential, Zapata said. A rushed appointment can leave a patient feeling dismissed even when the provider is not intentionally doing so.

“Patients who feel brushed off will be less likely to engage with that system again,” she said.

If something goes wrong during a pregnancy, that can mean a mother is less likely to call her doctor or seek help.

“There’s a lot of Black women that are scared to have children in our state, just because of the statistics,” Zapata said. “When we come into a provider, because of that unique background, we need more time.”

That need extends beyond the exam room. Zapata recalled treating a mother who, just 24 hours after giving birth, was pleading to leave the hospital because she had no child care. Another mother was discharged with her newborn to a homeless shelter.

“They don’t even have a place for the baby to sleep,” she said. “It is just heartbreaking.”

Those circumstances can make it difficult for a mother to focus on her own health or her baby’s health, even when medical care is available.

“Do you think they’re listening to us with their whole heart, with their full attention?” Zapata said of patients in these circumstances. “No, because their brain is thinking about how they’re going to survive.”

Doulas are one option to help bridge some of that divide, she said. Because they can provide advocacy, emotional support and culturally informed guidance, doulas can help women feel safer navigating a health care system that might not feel built for them.

For Black women, she said, that kind of support is not an extra. It is part of what they are asking for as the state tries to change outcomes that have persisted for generations.

‘Too many funerals’

Zapata’s daughter, Aameira, was in the neonatal intensive care unit for three months after she was born. She is now almost 16 years old. Her mother describes her talent for photography, her sassy personality, her beautiful singing voice — each moment of praise an appreciation for the fact that her daughter survived what many babies born that early do not.

It was the moments, days, weeks and months that followed Aameira’s birth that Zapata says shaped the trajectory of her life’s work. 

“When I walked out of the NICU with her in my arms, I made a commitment that I’m going to dedicate my career to finding ways to make sure every baby gets to walk out,” Zapata said.

That has remained a driving factor in her work as a doctor, as a state health official, as a mother and as a resident of a state where too many babies don’t make it to age 1.

“I’ve been to too many funerals of babies who didn’t make it to their first birthday. Words can’t express that. I’ve had to do CPR on a baby that came into the hospital already basically gone,” Zapata said. “When you have those types of memories, and screams of family members, and faces drilled in your mind, in your soul, it just really impacts the work that you do.”

Erin McGroarty is a health and policy reporter for the Cap Times in Madison. She can be reached at emcgroarty@captimes.com.

‘Too many funerals’: Wisconsin’s Black infant mortality crisis is harming generations 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.

In Minnesota, an elementary schooler has gone without surgery to treat a rare, life-threatening neck infection that isn’t responding to antibiotics.

Another young child can’t use their hearing aids because the family ran out of batteries and hasn’t come to get replacements.

Yet another child’s cochlear implant surgery was delayed by several months. 

These patients’ families, all immigrants, have been afraid of showing up to the hospital after immigration officers flooded their communities in recent months, said their doctor, pediatric otolaryngologist Asitha Jayawardena, a head and neck surgeon at Children’s Minnesota. 

Clinicians like Jayawardena say immigration arrests and detentions are taking a particularly acute toll on children’s health as families isolate at home. He’s seen some cases — such as the child with the neck infection — worsen because fearful parents aren’t coming in. 

“Without a doubt, it oscillates between being infuriating and absolutely disheartening,” Jayawardena said about the chilling effect. 

As the Trump administration’s immigration enforcement leads to sweeping arrests, healthcare workers say those actions have hit children hard — including children who are U.S. citizens and those in families without arrests.

Many healthcare providers report that since January 2025, they’ve seen a surge in missed pediatric appointments, delayed preventive care, and sick or injured kids going without treatment. Immigration and Customs Enforcement arrests have continued to climb — with a record 51,000 arrests in July — and experts predict continued unhealthy outcomes among children, causing collateral damage that could extend for years. 

Healthcare workers told Stateline that in addition to the physical healthcare fallout, they’ve also seen a significant increase in depression, anxiety and post-trauma symptoms among their pediatric patients. 

Delayed healthcare has critical consequences for young kids. For example, hearing loss, such as that experienced by Jayawardena’s patients, can hinder crucial development including speech, language and social skills. Along with missing health milestones and getting needed healthcare, kids are grappling with the long-term trauma of losing a parent.

“Community-wide trauma that is being inflicted is having a really important impact on families and children in particular. There are children that are losing their guardians. There are families that are losing their breadwinners,” said Amy Liebman, chief program officer of the Migrant Clinicians Network, a nationwide organization of healthcare workers serving migrant families.

“That certainly is going to ultimately impact their health and then their ability to access care,” she said.

The Trump administration also has introduced rules that allow federal agencies to take into account a family’s use of public benefits when reviewing applications for lawful immigration status. Dr. Gabriela Maradiaga Panayotti, a pediatrician in Durham, North Carolina, pointed to studies showing that such policies lead to a decrease in healthcare use, including among U.S. citizen children.

One of her patients, a U.S. citizen on Medicaid, had stopped a medication for ADHD that had helped him achieve better grades at school. His parents feared being targeted through Medicaid paperwork, so they didn’t refill his prescription. The child’s grades began to drop again.

“They didn’t want to be labeled as utilizing resources,” Maradiaga Panayotti said. “I hurt for him, especially because he’s at this tender preteen age where self-confidence and performance at school can really either build on and set a good foundation for success in high school, or can drop.”

Millions of children

Researchers at the Brookings Institution, a public policy research nonprofit, estimate that since Jan. 20 of last year, the day President Donald Trump was sworn in, and through early April of this year, over 146,000 U.S. citizen children have had a parent detained.

But many more are living with that fear. 

The Pew Research Center estimates 4.6 million U.S.-born children lived with an unauthorized immigrant parent in 2023, and roughly 2.5 million children could face the detention of both household parents, according to a Brookings analysis. 

But the trend cuts across immigration status — including those born to refugees, DACA recipients, asylees and people with temporary protected status. Across the nation, about a fourth of children are born to immigrant families, according to the Migrant Policy Institute.  

Increased ICE activity has included arrests at hospitals, and the agency has also made unprecedented efforts to obtain private health data, including Medicaid patient records, to extract addresses and immigration statuses — another major source of fear for families.

Jayawardena and his colleagues published a study in the American Academy of Pediatrics medical journal in August measuring whether pediatric outpatient care visits were disrupted during and after the large-scale immigration raids of Operation Metro Surge in Minneapolis, when the Trump administration deployed 3,000 agents, heavily targeting Somali and South Asian communities. 

The research team found that the rate of missed appointments among Hispanic or Latino children increased by over 50% during Metro Surge compared to the same time period — the first week of December to second week of February — in the prior two years.

Missed appointments increased by 80% among Spanish-speaking families and 53% among families needing language interpretation services. 

“The barrier is not necessarily lack of access, but more the fear and the isolation, and so the enforcement is having this chilling effect on immigrant families who, even though they may need these critical services, may be avoiding the hospital, the counseling, the victim services, and other essential care,” said Jasiel Fernandez, vice president of psychosocial supports at the global pro bono nonprofit KIND, or Kids in Need of Defense. “We see that happening over and over.”

The Migrant Clinicians Network, along with Physicians For Human Rights, surveyed nearly 700 healthcare workers across 30 states between March and August of last year, amid spikes in immigration activity. Most of the surveyed professionals — 84% — reported significant or moderate drops in pediatric patient visits since Trump’s January 2025 executive orders on immigration.

Kids also were spending less time outdoors, which affects overall health, and saw delayed diagnoses of their conditions. About 27% of clinicians said patients feared enrolling in benefits for their children, and couldn’t afford doctor visits. Preventive care, such as vaccinations, as well as chronic disease management and mental health care were the most affected, healthcare workers reported. 

And in both the survey and through interviews with Stateline, clinicians have reported seeing kids show up to emergency departments alone.

In Missouri, one pediatric emergency medicine physician, who spoke with Stateline on the condition of anonymity because he feared retaliation against his hospital, recalled an 11-year-old child who had been attacked by a dog, his legs riddled in bites. He came to the hospital with only his teenage sister.  

“He told us that (his parents) were scared to come in because ICE might be at the hospital,” the physician recalled. 

Others aren’t showing up to care at all. “Kids like these are so vulnerable that they kind of could fall through the cracks,” he added. “We see the downstream effects of policy changes, and we try to address all these needs. But when kids are coming in, they’re super sick.” 

Missed care, advanced illness

Some clinicians told Stateline that by the time some children reach their clinics, their health conditions have advanced to a more difficult stage. 

One North Carolina pediatrician has seen kids with asthma miss inhaler prescriptions, leading to more asthma attacks. In another case, a large family of refugee children came in covered in splotchy, itchy rashes — scabies. The family had been sharing two bedrooms. Afraid, they had postponed care for four weeks. 

“All of these children, totally ridden throughout their bodies, and it’s so uncomfortable. You can’t sleep because it’s horribly itchy,” said the pediatrician, who spoke to Stateline on the condition of anonymity, fearing retaliation since her clinic receives federal funding. 

“We’re creating tremendous problems for our community that will probably come back to bite us, because now these kids are going around with untreated medical conditions that are only going to get worse,” she said. “It’s a time when they need even more support than before, and our administration just isn’t really allowing that.”

She and others said they’re also noticing worsening depression among their patients.

“They’re spiraling out, and they’re not getting any support because they can’t come in and get care,” said the North Carolina pediatrician. She recalled one teenager telling her that they couldn’t sleep at night. “ ‘I’m sobbing and crying, terrified that my parents will be taken away,’ ” she recalled the teen telling her.

Elsewhere, one of KIND’s clients in California, a preteen sexual assault victim, has gone weeks without mental health care.

“The child’s sponsor, who is undocumented, is very afraid to take the young person to mental health appointments or any other kind of follow-up service,” Fernandez said. “Choosing basically to forgo that for the time being.”

In Texas, which has the most immigrant detainees of any state, a 14-year-old’s primary caregiver was detained. The teen has been suffering suicidal ideation.

“That young person is unable to access services,” Fernandez said. “Even if we think that a teenager has a certain level of agency to do certain things, when the caregiver is removed abruptly … the sponsor is not able to support, is not able to meet significant needs and monitoring for that young person.”

Fernandez said KIND has been offering Uber and Lyft rides to field offices because clients are afraid to drive to appointments to receive healthcare.

In southeast Florida’s Indian River County, Heather Miranda is CEO of Treasure Coast Community Health, which runs multiple clinics serving nearby communities of agricultural workers. Clinic staff in the northern area of the county, where Miranda said most immigration enforcement activity has been concentrated, told her they’ve seen a significant decrease of kids coming in — nearly 500 pediatric no-shows since February, 16% of all appointments. 

“They’ve seen kids not coming in for sick visits,” Miranda said. “Not coming in for their well-child or their vaccines. … It’s just been, overall, a decrease in preventative care, which is really, really important.”

Back in Minneapolis, Jayawardena said that even months after Operation Metro Surge, fear among his patient families remains “a persistent problem.”

“I want to help take care of these children, and the families want to get taken care of, as does my entire hospital system — and we cannot get them just physically into the hospital for things that are necessary,” he said.

“It’s just very disheartening knowing that there’s something I can do, but I am prohibited from doing it because families don’t feel safe.”

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

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Click here to read highlights from the story

• Nebraska and Montana implemented the new work requirement rules for Medicaid recipients earlier this year. 
• In Nebraska, officials say there’s been confusion about basic eligibility, with some people who should have received exemptions being denied coverage due to procedural errors. 
• Montana leaders stressed the importance of communication, particularly to Native American tribes, who should be exempt from the new rules. 
• Officials in Wisconsin say they’re implementing ways to automatically determine whether someone is working or if they’re required to follow the new rules. 
• Federal officials also narrowed the definition of medical frailty, meaning that people who have Medicaid because they are too medically frail to work will be required to prove their condition and the fact that it prevents them from working.

Starting in January, some Wisconsinites must prove they meet federal work requirements to enroll in Medicaid. Around 63,000 people are at risk of losing coverage, state officials say. It’s part of an effort by the Trump administration to reduce “waste, fraud and abuse” in the program and reduce federal spending by $326 billion over 10 years. 

As Wisconsin prepares to implement the measures detailed by the One Big Beautiful Bill Act, states like Nebraska and Montana have already put work requirements into effect. How the process is unfolding offers key lessons for states like Wisconsin facing a Jan. 1 deadline. 

Who needs to meet work requirements?

The new Medicaid requirements apply to states like Nebraska and Montana that voted to expand Medicaid to families living at 138% of the poverty level — with the exception of a few states that submitted a waiver to partially expand Medicaid, like Wisconsin. 

That program, called BadgerCare Plus, applies to individuals who live at or below the federal poverty level — $33,000 annually for a family of four — as compared to the $45,540 income limit for expansion states.

Only childless adults aged 19 to 64 under the BadgerCare Plus program must meet work requirements — about 200,000 people, according to state officials. That means parents of dependent children under age 19 and people with coverage other than BadgerCare Plus, such as SSI Medicaid or home- and community-based service programs, are exempt.

Other exempt groups include Native Americans, pregnant or postpartum people, caregivers of young children or disabled individuals, veterans with a total disability rating, participants in addiction or rehab programs, and those too medically frail to work. 

Starting Jan. 1, 2027, new BadgerCare Plus applicants must show they worked, volunteered or attended school for at least 80 hours in the previous month, or prove they were exempt for that month. 

Current BadgerCare Plus members will face the requirements beginning in March 2027. They  must show they met the work requirement in any one month of the last 12, or that they are exempt. They can show they received at least $580 in income in a single month or completed combined activities adding up to 80 hours. 

In July, Wisconsin Department of Health Services Secretary Kirsten Johnson told reporters officials aim to automate the process as much as possible.

Those system changes will cost an estimated $10 million in the first year, Wisconsin Medicaid Director Amanda Dreyer confirmed, which will be split between the state and federal government. 

Nebraska’s early lesson

Nebraska became the first state to implement the new requirements on May 1. 

Officials began to disenroll Nebraskans who didn’t meet the requirements on Aug. 1. Nebraska Medicaid Director Drew Gonshorowski told Tradeoffs in July roughly 200 people could lose coverage on that day. The state Department of Health and Human Services has not released official numbers. 

The state sent more than 75,000 letters, 38,000 text messages and 10,000 emails to notify people of the change. Amy Behnke, CEO of the Health Center Association of Nebraska, told Wisconsin Watch some residents still had basic eligibility questions. 

“There’s some confusion over who the work requirements apply to and who they don’t apply to,”  Behnke said. “The communication that went out from the state was pretty lengthy. It was about four pages long and at a collegiate reading level, and so it was a lot for somebody to digest.” 

It’s also hard to know whether someone is part of the Medicaid expansion without contacting the state directly. 

“Our health centers don’t have a really good way of being able to look that up,” she said. 

Her organization supports Nebraska’s federally qualified health centers, which provide low-cost medical care and help people apply for Medicaid. 

She’s already seen patients have their Medicaid applications denied due to procedural errors. One woman was denied because she didn’t meet work requirements — even though pregnancy made her exempt.

“She was able to get her Medicaid restored,” Behnke said. “But that’s always been our fear – that somebody’s not going to know that they’ve lost their coverage until they show up to pick up a prescription or they show up for a medical appointment.” 

Residents can call the state’s Medicaid help line, but wait times have stretched as long as 90 minutes, Behnke said. She recommends states consider hiring additional caseworkers, which Nebraska has not done. 

“They are hardworking individuals (at the call center), and there is just an additional load of work and information that’s needed that comes with these requirements,” Behnke said. 

Wisconsin DHS plans to use the additional FoodShare staff secured last year to help with implementing Medicaid requirements, Johnson said, noting the increased budget will add flexibility for other staff to help Wisconsinites. 

Behnke urged Wisconsin to prioritize flexibility in implementing the program. She highlighted that Nebraska requires members to meet requirements in just one month of the last 12 and allows individuals to self-attest to medical frailty — policies Wisconsin DHS confirmed it will follow. 

A balancing act in Montana

Montana also implemented work requirements on July 1 — the first state to do so after the U.S. Centers for Medicare and Medicaid Services released stricter guidelines on medical frailty. For three months, Montana enrollees won’t be penalized if they fail to document community engagement hours. 

Dr. Aaron Wernham, CEO of the Montana Healthcare Foundation, said the effects won’t become clear until Oct. 1 – the first day the state begins to disenroll people. The foundation estimates 29,000 people could lose coverage. 

Wernham said it remains unclear how Native Americans, who are exempt  from the requirements, will be asked to document their status. The state had limited interaction with the tribes and other stakeholders on how to communicate the change, he said, and urged Wisconsin officials to engage those groups now. 

Wisconsin could improve implementation by working with partners such as Covering Wisconsin to develop forms, define medical frailty and plan outreach, Wernham said.

Montana has effectively automated systems to determine whether someone is working, Wernham said. But automatically verifying medical exemptions has been more difficult as officials struggle to access claims data, the Montana Free Press reported. 

Defining medical frailty

The challenge comes as federal officials have tightened the definition of medical frailty. Rather than automatically exempting people with certain medical conditions, the rules require people to prove their condition and show that it significantly prevents them from working. 

The tightened medical frailty definition has overshadowed concerns over Montana’s ability to automate processes, Wernham said. 

“There are many patients with cancer that may have a disease that will be lethal if not treated, and yet they might not be too sick to work,” Wernham said. “The real question is, what’s going to happen with those people who have a very serious illness, any doctor would consider them medically frail, and yet it may be hard to say they’re too sick to work?” 

For the first year, people can self-attest that they are too medically frail to work. Wisconsin  officials confirmed DHS will rely on self-attestation and existing diagnoses codes, reassuring providers they would not have to determine medical frailty. But in 2028, states will have to determine how to verify those exemptions while risking federal audits.

Montana and other states should outline their plans for monitoring who is disenrolled from Medicaid and the potential impacts, Wernham said. That’s something Wisconsin has done by  announcing that roughly 63,000 are at risk of losing Medicaid due to a lack of work history on file. 

“States aren’t always eager to share their data, especially if it doesn’t look good with the public,” Wernham said. “But the fact is that transparency with regard to data on this program leads to better government.” 

State budget woes

Medicaid funding is often the largest source of federal funds for states, so it can have a big impact on their budgets. State Medicaid budgets could be reduced by an estimated $665 billion through 2034 under the One Big Beautiful Bill Act.

This leaves officials with few choices: raise taxes, cut other programs or cut Medicaid — which would mean reducing provider rates or limiting benefits or coverage. The Congressional Budget Office estimated 10 million more people will be uninsured nationwide by 2034 as a result of the new law. 

The cuts could affect the entire health care system, even those who are insured, said Vaishu Jawahar, director of policy programs at the national health care advocacy nonprofit Protect our Care. 

Programs could be cut or premiums will increase because hospital budgets will be strained. Hospitals could face more uncompensated care as more uninsured patients seek treatment, tightening budgets and potentially increasing costs for privately insured patients. 

Jawahar said people who lose insurance may forgo preventive care until their conditions become severe enough to require emergency treatment.

“They’re still going to have to provide care to uninsured people who will come in sicker,” Jawahar said. “… And so, how do hospitals make up for that? They will have to hike costs on people with employer-based insurance.” 

Medicaid cuts are expected to hit rural hospitals hardest. A March report by Public Citizen found 446 hospitals nationwide were at risk of closing or reducing services due to cuts. Samantha Peck, rural hospitals and clinics program manager for the Wisconsin Office of Rural Health, manages funds that benefit critical access hospitals across the state. 

About 13% of patients in Wisconsin hospitals use Medicaid, but Peck said critical access hospitals in Door County, Oconto, Shawano and New London average about 48% of patients on Medicaid, leaving them particularly vulnerable if more patients lose coverage. 

Maternal and mental health programs could be among the first cut, Peck said. 

“The biggest worry is that community hospitals will start reducing service lines,” Peck said. “What we’re already seeing is a reduction in maternal care, specifically labor and delivery.”

Clinics prepare to help Wisconsinites navigate changes

NorthEast Wisconsin Community Clinic, a free and low-cost health center in Green Bay, is educating people about the new requirements with its mobile outreach vehicle. 

In 2025, 47% of the center’s clients were on Medicaid, which means it’s preparing its budget to receive less federal reimbursement next year. Executive Director Kim Franzen said the clinic will continue serving the uninsured.

“While I’m concerned, I want to make sure that as a health center, it’s our responsibility to take care of people regardless of their ability to pay,” Franzen said. 

Franzen worries people might not realize their coverage was denied before racking up medical bills. 

“If you lose your Medicaid, now a person could potentially have four therapy sessions (before realizing) that ‘Oh, I didn’t know my coverage lapsed,’ and then as an organization, we have to step back and go, ‘OK, so do we bill the person? Do you write off the expenses?’” she said. 

Adam VanSpankeren is the navigator program manager for Covering Wisconsin, which receives federal funding from the Affordable Care Act Navigator Program and responds to calls about health insurance.

Despite recent funding cuts, VanSpankeren hopes people affected by the changes call Covering Wisconsin for help.

“I don’t love that people are affected, but that means we’re going to be able to help those people,” VanSpankeren said. “It’s the people that don’t call us that I worry more about.” 

This story was produced as part of the NEW (Northeast Wisconsin) News Lab, a consortium of five news outlets.

Some states started Medicaid work requirements early. What can Wisconsin learn? 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.

In 14 states, the closure of the closest rural hospital or its obstetric unit would force many Medicaid patients to drive an hour or more to get to another hospital that provides inpatient maternity care, according to an analysis released this week.

Nationwide, the median drive time between hospitals providing inpatient maternity care to Medicaid enrollees and the closest in-state alternative is 43 minutes for rural hospitals compared with 13 minutes for urban hospitals, the analysis found.

The study by KFF, a healthcare research organization, suggests that the closure of rural obstetrics units will accelerate as a result of the healthcare changes included in the broad tax and spending measure President Donald Trump signed last summer. That law will reduce some payments to hospitals and cut Medicaid enrollment by introducing work requirements.

Already, rural obstetric services are diminishing at a rapid rate: From 2010 to 2022, 238 rural hospitals closed their obstetrics units while only 26 hospitals opened new units. In 2023, almost half of rural counties did not have a hospital offering obstetrics services.

A 2022 report by the Government Accountability Office cited low Medicaid reimbursement rates and the challenge of recruiting and retaining providers as major factors.

Brittni Frederiksen, the lead KFF researcher for the report, said in an interview that rural hospitals already operate on thin margins, and that the additional cuts could push some of them over the edge.

“There are likely going to be rural hospitals that close their obstetric units or have to close the entire hospital, and so people will have greater distances to travel to safely deliver a baby,” said Frederiksen, an associate director at KFF who specializes in women’s health policy.

The states with the longest potential driving times, according to the KFF analysis, are Alaska, Nevada and North Dakota. The other states where the median trip would be an hour or more are Arizona, Colorado, Florida, Hawaii, Massachusetts, Montana, New Hampshire, New Mexico, Vermont, Virginia, and Wyoming.

The states with the shortest drive times are New Jersey, Louisiana, and Ohio.

A lack of access to maternity care can lead to increased maternal mortality, low birthweight and premature births.

The United States has one of the worst maternal mortality rates among higher-income countries, at 17.9 deaths per 100,000 live births in 2024, according to the federal Centers for Medicare and Medicaid Services. The U.S. rate is double, or even triple, the rate in most other high-income countries, according to The Commonwealth Fund, a philanthropic and research group.

Outcomes are even worse for women on Medicaid, the government insurance program for people with lower incomes. A recent survey of Medicaid patients who gave birth in 2023 and 2024 found that those patients experienced more complications, such as high blood pressure and gestational diabetes, than women with private insurance.

“We already have a maternal health crisis in this country, and already have very poor outcomes when it comes to delivering babies safely in this country. And then in rural areas, in particular, people already have to travel long distances to deliver,” Frederiksen said.

“Anytime you increase the distance to delivery, you know the likelihood that it could result in poor outcomes increases.”

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

LGBTQ+ adults are more likely than other adults to miss healthcare appointments due to cost or other reasons — with a third reporting their health worsened as a result, according to a new survey by health policy research group KFF.

Among the 2,640 LGBTQ+ adults surveyed, those who are transgender, younger than 30 and those with lower incomes or without insurance were most likely to miss or forgo care due to cost. Over three-quarters of uninsured LGBTQ+ adults reported missing needed healthcare, according to the survey.

Overall, 6 in 10 of the adults surveyed reported missing needed healthcare in the past year due to cost, being unable to find a provider with available appointments or other reasons, compared with 38% of non-LGBTQ+ adults. Transgender adults, who made up 9% of those surveyed, were the most likely to report missing care.

Along with being more likely to postpone or skip needed care, 22% of LGBTQ+ adults reported forgoing prescription medications due to cost, compared with 12% of non-LGBTQ+ adults. Almost a third — 30% — also reported struggling to pay medical bills, compared with about a fifth of other adults.

Three in 10 LGBTQ+ adults say their health got worse because they skipped or delayed care, nearly twice the share of non-LGBTQ+ adults. This was more common among LGBTQ+ women than men — 63% of women compared with 46% of men.

Among transgender adults, nearly half — 45% — said their health worsened.

Insurance denials were also more likely. Thirty-two percent of insured LGTBQ+ adults reported denials by insurance companies, compared with just over a fifth of non-LGTBQ+ adults. Denials or delays in care, prescriptions or treatments were also more pronounced among trans adults as well as those covered by Medicaid or a self-purchased insurance plan.

The survey also looked at care among different age groups. While younger adults in general are more likely to forgo care, LGBTQ+ people had an especially high rate in the survey. LGBTQ+ adults under age 30 were 20 percentage points more likely to report forgoing care than non-LGBTQ+ adults of the same age group, according to the report. Those gaps narrow when it comes to adults over age 65, which could be because of Medicare eligibility, the researchers wrote.

The report noted that LGBTQ+ people are, in general, younger than the overall U.S. population. They are also more likely to have lower incomes, and somewhat more likely to lack insurance coverage, the authors wrote. The survey findings might reflect those  disparities, rather than LGBTQ+ identity, “though those factors are certainly intertwined,” they noted.

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

WILMINGTON, Ohio — From her recliner in her tidy townhouse, Donna Logan offers advice to the first baby boomers to hit the big ‘8-0’ this year: Life can be good, especially with someone like Helen Aponte helping with laundry and housekeeping and the drive to the doctor’s office.

“I do most things on my own,” said Logan, 81, a native of Wilmington, Ohio. “But having Helen come in once a week gives me confidence.”

“I drive her, whatever she needs,” said Aponte, 52. “It makes me happy to help Donna stay in her home.”

Logan and Aponte found each other about a year ago through the Council on Aging in Southwest Ohio in rural Clinton County, about 40 miles northeast of Cincinnati. For three hours on Mondays, Aponte works directly for Logan as a home care aide for $15 an hour, paid by a county property tax for senior services.

Aponte helps Logan with the tasks of daily living, not with medical care. For a senior, that support can mean the difference between aging at home or in an institution charging thousands of dollars a day.

Many seniors who are relatively healthy but need some assistance could see that relationship as an ideal arrangement. But it won’t be possible for many baby boomers, the 65 million Americans who were born between 1946 and 1964.

This year, four million Americans in that generation, including Cher, Sylvester Stallone and President Donald Trump, turned 80. Every day for at least the next decade, another 10,000 will join them. By 2030, Americans over 65 will outnumber those under 18.

For decades, experts have warned that the country was not prepared for this demographic wave.

In 2002, a National Institutes of Health forecast urged states, among other things, to revamp policies to prioritize home caregiving over nursing homes. The study warned  that it was “becoming increasingly difficult for home care agencies and other providers to find and retain qualified caregivers,” and that the problem would only get worse as the U.S population aged.

A big factor then was the poor pay for home care workers. The future has arrived, and little has changed.

Despite the importance of their work, home caregivers are near the bottom of the nation’s pay scale: In 2024, the national median pay for home care aides was $16.78 an hour, or $34,900 per year, according to the U.S. Bureau of Labor Statistics.

The low pay and the difficulty of the work have created a labor shortage, worsened by the COVID-19 pandemic and the Trump administration’s immigration crackdown. There are 4.3 million home care aides today, but the federal government forecasts that by 2034, the nation will need more than 5 million of them.

Some states that cover nonmedical home care through Medicaid, the joint state-federal healthcare program for people with low incomes, have marginally increased workers’ wages. But those small gains could be wiped out in 2027, when billions of dollars in Medicaid cuts go into effect as part of the broad tax and spending measure that President Donald Trump signed last year.

The spending cuts in that law will put pressure on cash-strapped states to cut home- and community-based services, since the federal Medicaid law only requires them to provide institutional care.

The challenge in Ohio

The structural challenges of a larger older population fall mostly to the states, and Ohio is a bellwether. The population has been aging faster since the 1990s collapse of the state’s industrial base, “so I understood the challenge when I came into office,” said Ursel McElroy.

In 2019, McElroy, a state government veteran on aging policy, became director of the Ohio Department of Aging under Republican Gov. Mike DeWine. In an interview, McElroy defined the challenge, then and now.

“Our health care is a triumph of human ingenuity, but while we’re living longer, we’re spending more years in less than good health,” he said. “That’s the problem we want to solve for. How do we keep pace with the realities of aging?”

One reality is that many seniors, such as Donna Logan, cannot afford to hire an aide on their own, but they are not eligible for Medicaid coverage. Instead, they turn to the nation’s more than 600 area agencies on aging, a network established in the 1965 Older Americans Act.

The Council on Aging of Southwestern Ohio manages senior-services levies in four counties including Clinton, said spokesperson Paula Smith. From that money, the county’s Elderly Services Program can pay home care aides, who can be hired through an employment service or directly.

In 2021, the Biden administration proposed putting $400 billion into Medicaid’s home-based and community programs to support home care workers and improve their pay as they kept older Americans out of nursing homes where COVID-19 was rampant and deadly. The proposal did not pass. The shortage of home care aides worsened.

In the past two years, some states have raised the pay of those workers in their Medicaid programs, often to bring them closer to the state’s minimum wage.

In California, for example, the basic wage for home care workers rose this year to $16.90 an hour, which is the statewide minimum wage. Each of the state’s 58 counties then adds a location adjustment. The Los Angeles County wage went up more than $1 to $19.64 this year.

In New York, the hourly wage for home care aides rose by 55 cents, to $19.65 in New York City, Long Island and Westchester County and to $18.65 in the rest of the state. Other states that have recently adjusted home care aide wages include Illinois, up a dollar to $18.75 and Texas, from $10.60 to $13.

Ohio, where the minimum wage is $11, also raised its pay in 2025 to an average of $16 an hour because, McElroy said, the Department of Aging and advocates across the state “have come together more so than I’ve seen in years past.”

The nonprofit Councils on Aging across Ohio held roundtable discussions for legislators on the critical shortage of home care aides, and the importance of their work. Raises for the Medicaid-paid workforce of home care aides, advocates said, would help bring up wages for everyone doing that work. A social media campaign pushed for pay raises, and ultimately, the legislature approved them.

Smith, the spokesperson  for the Council on Aging of Southwestern Ohio, said more people are applying to become home care aides. While Smith said no one is quite sure why, the pay raises likely helped.

‘I am doing just fine here’

Donna Logan says baby boomers shouldn’t worry about turning 80. “They’re in a lot better shape, I think, than our parents,” she said one rainy summer morning in her Wilmington townhouse. “I know a lot of them want to stay at home, like me. I tell them, ‘Get Helen.’”

The handicapped tag on the rearview mirror of Aponte’s sedan allows her to ferry Logan to the grocery store or the doctor’s office. She helps Logan with housekeeping. Every week, Aponte shows Logan how to sign on to the computer to sign her time card for $15 an hour. “I’m getting the hang of it,” Logan said with a laugh.

She turned down her son’s offer to live with his family. With Aponte, “I am doing just fine here.”

Logan isn’t the only one. Aponte has 14 other clients, and they love her so much that in May, Aponte received a Council on Aging award as a home aide hero.

“I love doing this so much,” Aponte said. As a teenager, she took care of her grandmother and discovered a calling. She said her work now gives her flexibility to care for a disabled son.

In her years as a home care aide, Aponte has found one thing in common among seniors, no matter the generation.

“They have a lot of stories,” she said, “and they just want someone to listen to them.”

The measles outbreak reported earlier this month in Southwest Wisconsin has increased markedly this week, the state health department reported Friday.

With newly identified cases, the total number of people in Grant, Iowa and Lafayette counties confirmed with the viral illness has increased to 92, according to the Wisconsin Department of Health Services. Another six people have been identified as probably having measles.

In addition to those 98 patients, two other people in Wisconsin were diagnosed with measles at the beginning of 2026. All but one of the 100 Wisconsinites with confirmed or probable measles this year had not been vaccinated, according to DHS.

Of all Wisconsin measles patients this year, 40% are 18 years old or older, 46% are 5 to 17 years old and 14% are age 4 or younger, according to DHS. The department doesn’t publish the demographic information for specific outbreaks.

So far the Southwest Wisconsin outbreak has not been spreading through general public exposure, according to DHS.

“There’s ongoing transmission of disease from previously identified cases,” said Dr. Stephanie Schauer, DHS immunization program manager, in a video recorded by the department Friday. “So this speaks to the very infectious nature of measles.”

Nine out of 10 people who are susceptible to measles and exposed to someone with the virus, such as a family member or a person they live with, will come down with the illness, she said.

“So if one person in that household becomes sick with measles, and then they expose others in that household, those others are likely to become sick about 10 to 14 days later,” Schauer said.

The measles vaccine — typically delivered in combination with mumps and rubella vaccines — remains the best prevention from the virus, Schauer said.

Earlier this week the Centers for Disease Control reported 2,777 measles cases nationwide. The first two deaths from measles in the U.S. this year were confirmed this week in Pennsylvania, the Pennsylvania Capital-Star reported.

Wisconsin lawmakers who have sought to address child safety online told the Wisconsin Examiner on Thursday that a settlement worth up to $17.1 billion between the owner of Facebook and Instagram and most states in the U.S. is a win, but that it leaves a lot to be done to protect kids.

Wisconsin was one of 47 states involved in a lawsuit, filed in 2023 against Meta, that alleged that the social media giant purposely designed its platforms with addictive features, knew it was exposing children to serious mental harms and intentionally misled the public about the safety of those platforms. 

Wisconsin is set to receive between $219 million and $313 million from the settlement, depending on whether other social media companies agree to the terms. The company in its settlement did not admit to wrongdoing.

For years, concerns about the safety of children online and efforts to protect their mental and physical health have been bubbling up. Wisconsin has adopted laws to ban cellphones during class time and recently expanded its Wisconsin’s Internet Crimes Against Children Task Force.

Rep. Lindee Brill (R-Sheboygan Falls) and Rep. Renuka Mayadev (D-Madison) were part of a group of lawmakers tasked with studying ways the state could protect children online during the 2025-26 legislative session. The task force resulted in an array of proposed bills aimed at addressing the issue, though many — including barring addictive features online for young users, age verification requirements, prohibition against chatbots for children without safety features and mental health warning on social media — did not become law.

“It’s unfortunate that it got to the point that we’ve seen children lose their lives, go through mental health situations,” Brill said. “I believe these platforms understood what they were doing was damaging to children, so while it’s a win, it’s unfortunate that we had to reach a settlement to get this taken care of when this wasn’t addressed previously.”

Mayadev said Meta “capitulated” with the settlement and that “it’s about time” something was done.  

“Young people are feeling more than ever lonely, have had increased suicide ideation, have had more anxiety and eating disorders. We’ve just seen the tremendous detrimental effects of social media,” Mayadev said. 

Both lawmakers said that the settlement is just a start.

During a Wednesday press conference, Wisconsin Attorney General Josh Kaul said the settlement is the largest Big Tech settlement in the history of the country and the largest state consumer protection settlement since the settlements with Big Tobacco in the 1990s. 

According to the New York Times, the Meta settlement’s base cost will be $12 billion, but an additional $5 billion will be paid by Meta if other social media companies also agree to pay in $5 billion. The company has also agreed to the two-hour limit on screen time for children, though it could be decreased to a one-hour limit if other companies agree to the same.

Kaul said the next step is to determine where the funding should go. 

“What I’m going to be doing is everything I can to put these funds toward keeping kids safe in Wisconsin,” Kaul said. The funds, he added, could go towards initiatives such as crisis intervention services, after-school programming and digital wellness use and mental health programming.

Brill noted that while the settlement seems like a lot of money, it is only a small portion of what the multi-trillion dollar company brings in each year.

“I don’t think we can put a worth on the number of children and the damage it’s caused, so while we should celebrate it, I think it’s a cautious celebration because there’s so much work to do and so much loss that came in the meantime,” Brill said. 

Brill and Mayadev said they’d both like lawmakers to be involved in conversations over where the funds are allocated.

Kaul said the most important piece of the settlement is the sweeping safety changes Meta has agreed to make to its platforms. 

“I hope they can set a new standard for the entire industry so that kids who are using social media can stay safe and remain healthy as they’re online,” Kaul said. 

Changes include stronger age verification of users between the ages of 13 and 17, mandatory pauses at 15 minutes, 60 minutes and 90 minutes, limiting screen time for teenagers up to 17 for two hours a day, restrictions on access at night and an elimination of push notifications during school hours. 

“We’re gonna see stronger, more friendly, user-friendly parental controls in place as well, so parents are going to be able more easily to play a larger role in limiting their kids’ use of these platforms,” Kaul said. Beauty filters — which distort a user’s face in real time to change its shape or add makeup — will also be limited. 

Brill said she thinks a key part of the settlement is that the company appears to be keeping “parents in the driver’s seat .” She said she will be interested to see whether the other companies agree, however. Some of the work, she said, will be continuing to push for state-level laws that can address the issue, which she described as nonpartisan. Brill does not face a challenger in her bid for reelection this year. 

“I met some of the families who have had things happen with their children, and it’s absolutely devastating, and it doesn’t matter which way your house votes; it affects everybody,” Brill said. “We’re just seeing the mental health of our state and our children, being so affected by this, so my hope is we can make a smart decision with [the settlement funds], and that we can, as a Legislature, continue to move forward and introduce great legislation to a governor’s desk that’s willing to work with us on it.”

Mayadev said she doesn’t think  the settlement’s guardrails are sufficient.

“Why would we trust the company who has put our children in harm’s way to come up with the solution to protect them?” she said. “No parent — and I’m a parent — should feel like ‘OK, well now let me just hand over the phone and the social media apps because Meta and the other big tech CEOs are gonna care for my children.’”

Mayadev said that ideally regulations on companies would be put in place on a federal level. She said legislation would ensure it is the company’s obligation to make sure platforms are safe rather than burdening parents. She said that “children are bright” and can likely find ways around some of the changes that are being discussed. 

“At the federal level, we need our congressional folks to act because then we’d have uniform guardrails, guidelines for everybody in the United States to adhere to and to protect children,” Mayadev said. “If Congress continues not to act, we’re going to have to do it at the state level, and then what the problem with that is, it’s piecemeal. What we do is different than Minnesota, which is different than Michigan or Ohio.” 

New state oversight laws are pumping the brakes on private equity’s push into healthcare, according to new data.

The number of private equity-involved healthcare deals has declined since last year, and the value of those deals in the first half of 2026 is lower than it was for the same time in 2025, according to a new report from Pitchbook, a company that tracks private capital markets and investment data.

The report’s authors say that a slew of new state laws is one reason why.

At least 25 states have proposed or passed laws increasing oversight of healthcare transactions in recent years, restricting the power of companies that are not run by physicians to control medical practices, or limiting how private equity and other companies can operate.

California, Oregon and Rhode Island each had new laws or regulations take effect this year that require more documentation and transparency on mergers, acquisitions and other deals among healthcare companies.

“[P]rivate equity and increasing market consolidation drive up the cost of care, further inhibiting patient access,” Rhode Island Attorney General Peter Neronha, a Democrat, said in a January statement announcing his state’s new regulation.

Neronha said the new oversight will give his office “a bird’s eye view to ensure that future medical group mergers do not harm Rhode Islanders’ access to health care services.”

New state laws and regulations have made the purchase of healthcare companies and other similar financial transactions take longer and cost more, PitchBook analysts found. And rolling up smaller companies into larger conglomerates — a consolidation strategy that private equity has relied on in myriad industries, including healthcare — is harder to do under tighter state scrutiny.

The healthcare sector hit hardest by the new private equity rules is physician practice management, or companies that perform administrative tasks such as patient scheduling and billing. Deals in that corner of healthcare, the sector in which private equity has the largest role, are on track to decline by half this year, compared with 2025.

Last year, at least seven states (California, Indiana, Massachusetts, Maine, New Mexico, Oregon and Washington) enacted laws that built guardrails around private equity’s involvement in healthcare.

Some states have targeted private equity in specific areas of healthcare: Earlier this year, Connecticut passed what may be the strongest law in the country to address accountability and transparency for private equity-owned nursing homes.

Lawmakers in Hawaii, Indiana, New York, Pennsylvania, Vermont and Virginia all proposed bills this year that would add oversight of healthcare transactions or limit how private equity is allowed to operate.

In the past decade, private equity investors have spent $1 trillion acquiring healthcare companies.

This increased state oversight has followed mounting public outrage over hospital closures, nursing home crises, patient abuse and neglect, and other failures that regulators have tied to private equity’s involvement in healthcare.

Proponents of private equity say its investments fill critical gaps in the U.S. health care system, providing much-needed capital to help hospitals and physicians upgrade technology and streamline their processes.

But research has found few positive effects. One large 2023 study found that private equity involvement increased the nursing home death rate by 11%. Other studies have linked private equity involvement to increases in emergency room visits and rising Medicare costs. A 2022 Moody’s Investors Service report found that almost 90% of financially stressed health care companies are owned by private equity.

States have stepped in to regulate, even as congressional investigations have not yielded new federal laws.

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

Part 1 of an occasional series on how people are being affected by the expiration of Affordable Care Act subsidies.

EDWARDS, Miss. — Every now and then a freight train rumbles through, creaking and groaning on the rusted tracks that run along the edge of the largely deserted downtown. On some days, that train is just about the only thing moving.

Grandma’s Ice Cream Shoppe, an ice cream parlor owned by a retired preacher and his wife, gets only one or two customers per day. There is a small barber shop, and the empty ruins of a former thrift store. The sugary, smoky red meat at Lee’s Heavenly Barbecue and the fried shrimp and catfish at the M & L Fish Hut draw some folks. But the ellipticals and treadmills are silent, as usual, at the 4-year-old Kut-N-Fit Wellness Club on Vicksburg Street.

Derrick Clark, 51, has lived in Edwards his whole life.

Clark has always struggled with his weight and he readily describes himself as obese. About two decades ago, he was diagnosed with Type 2 diabetes.

“My grandmother, my uncle, my dad are all diabetics, and I’ve had some relatives that have gotten some of their limbs cut off because of their diabetes,” Clark said. “When it’s a hereditary disease that runs in the family, it’s kind of hard.”

Last year, Clark was reelected as the at-large member of the Edwards Board of Aldermen. But the part-time job only pays about $500 a month. His family owns a small sports bar in town, but it’s only open for a few hours a day and doesn’t generate much additional income.

He has no health insurance.

As is the case with many chronic diseases, the worst consequences of diabetes — such as blindness and amputations — can be prevented with routine care. Clark and many other diabetes patients in Mississippi were getting that care over the past few years through subsidized Affordable Care Act insurance plans.

But Congress allowed the so-called enhanced subsidies to expire at the end of last year. Now the number of diabetic Mississippians without insurance, and thus regular care, is once again on the rise: According to state data, enrollment in ACA plans has fallen by nearly two-thirds in just eight months. The medical and financial consequences could be dire — for individual patients like Clark and for the state.

Mississippi maladies

Designed as a temporary pandemic-era measure, the enhanced subsidies were made available by the American Rescue Plan Act in 2021 and later extended through the end of 2025 by the Inflation Reduction Act.

 

 

In 49 states (all but New Mexico), the number of people enrolled in ACA plans, also known as Obamacare, has declined since the subsidies expired and coverage became more expensive. Nationwide, participation has declined this year by nearly 3 million people, to about 19.2 million from 21.8 million in 2025, according to the Trump administration. The 2025 figure was the highest ever recorded, after six years of steady increases.

But few if any states are feeling the absence of the subsidies as acutely as Mississippi.

By many measures, Mississippi is the poorest state, with more than 14% of its families living below the federal poverty line. Its traditional Medicaid program has strict income limits, and excludes nearly all non-disabled adults, including Clark. And it is among the 10 states that have not expanded Medicaid to single adults and higher-income parents under the Affordable Care Act.

Mississippi is also one of the unhealthiest states. The federal Centers for Disease Control and Prevention has identified a “diabetes belt,” where people are most likely to have the chronic disease. It includes 644 counties across 15 states, primarily in the South; Mississippi is the only state where every county made the list.

In addition to its high diabetes rate, Mississippi has the nation’s second-highest heart disease mortality rate, and it is one of only two states, along with West Virginia, with an obesity rate above 40%.

Black people make up more than 36% of Mississippi’s population — the highest percentage of any state — and Black Americans are more likely than other racial groups to have chronic diseases, including diabetes. That’s largely because Black people are more likely to live in poverty, to have trouble accessing healthcare, and to be exposed to pollution and chronic stress.

 

 

When the subsidies significantly lowered the cost of Obamacare coverage — making it free or nearly free for some people with low incomes — Mississippi state health officials made a concerted effort to get residents to enroll. Dr. Daniel Edney, Mississippi’s state health officer, said the state launched a public information campaign to encourage people to sign up at their local health departments.

It worked. The number of Mississippians enrolled in Obamacare plans more than tripled, from fewer than 99,000 people in 2020, the year before the subsidies went into effect, to more than 338,000 at the end of 2025, according to state data.

“Our uninsured rate went down significantly, and I’m convinced it’s one of the reasons why our overall population health scoring has improved,” Edney said in an interview in his office in downtown Jackson.

In its 2025 public health report card, the Mississippi State Department of Health reported lower rates of opioid-related deaths, HIV, syphilis, congenital syphilis, teen births and accidental deaths. Health officials acknowledged that the state had made less progress on chronic conditions such as hypertension and obesity, but also noted that it went from dead last in overall national health rankings three years ago to 48th last year.

But when the subsidies expired at the end of last year, Mississippi’s Obamacare enrollment numbers plunged: Roughly 134,000 residents were still enrolled as of Aug. 21, about 40% of last year’s total. And the state projects that the number will fall to around 127,000 next year.

Many of the Mississippians who dropped their coverage have diabetes or other chronic conditions. Without insurance, they are likely to put off routine care, Edney said.

“What’s gonna happen to them? Probably present to the emergency room, eventually showing up once their vision is blurry, or they start having chest pain, or they have a sore on their foot that won’t heal,” he said. “At that point, you’re scrambling to get them placed into care.”

The Obamacare subsidies made a huge difference for Clark, who is unmarried and does not have any children. With coverage, his insulin and medications to control his blood pressure and blood sugar cost him about $15 per month, he said. But he could no longer afford his insurance plan when the subsidies expired and his premiums went up by “hundreds of dollars.”

Without insurance, he says his medications now cost him about $200 per month — and that’s with discounts he gets from medical clinics. Sometimes, he said, family members give him insulin they don’t plan to use.

At some point, he said, he might have to choose between paying for medications and paying his other bills.

“I still have utilities and water and gas and food and still have to buy my medicine monthly out of pocket,” Clark said. “I’m just praying for a better day and trying to lose some weight so I can try to get my diabetes in control.”

Opening a gym 

Like Clark, 49-year-old hair stylist and salon owner Angie Myles-Griffin grew up in Edwards, and she never really wanted to leave. But the limitations of living in a small town hit home after she gave birth to her third child and she set out to lose some of the weight she had gained: She had to drive more than an hour round trip to Jackson to find a gym and a grocery store selling healthy food.

Frustrated by the back and forth, Myles-Griffin decided to do something about it: She became a certified personal trainer and opened her own gym in Edwards, the Kut-N-Fit Wellness Club, right down the street from Lee’s Heavenly Barbecue.

“I became very passionate about health and just fitness overall,” Myles-Griffin said. “So I wanted to bring that back to my community, so people wouldn’t have that excuse of having to drive.”

Myles-Griffin said that in 2024 she partnered with the University of Mississippi Medical Center in Jackson to lead a yearlong diabetes prevention program for 20 Edwards-area women. Myles-Griffin gave participants fitness and nutrition coaching at her new gym and even brought in dieticians to show them how to prepare healthy meals. A dozen people stuck with it.

But since the medical center concluded its sponsorship, most of Myles-Griffin’s clients have melted away. Even though Kut-N-Fit is conveniently located, she said most Edwards residents just don’t have the “mindset” to work out regularly. And Edwards residents still have to drive about a half hour to get to a grocery store with a wide selection of healthy offerings, she said.

Unfortunately, a lack of transportation is one of the many challenges that Edwards residents face.

“If you don’t have transportation, you can’t get to a job, and if you can’t get to a job, there’s no income,” Myles-Griffin said. “And so when there’s nothing going on, it’s like a lack of motivation.”

Poverty, a lack of exercise, obesity, diets high in sugar, unhealthy fats and processed ingredients — that confluence of factors exists in many Mississippi communities. It’s a recipe for Type 2 diabetes, and it’s costing Mississippi billions of dollars.

Diagnosed cases of diabetes cost the state an estimated $5.1 billion annually — $3.4 billion from direct medical expenses and another $1.7 billion from lost productivity in 2022, according to the American Diabetes Association.

And when diabetics don’t get regular care, because they don’t have insurance or don’t have easy access to a doctor, the most extreme — and expensive — health outcomes become more likely. Mississippi’s lower extremity amputation rate is about twice the national rate, according to the American Heart Association.

Irena McClain, the executive director of the nonprofit Diabetes Foundation of Mississippi, said that since the subsidies expired, her organization has been receiving more calls from people asking for help. Without insurance, medical care for diabetes can cost people upward of $1,000 per month, according to a 2022 study.

“I had someone call me up last week, whose doctor wants her on an insulin pump to control her Type 1 diabetes, and she doesn’t have any insurance. She can’t get a pump unless someone donates a pump to us,” McClain said. “And there’s certainly a lot of people who need help much more than the amount that these charities have to give. I don’t know what’s going to happen.”

In Jackson, McClain said, charities, free clinics and community health centers are struggling to provide care to all the diabetes patients who have lost their Obamacare coverage.

Mississippi hospitals also are feeling the pinch, according to Richard Roberson, president and CEO of the Mississippi Hospital Association. In 2023, the most recent year for which numbers are available, Mississippi hospitals provided more than $600 million in “uncompensated care,” or care for which they received no payment from either the patient or an insurer.

“That trajectory of costs combined with the trajectory of uninsureds is just going to really exacerbate the challenges for hospitals,” Roberson said. He added that changes to hospital funding included the broad tax and spending law President Donald Trump signed last summer, the One Big Beautiful Bill Act, will increase the financial strain.

“We’re just going to start seeing that decrease in revenue, increase in cost, and at some point on the axis, they’re going to cross, and it’s going to be bad,” he said.

No help coming

Meanwhile, the cost of Obamacare coverage keeps going up. Next year, the median proposed premium increase is expected to be close to 15%, the second consecutive year of a double-digit premium hike.

In addition to the expiration of the federal subsidies, prices have increased because of other factors, including labor shortages and the rising cost of prescription drugs, driven in part by the growing demand for GLP-1 drugs such as Ozempic and Wegovy.

At least 10 states are using their own money to help people buy Obamacare health plans, partially replacing the expired subsidies. But Mississippi isn’t one of them.

“It’s not that there’s a big money room in the basement where we can go get the money that we’re keeping from everyone,” Mississippi Republican state Rep. Lee Yancey, who serves on the House’s public health and human services committee, told Stateline. “It’s just there’s a limited amount, and there’s only so much you can do.”

Yancey expressed sympathy for Mississippians who can’t afford Obamacare plans without the subsidies. However, he added, he doesn’t believe that “just because a problem exists the government is the one that has to fix it.”

Without the Obamacare plan he used to have, Clark said he has little choice but to drive to Jackson every month to get discounted medications at the Jackson-Hinds Comprehensive Health Center.

“Sometimes you got to do what you got to do, and with this high price of gas and food … it’s just rough,” Clark said as he stood outside the clinic.

“If you go in there, you see it’s not about a race thing,” he said. “It’s just poor people — the working poor.”

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

This story was updated to clarify that poverty, a lack of exercise, obesity and diets high in sugar, unhealthy fats and processed ingredients are risk factors for Type 2 diabetes, not diabetes generally.

This story is part of “Uninsured in America,” a project led by Public Health Watch, a nonprofit newsroom based in Texas. The project focuses on life in America’s health-coverage gaps and the impact of potential Medicaid cuts and other changes.

An outbreak of measles in two counties reported earlier this month has spread and is affecting 48 people, the state health department reported Friday.

The Wisconsin Department of Health Services has identified a total of 41 confirmed cases and seven “probable” cases, reported in Grant, Iowa and Lafayette counties. They include two cases in Grant County, which were reported earlier this week, and 35 in Iowa County.

In Lafayette County, the count is now four confirmed measles cases and seven probable cases. One of the confirmed cases is new, along with the four probable cases, DHS reported in an updated announcement. 

So far DHS has not found evidence of public exposure to the virus, meaning the cases identified so far appear to have been spread between people who knew each other.

State health officials are recommending that people check their vaccination status. The MMR (measles, mumps and rubella) vaccine is the best protection against measles, health officials say.

DHS is recommending that anyone who isn’t sure whether they have the MMR vaccine check their vaccination status at the Wisconsin Immunization Registry or with their local public health department or healthcare provider.

A federal report in July found that nationwide, measles cases have reached their highest level in 35 years. The reemergence of the viral illness, which public health experts said had been eliminated by 2000, coincides with declining vaccination rates in the U.S.

Since Jan. 1, the number of Wisconsin measles cases has grown to 50, according to DHS, and with one exception, everyone who has taken ill was not vaccinated for the disease. 

DHS operates a Measles Dashboard and a webpage for Outbreaks and Investigations that supplies more public information about public health conditions, with 12% of cases in children age 4 or younger, 44% in children ages 5 to 17, and 44% in adults 18 or older.

This report was updated with additional information from DHS.

When Kaiser Permanente triage clinician Harimandir Khalsa began working in the psychiatry department at Kaiser’s Walnut Creek Medical Center in Northern California, she was on a team of nine people. Today, just over three years later, she is one of only three triage clinicians left. Some of the work once handled by employees has shifted to automated and algorithmic tools.

This change has coincided with a sharp increase in the number of patients who are upset by the time they speak to her. On a typical day, as many as a third of her almost two dozen triage calls are with patients who have struggled to access appropriate care.

“What has increased is frustration. Sometimes people are like, ‘I’ve been sent all over the place,’” she said. The decline in triage staffing and the increasing use of artificial intelligence-powered systems at Kaiser have also led to dangerous delays, missed diagnoses and inappropriate treatment decisions, according to multiple Kaiser mental health care workers.

To understand some of the ways that AI is affecting mental health care, Capital & Main spoke with more than a dozen therapists, clinicians, academic experts and advocates in Wisconsin and California, who said the hasty integration of the technology is eroding patients’ access to timely and appropriate mental health care. While AI is changing work in many professions, its use can have particularly high stakes in the mental health field, workers said, by creating barriers to care for patients who are already struggling with major depression, bipolar disorder and other serious conditions.

Increasing transparency around its use and blocking the deployment of AI in triage decisions have become major goals in collective bargaining for these workers. Already something of a national leader in AI regulation, the state of California, where Kaiser is headquartered, now has pending legislation that would create safeguards around the technology in medical settings.

Capital & Main interviewed mental health care workers employed by Kaiser and Rogers Behavioral Health, a Wisconsin-based provider of addiction and mental health treatment. Spokespeople for these health care providers denied that their AI systems are replacing the work of mental health professionals. “Clinical assessments, triage and treatment decisions are made by licensed clinicians, and any technology we use is designed to support — not replace — clinical judgment,” Kathleen Chambers, a Kaiser spokesperson, wrote in an email.

Distressed patients and dangerous delays

About two years ago, Ilana Marcucci-Morris, a Kaiser therapist who works in Oakland, noticed that the path to mental health care was becoming increasingly dictated by technology. Instead of being referred directly by primary care doctors and contacted to schedule appointments, patients were routed through an app, nonclinical call center staff or simply given a phone number to call. “Now the onus is on the patients to be their own care coordinators,” she said.

This dynamic can be particularly challenging for some patients. “Lack of motivation and lack of follow-through are the most common symptoms of depression on the planet,” Marcucci-Morris said. “We wouldn’t tell a paraplegic, ‘Hey, walk down the hall in order to get your wheelchair.’”

Khalsa and Marcucci-Morris are now spending more time doing what is called “service recovery” — the effort to repair trust in patients whose expectations of care haven’t been met. Even when broader use of automated and algorithmic systems does not eliminate human jobs, it can change their nature, increasing the emotional labor needed to reassure patients disserved by those very systems.

“More often than not, I’m de-escalating an upset patient because they were sent down the wrong path and are suffering, so they’re frustrated with us,” Marcucci-Morris said.

Melissa Stevens, a clinical psychologist at Kaiser in Northern California who works in a chronic-pain program, will often make referrals within Kaiser when patients need psychiatric care for intense depression or delusions. Over the past year, however, she said that Kaiser’s reliance on an AI-powered triage system has made those referrals much harder. She sometimes hears from patients who were never contacted or who were placed in group classes for anxiety or depression, even when they needed a higher level of care.

“It’s getting dismissed by whatever their filtering system is until I actually pick up a phone and call a human,” she said, adding, “I’m like, ‘What’s happening here?’”

Such delays can be not only frustrating but also dangerous, said Khalsa. “I’ve definitely seen those cases where there’s been a delay of sometimes weeks with this new triage system or where self-harming or a prior suicide attempt has been missed,” she said.

Kaiser now connects patients with multiple third-party apps and digital programs, such as Calm, which offers guided meditations, and Meru Health, a 12-week mental health program that includes up to four telehealth sessions with a licensed therapist and contains short videos and activities in its app. “Kaiser is saying, ‘Hey, it’s so great; you can just instantly get some cognitive behavioral techniques about sleep,’” Khalsa said. “But what if this person is in the midst of a manic episode, and they’re not sleeping because they’re manic? A little app isn’t going to help.”

While Kaiser workers said these apps and programs can provide valuable information and insights in some cases, they told Capital & Main that in other cases they do little for patients, who get worse without appropriate treatment.

“It’s not weekly therapy, and so I’ve had a lot of patients come back from that, and then three or four weeks in, they’re in worse shape than when they started,” Marcucci-Morris said. “The ones that really trouble me go through the full 12-week program, and then they go to a medical appointment again, and their depression is worse.”

Inappropriate placements

In late 2024, Rogers Behavioral Health, which has facilities in 10 states, announced a partnership with the company Limbic, which offers AI products to help mental health care providers with intakes, case management, clinical assessments and other tasks.

The partnership’s stated goal, according to a Rogers press release, was “to create easier pathways to care for anyone making the courageous decision to seek mental health support”. By August 2025, Limbic published a case study on Rogers’ use of its products, including an AI intake chatbot and an AI voice agent. The report claimed that Limbic used “real-time routing and prioritization based on AI-generated clinical intelligence.”

For Rogers workers interviewed by Capital & Main, the integration of Limbic was not the roaring success that the report suggested. Erin Quinlan, a behavioral specialist at a Rogers facility in Madison, Wisconsin, has noticed many patients placed in an inappropriate level or type of care since Rogers began using Limbic.

A recently admitted patient who was “a very severe suicidal risk” requiring inpatient care was instead admitted into “the lowest level of care” provided in her building: intensive outpatient care, Quinlan said. She estimated that in her behavioral health group classes, which usually have at least eight participants, typically at least one person should not have been placed in the class.

“If a patient does not have the ability to regulate their emotions through skills, they will become overwhelmed incredibly quickly, and we will have them in crisis,” she said, noting that such crises have involved patients crying, screaming and attempting to leave the facility.

In an email to Capital & Main, a Rogers Behavioral Health spokesperson, who asked that their name not be used, credited AI with “allowing our team members to spend more time focused on patient care,” adding that the tool was used to gather information from patients in “a HIPAA-compliant way.” The email also said that “only licensed Rogers clinicians make admission, placement and treatment decisions.” Limbic did not respond to multiple requests for a comment.

Kate Zolandz, a former Rogers therapist, , said she also saw inappropriate placements increase after the introduction of Limbic. Zolandz, who worked for four years in the company’s West Allis, Wisconsin facility, was particularly struck by an apparent lack of screening for past aggressive behavior after the adoption of Limbic. “When they’re crying, they’re dysregulated, they’re screaming, they’re throwing things, it disrupts patient care, but it also stretches staff even thinner because they’re needing to attend to this immediate crisis,” she said.

A way forward: Guardrails and the uniquely human

Some of the problems identified by mental health care workers could in theory be improved with better AI. Yet experts and clinicians caution that some problems are only fixable by ensuring a central place for licensed human caregivers in mental health and other health care. Labor unions and legislators are currently proposing ways to place guardrails around the use of AI in union contracts and state law.

“Ultimately, AI tools are just that: They’re tools. The provider is the trained licensed professional, and so their judgment is what’s important,” said Leanna Fortunato, a clinical psychologist and the director of digital health and innovation at the American Psychological Association.

A key provision of California Assembly Bill 2575, authored by Assemblymember Liz Ortega, seeks to defend the judgment of professionals by protecting health care workers from retaliation if they override the recommendation made by AI. The bill would also require health care facilities to be more transparent with workers about the risks and uses of AI systems and would shift liability to AI developers and facilities for any harm to patients. The bill passed the Assembly by a wide margin and has since advanced through several Senate committees, where it awaits a floor vote.

The California Hospital Association and Kaiser are among the signatories to a March letter opposing the bill. David Simon, senior vice president of communications at the California Hospital Association, wrote to Capital & Main, “At the heart of our concern is that this bill would undermine the many ways that AI utilized by clinicians through clinical decision support systems can improve nearly every aspect of health care — from quality, patient experience and affordability to clinician efficiency and well-being.”

Robert Wachter, chair of the department of medicine at the University of California, San Francisco, and author of the 2026 book A Giant Leap: How AI Is Transforming Healthcare and What That Means for Our Future, was also critical of the bill. “We need some room for safe experimentation with oversight, as opposed to locking in the status quo,” he said.

Ortega told Capital & Main she recognizes the importance of AI in improving health care and credited it with “saving lives and being able to identify serious health conditions.” However, she said, AI “can also get it wrong” and that patients and workers deserve protection and transparency from health care providers. Another pending bill, AB 1979, authored by Assemblymember Mia Bonta, would outlaw clinical decisions based solely on AI output and strengthen data privacy protections. The National Union of Healthcare Workers, National Nurses United and the California Nurses Association support both bills. (Disclosure: NUHW and CNA are financial supporters of Capital & Main.)

In Northern California, Kaiser health care workers have made the appropriate deployment of AI a major issue in contract talks. However, Kaiser is currently refusing to agree to language stating that artificial intelligence “is not to replace but to assist” employees “in providing safe therapeutic and effective patient care and support,” according to NUHW.

Chambers, the Kaiser spokesperson, did not respond to a question about the proposed language but said in a statement to Capital & Main: “As part of our ongoing negotiations with NUHW, our proposals are focused on ensuring our members have timely access to high-quality mental health care, supporting our clinicians in delivering excellent care and meeting the growing demand for services.”

The roughly 2,400 Kaiser mental health care workers in Northern California represented by the NUHW have been without a contract since last September, and the health care giant’s hospital system’s use of AI has emerged as a major source of disagreement.

That disagreement also prompted the NUHW to file a complaint with California’s Department of Managed Health Care in April last year, alleging that Kaiser uses AI to triage patients in violation of California law. The union also filed a second complaint on July 2o, alleging that Kaiser’s web-based “e-visit” tool also violates state law. In written materials quoted by NUHW, Kaiser said its intake system uses “built-in logic and algorithm” to identify a patient’s level of distress before directing call-center agents to schedule care.

The union is arguing that triage must legally be performed by licensed clinicians, a view shared by Robin Feldman, a professor of law at UC Law San Francisco and the director of its Center for Innovation. “California law requires that a licensed health care professional must make the decision about the level of care a particular patient needs,” Feldman wrote in an email.

In February, Kaiser reached an agreement with the U.S. Department of Labor to pay more than $28 million to its patients who had to go out of network for mental health care between 2021 and 2024. The settlement announcement said that Kaiser “used patient responses to questionnaires to improperly prevent patients from receiving care.” Chambers said that this matter did not involve AI.

Kaiser has claimed that a shortage of mental health care workers was partly responsible for its struggles to provide adequate care. Some of its workers cite Kaiser’s roughly $67 billion in unrestricted cash reserves to question that claim.

Meanwhile, in West Allis, Wisconsin, Rogers’ mental health care workers voted 54-4 to join the NUHW in April, but Rogers has not yet agreed to meet with them and negotiate. Transparency on exactly how AI is used was a key issue identified by several workers who spoke with Capital & Main.

Even with better AI systems and more transparency on how they are used, therapists at Kaiser and Rogers stressed that such tools cannot produce the same benefits as a strong relationship with a human caregiver.

“Therapy works because you build a relationship with your therapist,” said Zolandz, the former therapist at Rogers. “AI can’t build that connection in the same way that an actual human being can.”

Copyright Capital & Main 2026. Credit and a link to the original story at Capital & Main are required when republishing.

Capital & Main is an award-winning nonprofit publication whose mission is to educate the public on matters of importance such as economic inequality, climate change, health care, threats to democracy, hate and extremism and immigration.

Hospital costs in Wisconsin are about 26% higher than in Illinois, according to a new study comparing the two states, but a hospital trade association questions the report’s methods and disputes its conclusions.

The reason for the difference isn’t certain, says the report’s co-author, University of Wisconsin economist Anthony Lo Sasso. But he says it could be because most metro areas in the state have one dominant hospital and healthcare system.

For hospitals, “it’s not a monopoly market, but it’s a consolidated market,” Lo Sasso said in an interview.

Illinois metro areas appear to have more evenly matched competing healthcare systems — in Chicago, but also in smaller communities around the state, he suggested.

Lo Sasso said the consolidation in Wisconsin appears to give hospital systems more power to negotiate smaller discounts with health insurance plans.

Lo Sasso is based at the UW-Madison La Follette School of Public Affairs. The report was produced jointly with Capital Policy Analytics in Washington, D.C., and was released by the Center for Research on the Wisconsin Economy at UW-Madison.

The report uses data hospitals and health insurers report to the federal government. Hospitals must report their charges for each service. Insurers must report the rates for each service that they’ve negotiated with hospital systems.

In both states, the report focuses on the rates paid by two health insurers, UnitedHealthcare and each state’s Blue Cross plan — Blue Cross Blue Shield of Illinois, and in Wisconsin, Anthem Blue Cross. Both United and Blue Cross have a substantial group of fixed, negotiated rates in both states, the report found.

While Wisconsin has “a handful of large, vertically integrated systems with extensive control over physician supply, service lines, and affiliated health plans,” the report states, Illinois “maintains a more competitive landscape.”

The Illinois sample included 67 hospitals throughout the state, while Wisconsin’s consisted of 58 hospitals. The study compared the charges for services in 26 billing codes that were found in both  states.

“We use 26 high-volume procedures,” Lo Sasso said, that included heart surgery, maternity, orthopedic surgery and trauma procedures. He said the hospitals in the study were “highly representative of each state.”

The report states that Wisconsin hospitals’ 26% higher prices were consistent through a variety of analyses. In addition, at one hospital chain with operations in both Illinois and Wisconsin — Advocate Health, which is Advocate Aurora in Wisconsin — Wisconsin prices were 23% higher, the report found.

Christian Moran, senior vice president for finance and payment at the Wisconsin Hospital Association, said he didn’t believe the report adequately supported its conclusions.

The hospitals included were “not a representative sample,” accounting for less than half of all Wisconsin hospitals, he said.  He also took issue with the use of two dozen billing codes when there are more than 700 codes to choose from.

“I just don’t believe it’s appropriate to draw conclusions based on that sample and without looking at the broad array of things that are driving healthcare costs,” Moran said.

A federal judge in the District of Columbia issued an order Wednesday blocking U.S. Health and Human Services from implementing sweeping changes to grants under the Teen Pregnancy Prevention Program while a lawsuit proceeds, but dozens of existing grants that were canceled this summer will remain so for now, unless the administration chooses to reinstate the funds.  

The agency canceled 53 out of 67 grants under the program at the end of June, affecting grantees in more than two dozen states, including Louisiana, New York, Oklahoma and Texas. Grantees were given no advance notice and were told their programs did not align with agency priorities — most were told their programs normalized or promoted sexual activity for minors. The grants were canceled two years before their expiration dates.

Following the cancellations, three affected grantees and sex education advocacy group SIECUS: Sex Ed for Social Change filed a lawsuit in the District of Columbia federal court district on July 14. U.S. District Judge Christopher Cooper, an appointee of former President Barack Obama, said the plaintiffs are likely to succeed in the case, warranting his decision to block the Trump administration’s actions. 

But Cooper said it’s unclear whether he can order the restoration of nearly $70 million in canceled funds, and that other court cases need to be resolved before he can move forward with that kind of action.

Congress established the Teen Pregnancy Prevention Program in 2010 as a national, evidence-based grant program that would fund diverse programs working to prevent teen pregnancy using methods that have repeatedly shown to be effective. Grant recipients typically offer educational programs about preventing pregnancy or identifying healthy relationships, and provide referrals for community and healthcare resources as needed. 

Since then, teen pregnancy rates have fallen about 72%, which researchers say is the biggest contributor to the overall drop in national birth rates.

To replace the canceled grants, HHS published two notices for new programs that focused less on preventing pregnancy and more on fertility tracking, “body literacy” goals and “reproductive goals counseling.”

“HHS is perfectly entitled to formulate its own views about how to stem teen pregnancy — or even whether it is worth preventing at all — and to pursue policy initiatives consistent with its viewpoint,” Cooper wrote in his ruling. “But it is not at liberty … to impose conditions on grant recipients that Congress did not intend or that are unreasonable or unexplained. The preliminary record suggests that HHS has done just that.”

Cooper said HHS could choose to reissue the grant funding opportunities under the previous guidelines, but it can’t move forward with the new ones while the lawsuit proceeds.

The judge also noted that in July 2025, HHS issued a notice telling grantees to revise their programs to align with current executive orders, including by deleting any references to health equity and inclusivity, and offered guidance about what it considered medically accurate and age appropriate content. 

Three grantees sued over the notice, saying it was contrary to the statute guiding the program as established by Congress, and another D.C. judge agreed, vacating the guidance and blocking its implementation. 

“As the saying goes, ‘When at first you don’t succeed, try, try again.’ HHS has taken this adage to heart,” Cooper wrote this week, citing the 2025 court case. “Unfazed by the adverse ruling, HHS issued new (grant funding notices)  that repackaged the vacated policy changes and imposed additional grant parameters.”

The administration could appeal the decision in the coming weeks. Stateline has requested comment from HHS officials.

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

A vote that U.S. Rep. Tom Tiffany cast in June 2025 has become a centerpiece of healthcare advocates’ criticism of the Republican candidate for governor.

Tiffany, along with all Republican members of Congress and no Democrats, joined in the passage of the 2025 HR 1 — the legislation that President Donald Trump and U.S. House Republican leaders dubbed “The One Big Beautiful Bill Act.”

The measure made cuts to Medicaid and federal nutrition benefits over the next 10 years, along with a range of other changes to federal programs. The Medicaid changes alone have been projected to cut $900 billion to $1 trillion from the health insurance plan for people with low incomes.

The legislation also extended a series of tax cuts that were passed in Trump’s first term — cuts that primarily benefit wealthy Americans, according to the Center on Budget and Policy Priorities in Washington.

After the bill’s final passage in July 2025, Tiffany issued a statement praising the outcome for “providing tax cuts for seniors, parents, workers and small businesses” as well as for funding federal immigration agencies that have been deployed across the country.

Tiffany also said he would “remain committed to protecting Social Security, Medicare, and Medicaid for our seniors and the most vulnerable, while rooting out waste and curbing the reckless spending that threatens future generations.”

But in press conferences last week and Tuesday, healthcare advocates said that bill was central to their opposition to Tiffany’s healthcare record.

“When he voted for the one big beautiful bill, he essentially voted for a $1.1 trillion cut in healthcare,” U.S. Rep. Mark Pocan (D-Black Earth) said at a press conference Tuesday organized by the groups Main Street Action and Protect Our Care. “And that’s the biggest cut we’ve ever seen in this country.”

In addition to benefit cuts, advocates have focused on what HR 1 lacked. U.S. House Democrats tried to persuade the Republican majority to extend enhanced health insurance subsidies for people buying their health coverage on the Affordable Care Act marketplace.

The enhanced subsidies were enacted in 2021 and expired at the end of 2025. Democrats’ repeated attempts to extend them were rejected, not only during debate on HR 1 but several times later in 2025 as well as early in 2026.

Pocan said he’s spoken with small business owners across his South Central Wisconsin district who have been affected by the ACA premium increases that resulted.

“We’ve seen small business owners in Baraboo on the Affordable Care Act say that their monthly portion they pay in has doubled or even tripled,” Pocan said. One constituent he spoke with “just got out of the [insurance] system altogether,” setting aside the cash that would have gone to an insurance premium in hopes that it would be enough to cover a healthcare emergency.

“That’s not a healthcare plan,” Pocan said. “That’s not about making health insurance more affordable. That’s about taking insurance away from people.”

According to a July 28 report from KFF, a nonprofit healthcare policy analysis and news organization, coverage through the ACA fell nationwide by 2.6 million in 2026 from 2025 after seven years of steady increases. In Wisconsin, coverage fell 16%, by 45,000 people.

Gov. Tony Evers issued a statement Tuesday blasting Wisconsin’s Republican congressional delegation for letting the enhanced subsidies expire. 

“Congressional Republicans’ refusal to extend the tax credits caused healthcare coverage costs to skyrocket, pricing families in Wisconsin and across the country out of having coverage at all,” Evers said.

Macy Buhler, a De Forest childcare provider and Main Street Action member who joined the press conference with Pocan, said that without those additional subsidies, the cost of insurance for some of her employees rose to unsustainable levels.

Buhler said she can’t cover healthcare for her childcare teachers directly, but has been providing them a stipend to help teachers who need health insurance purchase it on the federal ACA marketplace, HealthCare.gov. She doubled that stipend for 2026, she said — a $40,000 increase in just that expense.

“Early childhood teachers deserve real access to healthcare and medication, not a Congress who makes it impossible for them to afford both,” Buhler told reporters. “Tom Tiffany voted for this bill. We cannot trust him with our healthcare.”

Buhler told the Wisconsin Examiner that she’s “lost some staff and closed a classroom because they can no longer afford to be an early childhood educator, a teacher.”

Nancy Higgs, a self-employed interior designer specializing in affordable approaches for her customers, has been in business since 2023. The ACA coverage made it possible to get health coverage, she told the Wisconsin Examiner.

After a good first year, the business struggled following the 2024 election. Because her net income was too low, she switched to enroll in Medicaid — called BadgerCare in Wisconsin — for her healthcare.

Higgs said she isn’t sure what will happen to that coverage under the HR 1 changes, which don’t take effect until January 2027.

During a virtual news conference on Thursday, Aug. 13, Dr. Sophie Kramer, a Madison internal medicine physician, said the loss of insurance coverage, whether from Medicaid or an ACA policy, will lead to poorer health. The news conference was sponsored by the Committee to Protect Health Care.

“So much of what we do depends on patients having consistent access to healthcare. I treat patients with chronic diseases like diabetes, cancer, heart disease, hypertension — and those don’t disappear when someone loses insurance, they just become harder to manage,” said Kramer. “I’ve seen too many patients suffer from treatable conditions simply because they didn’t have access to affordable care.”

Dr. Kristen Dall-Winther, another participant in that news conference, owns her own practice in Wisconsin’s 7th Congressional District. Tiffany has been her U.S. representative since 2019.

“I see first hand what happens when patients struggle to afford care, when rural hospitals are under financial pressure, and when people put off seeing a doctor because they are worried about what it will cost,” Dall-Winther said. “Tom Tiffany has repeatedly voted for policies that make those problems worse.”

Dall-Winther cited forecasts that HR 1 could eventually cost more than 250,000 Wisconsin residents their healthcare coverage.

Kramer also cited Tiffany’s vote against a federal bill that would have codified a right to abortion in September 2021. The measure passed the House on a party-line vote but stalled in the U.S. Senate.  

Nine months later, in June 2022, the U.S. Supreme Court overturned the nearly 50-year-old decision in Roe v. Wade that had legalized abortion nationwide. An 1849 Wisconsin statute that was interpreted as an abortion ban went into effect as a result.

“Tom Tiffany could have voted to protect that federal right to abortion in law, but he voted against it, allowing state bans like ours to interfere in personal medical decisions,” Kramer said.

The Wisconsin Supreme Court subsequently ruled that the Wisconsin law didn’t apply to elective abortion.

A report earlier this week of a couple of measles cases in Southwest Wisconsin has turned into an outbreak, with 13 more confirmed cases and six probable cases of the viral illness, the state health department reported Thursday.

The outbreak, in Iowa and Lafayette counties, highlights the importance of getting vaccinated for measles, considered the safest and most effective way to prevent the spread of the virus, said Dr. Ryan Westergaard, the chief medical officer in the communicable disease bureau of the Wisconsin Department of Health Services.

The new group of measles patients who have been diagnosed are in Iowa County, Westergaard told reporters at a DHS briefing on the findings. Most of them were not vaccinated for measles, he said.

DHS announced two measles cases Tuesday, one in Iowa County and one in Lafayette County, that were confirmed through tests at the Wisconsin State Lab of Hygiene. 

Those were the third and fourth measles cases in Wisconsin in 2026, and were not related to the first two this year, which were linked to out-of-state travel.

Subsequent investigation by the local public health departments in the two counties turned up the 13 confirmed and six suspected cases that DHS announced Thursday. None of the current cases have been tied to travel. 

“The rapid emergence of these cases, particularly among people who have not traveled outside of Wisconsin, indicates that there is active local transmission, and it’s very likely that additional cases exist in the community that have not yet been identified or reported to public health,” Westergaard said.

State tracks 23 cases so far

Westergaard said DHS would not release the ages or age range for any of the people with confirmed measles cases in the current outbreak in order to protect their privacy.

The department maintains a state registry for all measles cases that includes age ranges and vaccination status. Thursday evening, that record showed that of the 23 confirmed or suspected cases identified in Wisconsin in 2026, three were in children age 4 or younger, 11 were in children ages 5 to 17, and nine were in adults ages 18 or older.

Westergaard said that it’s likely that there are more people with measles whose cases haven’t been identified and therefore aren’t on the state’s dashboard.

With one exception, the patients identified in 2026 were not vaccinated for the measles virus, according to DHS. One has been hospitalized.

Vaccine is ‘single best tool’ to stop outbreaks

DHS is asking people to verify whether they’ve had the MMR vaccine — the shot that includes protection against measles, mumps and rubella. That information is probably available from a person’s regular health provider, if they have one, or from the Wisconsin immunization registry.

The MMR vaccine is usually given in a two-shot sequence: the first dose when a child is 12 to 15 months old, and the second when the child is 4 to 6 years old.

“Having received two doses of MMR vaccine provides exceptional, long-lasting protection, and this vaccine remains our single best tool to stop this and future outbreaks,” Westergaard said.

For an adult without a record of the shot or who is uncertain about having had it, it is safe to get an additional shot, he said.  

DHS is also asking people to be familiar with measles symptoms. Westergaard said those include a high fever, a red rash that starts at the head and spreads down and covers the whole body, a cough, a runny nose and red or bloodshot eyes.

A person who develops those symptoms, or whose family member experiences them, should call their regular healthcare provider, Westergaard said.

People with the symptoms should call ahead before visiting a clinic, urgent care or the emergency room, he said, so that medical personnel can take precautions to prevent airborne spread of the virus before a patient arrives to protect other patients in the facility’s waiting room.

Easily spread virus

“Measles is known to be one of the most contagious viruses,” Westergaard said, “and we treat every case very seriously, because our goal is to completely stop measles transmission in the community anytime we have a case or a cluster of cases.”

Measles can cause serious health problems, according to DHS — pneumonia, deafness, and brain damage as a result of swelling from the disease.

Local public health agencies in the two counties haven’t identified specific public places where the virus might have spread, Westergaard said.

One of the jobs of local public health departments is to track contagious illnesses such as measles in their communities or counties, he said. DHS supports local agencies as they work to trace who else has been exposed to the virus.

Trump urges shift in childhood vaccine recommendations, calls for splitting up MMR vaccine

When a person who’s been exposed has been identified, they’re monitored for symptoms “to make sure that if any new cases pop up, we can get them isolated right away,” Westergaard said.

While the current outbreak is still small, “it’s a dynamic situation,” he added. With help from DHS, local health departments are tracing the spread of the virus and watching for more people who develop symptoms, “because that would be a sign that it’s getting larger.”

New Trump order ‘contradicts the best available science’

Thursday’s announcement follows an order Monday from President Donald Trump. Wisconsin’s top health official said Thursday that Trump’s order goes against the best scientific recommendations for measles prevention.

Trump’s order calls for separating the MMR vaccine into separate shots for each illness.

“There is no new scientific evidence that justifies changing recommendations that have, and continue to, protect children across the United States,” said Kirsten Johnson, secretary-designee of Wisconsin DHS, in a statement released Thursday.

“The executive order does not square at all with our recommendations on how to prevent measles or other vaccine-preventable diseases,” Westergaard said. “It was not science-based. It actually contradicts the best available science about how to prevent disease and keep kids healthy.”

DHS early this year turned from the Trump administration’s Centers for Disease Control and Prevention’s vaccine recommendations after the agency cast aside previous longstanding vaccine guidance.

DHS instead has endorsed the childhood vaccine recommendations from the American Academy of Pediatrics and the American Academy of Family Physicians.  

Westergaard said vaccinations in Wisconsin have fallen below the 95% rate that helps ensure widespread protection from illnesses that vaccines can prevent, and are even below 90%. That has happened for many complex reasons, he said — including misinformation, sometimes spread deliberately.

Wisconsin has so far avoided the “massive outbreaks” of measles that have occurred in states such as Utah, Texas and North Carolina, Westergaard said. Public health officials can contain the illness if they learn early of cases and are able to move quickly to identify and quarantine patients. But that’s more challenging because the state’s vaccination rate is lower than it should be, he said.

In addition to encouraging more vaccination, cooperation with public health measures is “a second layer of defense,” Westergaard said. “Let’s work together as a community, as a team, when an outbreak happens — be willing to share information, be willing to stay home when any symptoms happen, and allow us to identify the extent of an outbreak and to stop it.”

When college students head back to campus for the fall semester, more of them will have guaranteed access to abortion medication.

Colorado recently joined California, Illinois, Massachusetts and New York in requiring public colleges and universities to provide abortion medication to students on campus or arrange to make it available to them through an off-campus provider.

Unlike the other states, Colorado’s new law also applies to private colleges and universities. However, Colorado schools are exempt if offering the medication would be “contrary to the institution’s sincerely held religious beliefs or practices” or if doing so would jeopardize a federal grant. Federal dollars cannot be used to pay for abortions except in limited circumstances.

All five states have enacted laws to expand access to abortion in recent years, both before and after the 2022 U.S. Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, which cleared the way for states to fully deny abortion access for the first time in 50 years. Since that decision, more than a dozen states have enacted near-total abortion bans.

“In a post-Dobbs era where patients and providers navigate a frightening national landscape, Colorado has stepped up to safeguard reproductive healthcare,” Colorado Democratic state Rep. Kenny Nguyen, who cosponsored the measure in his state, said in a statement. “While abortion is legal, it’s not always accessible, and this law makes it easier for college students to access abortion medication on campus.”

The new Colorado law states that if an institution has an on-campus pharmacy, it must make abortion medication available to enrolled students. If not, health care providers on campus are required to submit a prescription for abortion pills to a pharmacy off campus.

California’s law, which has been in effect since 2023, was the first such measure. It requires every student health clinic on a California State University or University of California campus to offer abortion medication, funded by the state.

California is now considering expanding that law to include community colleges. A proposed bill would require community colleges with health centers to offer access to medication abortion beginning in 2029, if the legislature provides funding.

California campus health center directors have cautioned that many community colleges might not have the money, staff or clinical capacity to provide the service. But the bill’s supporters say offering abortion medication on campus would make it much more accessible to lower-income students who might not have sufficient insurance coverage or a car to procure it elsewhere.

“We are closing a critical gap by ensuring that community college students, one of the most diverse and economically vulnerable populations in our state, have the same access to care as their peers at four-year institutions,” said Democratic Assemblymember Catherine Stefani, the lead author of the bill, during a health committee hearing in April.

Massachusetts, which approved its campus abortion accessibility law in 2022, this week took another step to expand abortion access when Democratic Gov. Maura Healey signed legislation making it the 10th state (plus the District of Columbia) to allow abortion at any point in pregnancy. Most abortions occur in the first trimester; beyond the second trimester, abortions are rare and sometimes related to fetal or maternal health issues.

New York enacted its law requiring public college and university access to abortion medication in 2023, and Illinois started enforcing its mandate on public schools last fall, becoming the first state in the Midwest to do so.

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

A largely overlooked part of the executive order President Donald Trump issued this week scaling back the schedule for childhood vaccines threatens legal action against the four states that don’t allow personal or religious exemptions to school vaccine requirements.

Those states — California, Connecticut, Maine and New York — are among the states with the highest immunization rates, and they are among those that have been most successful in controlling the worst measles outbreak in more than three decades.

All 50 states and the District of Columbia require students to have certain vaccines before attending public school. All allow exemptions for children who cannot be vaccinated for medical reasons. Forty-six states plus the District of Columbia also allow exemptions for religious and/or personal beliefs.

Trump’s order, which he signed on Monday, says the attorney general will take legal action against states that do not provide “religious and medical exemptions from childhood and adolescent immunization requirements.”

Some health officials said that Trump’s order, which has questionable legal authority, is unlikely to prompt the states without nonmedical exemptions to change course. And any legal action would take years to wend its way through the courts.

But they criticized the executive order, and its legal threats, for contributing to the misinformation and skepticism that have lowered vaccination rates nationwide.

“It puts a lot of misinformation and a lot of fear and doubt in parents’ minds,” said Dr. Thomas Lew, clinical assistant professor at the Stanford University School of Medicine. “It clouds the conversation around vaccines and their importance and their safety.”

Dr. Molly O’Shea, a pediatrician who practices in suburban Detroit, warned that nonmedical exemptions “increase the number of parents who opt to forgo one or more vaccines for any list of reasons.”

“The learning environment is then more fragile because of the risk of disruption by infectious illness,” she said.

At the same time, O’Shea said, public health requires empathy with parents who are sincerely worried about their children’s well-being and may have been misinformed about the safety and effectiveness of vaccines.

“Families who are opting not to vaccinate are doing it from the same place that we’re recommending vaccines. They want their children healthy and well,” O’Shea said. “Just because we come to the opposite conclusion doesn’t mean we didn’t start with the same values.”

In response to Trump’s order, political leaders and health officials in many states, including California, Connecticut,  Maine and New York, vowed to maintain their vaccination rules.

California currently has 52 measles cases, Connecticut has two, Maine has five and New York has 10. All four states have vaccination rates higher than 95%, considered critical to “herd immunity” that can protect the unvaccinated to some degree.

“Maine will continue to follow the science and the facts, and our approach to vaccines remains unchanged by yesterday’s executive order,” Maine Democratic Gov. Janet Mills said in a statement published Tuesday.

As of early August, measles cases were at their highest level since 1991. The states with the highest numbers were South Carolina (670), Utah (524), Pennsylvania (216), Texas (216) and Virginia (176). All of those states allow families to opt out of the school vaccine requirement for personal or religious reasons.

Of the five states with the most cases, only Virginia has a school vaccination rate of more than 95%.

Virginia’s statewide rate was 95.6% for 2024-25, but the measles outbreak was in two rural counties west of Richmond, where measles vaccination rates are less than 75%.

Deaths from another vaccine-preventable childhood illness, whooping cough, also are on the rise. Last year, there were 32 whooping cough deaths, the most since at least 1999. Before vaccines became available in the 1940s, as many as 200,000 children contracted whooping cough every year and 9,000 died.

Whooping cough death statistics for every state were not available, but Kentucky reported three whooping cough deaths last year, its first fatalities in five years, while Louisiana reported two deaths.

Stateline reporter Tim Henderson can be reached at thenderson@stateline.org.

A new federal rule will end Medicaid coverage for gender-affirming hormone therapies and procedures for kids under age 18.

The Centers for Medicare & Medicaid Services announced Tuesday a rule that prohibits state Medicaid plans from covering gender-affirming procedures for minors and using federal Medicaid dollars for such care. 

The rule also prohibits Children’s Health Insurance Program, or CHIP, funds from being used for kids under 19. CMS is defining such care to include puberty blockers, cross-sex hormones and surgical operations. The policy takes effect Oct. 13.

The Trump administration asserts that gender-affirming care is dangerous for kids, while many medical groups say it’s safe and can improve the mental health of children and adolescents. Surgical gender-affirming care operations are very rare for children.

For kids on Medicaid and CHIP who are currently on gender-affirming hormone therapy, the agency said state plans may continue to use federal money up to six months from now. Funds can still be used for mental health care for kids, the agency said.

U.S. Department of Health and Human Services Secretary Robert F. Kennedy Jr. asserted in a new release that gender-affirming procedures “carry serious risks and can cause irreversible harm.”

In response to several Trump proposals on gender-affirming care, many of the nation’s leading medical associations, including the American Medical Association and the American Academy of Pediatrics, have affirmed the safety of care that aligns with a child or teen’s gender identity.

“These rules are a baseless intrusion into the patient-physician relationship,” Dr. Susan Kressly, then president of the academy, said in a December statement. “Patients, their families, and their physicians — not politicians or government officials — should be the ones to make decisions together about what care is best for them.”

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