A farmhouse sits along a gravel road near Elgin, Iowa. For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a new report. (Photo by Scott Olson/Getty Images)

For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a report released Monday.

The nonprofit Commonwealth Fund based its analysis on federal health workforce data. Its report comes just days after states applied for portions of a $50 billion rural health fund included in the broad tax and spending law President Donald Trump signed in July. Some states want to use the federal money to expand their rural residency programs, as physicians who complete their residencies in rural areas are more likely to practice in one.

About 43 million people live in rural areas without enough primary care physicians, according to the report. Across the country, nearly all — 92% — of rural counties are considered primary care professional shortage areas, compared to 83% of nonrural counties. Forty-five percent of rural counties had five or fewer primary care doctors in 2023. Roughly 200 rural counties lacked one altogether.

Nationally, the report found there was an average of one physician per 2,881 rural residents. States in the South had 3,411 patients per physician, whereas states in the Northeast had 1,979 residents per physician.

Rural residents are less likely to use telehealth for primary care, largely because of limited broadband internet access. About 19% of rural respondents said they received health care from a primary care physician via telehealth over the past year, compared with the national average of 29%.

The report also took the pulse of states’ participation in national programs for rural areas, such as a federal loan repayment and scholarship program for physicians working in areas with a shortage of health care providers. In 2023, 40% of rural counties had at least one primary care clinician participating in the program — compared to 60% of nonrural counties.

While the demand for primary care physicians will surpass the supply, the study estimates that the supply of rural nurse practitioners will exceed demand over time, as nurse practitioners are the fastest-growing type of clinician in the U.S., regardless of geography, the authors wrote.

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

 

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Two of the biggest political issues of the year are immigration and health care.

In the latest Marquette Law School Poll, 75% of Republicans said they were very concerned about illegal immigration and border security while 83% of Democrats said they were very concerned about health insurance. Those were the top issues among those groups. (Among independents, 79% said they were very concerned about inflation and the cost of living, making it their top issue.)

Here’s a look at some recent fact checks of claims related to health care and immigration. 

Health care

No, Obamacare premiums aren’t doubling for 20 million Americans in 2026, but 2 to 3 million Americans would lose all enhanced subsidies and about half of them could see their premium payments double or triple.

Yes, Obamacare premiums increased three times the rate of inflation since the program started in 2014. They’re making headlines now for going up even more.

No, 6 million people have not received Obamacare health insurance without knowing it. There wasn’t evidence to back a claim by U.S. Sen. Ron Johnson, R-Wis., about the level of fraud in the program.

No, Wisconsin does not have a law on minors getting birth control without parental consent. But residents under age 18 can get birth control on their own.

Immigration

Yes, unauthorized immigrants have constitutional rights that apply to all people in the U.S. That includes a right to due process, to defend oneself in a hearing, such as in court, though not other rights, such as voting.

No, standard driver’s licenses do not prove U.S. citizenship. There’s a court battle in Wisconsin over whether voters must prove citizenship to cast a ballot.

Yes, U.S. Immigration and Customs Enforcement (ICE) is offering police departments $100,000 to cooperate in finding unauthorized immigrants. It’s for vehicle purchases.

No, tens of millions of unauthorized immigrants do not receive federal health benefits. 

Here are 8 claims related to health care and immigration … and the facts 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.

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The amount some pay for Affordable Care Act health insurance will double when enhanced subsidies expire, but there isn’t evidence the number is 20 million.

KFF, a health policy nonprofit, estimates monthly payments for Obamacare recipients will increase, on average, $1,016 – more than doubling, from $888 in 2025 to $1,904 in 2026.

That counts increases to premiums and lost subsidies.

U.S. Sen. Bernie Sanders, I-Vermont, citing KFF, made the 20 million claim. U.S. Sen. Ron Johnson, R-Wis., said Sanders was wrong.

KFF doesn’t say how many of the 24 million Obamacare enrollees will see premiums double.

But 2 to 3 million people on the high end of income eligibility would lose all enhanced subsidies. About half could see premium payments double or triple. 

Enhanced subsidies, created in 2021, expire Dec. 31. Some Obamacare enrollees will receive lower enhanced subsidies or none. Standard subsidies remain.

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

Sources

• KFF: ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire
• U.S. Sen. Bernie Sanders: Email
• KFF: Email
• Centers for Medicare & Medicaid Services: Health Insurance Exchanges 2025 Open Enrollment Report
• The Journalist's Resource: The battle over Affordable Care Act insurance subsidies: What to know as open enrollment looms
• NBC News: What the government shutdown's end means for Obamacare subsidies
• PolitiFact: Fact-checking Democrats’ talking points about Affordable Care Act subsidies

Will 2026 Obamacare premiums double for 20 million Americans? 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.

Senate Minority Leader Chuck Schumer, D-N.Y., left, accompanied by Sen. Cory Booker, D-N.J., points to a poster depicting rising medical costs if Congress allows the Affordable Care Act tax credits to expire in December as he speaks to reporters following a Democratic policy luncheon at the U.S. Capitol on Oct. 15, 2025 in Washington, D.C. (Photo by Andrew Harnik/Getty Images)

WASHINGTON — Congress has roughly two months to find bipartisan agreement to curb rising health insurance costs if lawmakers want to avoid another government shutdown.

That herculean task would be difficult in the best circumstances, but is much more challenging after lawmakers spent the last 43 days criticizing each other instead of building the types of trust that are usually needed for large deals. Democrats maintained they wanted to address skyrocketing premiums for individual health care plans, while Republicans insisted those talks had to occur when the government was open.

At the same time, congressional leaders will try to wrap up work on the nine full-year government funding bills that were supposed to become law before Oct. 1 and weren’t included in the package that reopened the government. 

Congress must pass all of those bills or another stopgap measure before the new Jan. 30 deadline, regardless of how well or disastrous talks on a health care bill turn out. 

The two-track negotiations will push party leaders to compromise on issues they’d rather not, especially as next year’s November midterm elections inch closer. 

Early signs were not good.

House Speaker Mike Johnson said during a Wednesday night press conference the enhanced Affordable Care Act tax credits set to expire at the end of the year are a “boondoggle” and that “Republicans would demand a lot of reforms” before agreeing to extend those in any way. 

“We currently have 433 members of the House of Representatives. There’s a lot of opinions in this building. And on our side, certainly, a lot of opinions on how to fix health care and make it more affordable. I have to allow that process to play out,” Johnson, R-La., said. 

While Senate Majority Leader John Thune, R-S.D., made a commitment to hold a vote on a health care bill before the end of December to conclude the shutdown, Johnson has avoided giving a timeline for when he would bring any similar legislation to the floor. 

President Donald Trump, aside from throwing insults at Democrats, largely stayed on the sidelines of the shutdown fight, though he suggested the funds used for the tax credits should in some way go directly to individuals instead of large insurance companies.

Pessimism over progress

The shutdown highlighted the stark differences Republicans and Democrats hold on health care as prices for insurance continue to spike, forcing millions of Americans to choose between taking care of themselves and breaking their budgets, States Newsroom found in interviews with members of Congress. 

GOP leaders held together throughout the funding lapse and didn’t negotiate on the expiring ACA marketplace tax credits, or anything else. 

Now that it’s over, Republicans will need to put something forward.

Connecticut Rep. Rosa DeLauro, the top Democrat on the House Appropriations Committee, said her sense is that Congress will “probably be in the same place on January 30th that we are now.”

“We have two parties here, two sides,” DeLauro said. “In the past … we’ve had serious negotiation back and forth, and that’s what we need to do, and that’s not happening.”

While Republicans have unified control of government, major legislation needs the support of at least 60 senators to advance in that chamber. Republicans hold 53 seats at the moment, meaning at least some Democrats must support a bill for it to pass. 

DeLauro did not rule out another shutdown, saying Democrats plan to take the next few months “one day at a time,” while closely watching what Republicans are willing to do on the nine full-year appropriations bills and health care costs. 

Maryland Democratic Rep. Steny Hoyer, former House majority leader and a senior member of the Appropriations Committee, said Republican leaders keeping that chamber in recess for nearly two months leading up to and during the shutdown significantly delayed work on the full-year government funding bills. 

Hoyer said that scheduling decision was a clear “indication they’re not interested in solving the problem.”

“If they were, they would have had members here working on appropriation bills,” Hoyer said. “And the only way you’re going to ultimately solve this problem is to pass appropriation bills.”

Hoyer said the real question facing Congress now isn’t whether there is time to work out agreement on the remaining nine government spending bills, but whether there’s a will to make the types of compromises needed. 

Untangling spending bills

The spending package that reopened the government included three of the dozen full-year bills, funding the Agriculture Department, Food and Drug Administration, Legislative Branch, military construction projects and Department of Veterans Affairs.

The remaining appropriations bills will be considerably tougher to resolve, especially because the House and Senate have yet to agree on how much they want to spend across the thousands of programs. Trump proposed major cutbacks in multiple programs in his budget request earlier this year that Democrats have strongly resisted.

The Defense, Homeland Security, Labor-HHS-Education and State-Foreign Operations bills will be some of the more difficult to settle. 

Congress could always lean on another stopgap spending bill to keep funding relatively flat for the departments and agencies not covered by a full-year bill before Jan. 30. But lawmakers will need bipartisan support to advance in the Senate.

Washington Democratic Rep. Pramila Jayapal, former chair of the Congressional Progressive Caucus, said Republicans don’t seem to grasp how much Americans are struggling with the cost of living, including for health insurance and health care. 

“My constituents are already telling me that they’re making that choice between having health insurance or having a house to live in, and they’re going to choose the house,” Jayapal said. 

Whether or not a partial government shutdown begins in early 2026 will likely depend on whether Republican lawmakers from swing districts force bipartisanship on a health care bill. 

“I really don’t know,” Jayapal said. “I think it depends on these vulnerable House Republicans, who are not going to be able to go back to their constituents without telling them that they’ve done something on health care.”

Political juice and a backbone

Democratic Rep. Melanie Stansbury of New Mexico said she wouldn’t be surprised if Congress is unable to strike a deal on government funding and winds up in a partial shutdown by February. 

“Do I think that the Republicans have the political juice to get … the rest of their appropriation bills across the finish line and a health care deal? No,” Stansbury said. 

She added that she hopes a handful of Republicans decide to join Democrats on the discharge petition bill that would force a floor vote on a bill to extend the ACA marketplace subsidies for three years. 

“We gotta find a few brave Republicans who still have a backbone and some guts to stand up to this administration and actually care for their constituents,” Stansbury said. 

But any bipartisan deal to extend those health care tax credits seems fraught, as House Minority Leader Hakeem Jeffries slammed Republicans as having “zero credibility on this issue.”

He pointed to Republicans trying several times to repeal the Affordable Care Act, including their last attempt in 2017, when GOP Sens. Lisa Murkowski of Alaska, Susan Collins of Maine and the late John McCain of Arizona crossed party lines to vote against repealing the 2010 law.

“There’s no evidence that they’re serious about extending the Affordable Care Act tax credits,” Jeffries, of New York, said. “Republicans have zero interest in fixing the health care crisis that they’ve created.”

‘No point in taking 41 days to cave’

When Democrats controlled both chambers, temporary health care subsidies were originally passed as part of the COVID-19-era American Rescue Plan in 2021 for two years. 

With Democrats still controlling both chambers, lawmakers approved the Inflation Reduction Act, the 2022 signature climate policy bill from the Biden administration, that extended those health care subsidies for three years, expiring at the end of December 2025.

The outcome of the just concluded shutdown is shaping some House Democrats’ views.

Virginia Democratic Rep. Bobby Scott said if there is a new shutdown come February, Senate Democrats will have to decide whether they’re going to “cave again, or at least engage in negotiations.” 

“When the (Senate) Democrats say: ‘Our strategy wasn’t working,’ it wasn’t working because they assume you’re going to cave, which you just proved,” Scott told States Newsroom. “Their strategy worked — trying to get them to negotiate and talk to you doesn’t because they know you’re going to cave.”

Scott said “there’s no point in taking 41 days to cave,” pointing to the eight members of the Senate Democratic Caucus who broke ranks to advance and later approve the package to reopen the government. 

“Why don’t you just cave right at the beginning, on February 2nd?” he said. “If the Republican strategy is: ‘We’re not going to negotiate at all because you’re going to cave,’ you have to show them that you’re not going to cave, then you can have a discussion.”

Scott said the same health care issues will still exist if nothing happens between now and the package’s Jan. 30 government funding deadline.  

“By then, we’ll know that several million people don’t have health insurance, we’ll know that rural hospitals are beginning to suffer,” Scott said. 

Delaware Democratic Rep. Sarah McBride said that “from today through November (2026) and after, we will continue to be talking about health care, to be fighting for health care.”

“I think what you’ve seen over the last several months, you will continue to see from us through November and then, God willing, once we’re in a majority, we’ll do all that we can to reverse these cuts and restore care and expand access to it,” she said. 

Sen. Tammy Baldwin (D-Wisconsin) speaks Wednesday about the effort to extend enhanced Affordable Care Act insurance premium tax credits that will expire at the end of 2025. Nancy Peske, left, and Julia Harris-Robinson, center also joined the press conference. (Photo by Erik Gunn/Wisconsin Examiner)

With the loss of enhanced subsidies for the health insurance she has bought on the federal marketplace HealthCare.gov, Nancy Peske’s health plan will cost $1,163.50 a month in 2026.

That’s more than three times what she paid this year — $372 a month, Peske said Wednesday.

But if there’s one thing she wants everyone to know, it’s this: The higher prices for health insurance aren’t just something that she and other people who buy their coverage on the federal marketplace are facing.

Long before the ACA, Peske learned about “the premium death spiral,” she said.

“The more you raise the price, the more people drop out of the pool. This means you have to raise the price, which means more people drop out of the pool. And it goes on and on and on,” Peske said.

“It’s not just my health insurance that’s going to go up. It’s everybody’s — right?” she said. “We’re all in this together.”

Peske was one of two people who have relied on HealthCare.gov, created as part of the Affordable Care Act, who spoke Wednesday at a press conference in Milwaukee with Sen. Tammy Baldwin (D-Wisconsin).

Baldwin called the press conference  to draw attention anew to the skyrocketing cost of health insurance — and to the failure of Congress to address it in the stopgap spending bill that passed the U.S. Senate Monday, the U.S. House Wednesday evening and was signed by President Donald Trump.

“This is a health and wellness issue,” Baldwin said. “This is an affordability and cost-of-living issue, and this is a quality of life and dignity issue. And it touches every single one of us right now.”

A success amid ‘a broken system’

Health care in the U.S. is “a broken system that prioritizes profits over patients,” Baldwin said. Despite that, she said, the 2010 Affordable Care Act was an important advance for expanding health care access.

She said that was improved by enhanced federal subsidies enacted in 2021 to offset the cost of health insurance for people who must buy their own policies on the federal HealthCare.gov marketplace that was created by the ACA — making insurance more affordable and drawing record numbers of people to the marketplace to get health coverage.

The enhanced subsidies expire at the end of 2025, however, and until this week a Republican stopgap spending bill that passed the U.S. House in September stalled in the U.S. Senate as Democrats pushed unsuccessfully to extend the subsidies.  

“That is what is at the center of the government shutdown and debate in Washington, D.C.,” Baldwin said. “We know the impact of taking away these tax breaks. For 275,000 Wisconsinites, their health care [insurance] costs will double, triple or even more. For 30,000 Wisconsinites, they predict the price will be too high, and that those Wisconsinites will go without insurance altogether.”

A handful of Democratic Senators changed their votes Monday to advance the spending bill in return for a promise of a future vote on the subsidies, with the House taking up the revised bill Wednesday. Baldwin didn’t join them.

“I said the entire time that a handshake deal with my Republican colleagues to reopen the government and no real action to lower health care costs was simply not good enough,” said Baldwin of her vote against the bill.

She also forced an amendment to extend the tax credits for a year — a compromise, she said, because she wants them extended permanently, but one she offered “to avoid catastrophe for families across Wisconsin and give folks breathing room while we negotiate longer-term solutions.”

The amendment failed on a party-line vote.

“Every single Republican voted no on my amendment,” Baldwin said. “They chose to send a clear, unmistakable message that they are OK with jacking up health care costs on 22 million Americans.”

Early retirement, then sticker shock

HealthCare.gov user Erica Topps also joined Baldwin’s news conference. Topps took early retirement in April and bought a health insurance policy through the federal marketplace for herself and her college-age daughter that started in June.

At the marketplace open enrollment for 2026 that started Nov. 1, that plan’s premium increased by $1,200 a month and the deductible went from $6,700 per person to $10,600 per person, Topps told reporters She found another plan via the marketplace and is enrolling, but she’s concerned about the future beyond that.

“Part of my plan is to go back to work” so she can get health insurance, Topps told the Wisconsin Examiner, because it will be 10 years before she can qualify for Medicare.

Before taking early retirement, “I did my due diligence,” she said. “I feel like the rug was pulled out from under me.”

Peske is a freelance writer, editor and consultant. She is also a cancer survivor, whose diagnosis two years ago was covered thanks to her HealthCare.gov policy. Going without health insurance is unthinkable, but at the age of 63, she must wait another two years before she can go on Medicare, she said.

Peske told the Wisconsin Examiner that she will scrape together the money to afford her new premium. “I’ll not put a dime into my underfunded retirement account,” she said. She expects to “tighten the belt” on household expenses, “and I will probably cut into my savings.”

Freelancers and small businesses account for 40% of the U.S. economy, Peske told reporters.

“Do you want everyone to go out of business?” she asked. “Should I just do what so many people do and get a much lower paying job at a company? Because I’m desperate for health care. I don’t think that’s the solution. I think you want to keep people like me in business, generating money, adding to the economy, and being able to live, to not die of cancer.”

Seeking inroads with GOP lawmakers

Baldwin said she has been talking with Republicans about finding common ground in increased transparency in the health care system, from insurance companies, pharmacy benefit managers and providers.

In addition, she told the Wisconsin Examiner after the press conference, she continues to have conversations with GOP Senate colleagues who have expressed interest in continuing the subsidies to avert the sharp hike in premiums.

None of them were willing to break ranks and vote for her amendment this week, however.

“Those discussions were happening informally, in quiet, not in the public spotlight,” Baldwin said. “But they were afraid to vote on something that they, probably, some of them want, because Donald Trump said you can’t talk about this before the government reopens.”

Baldwin said that the next step will be for the Democrats to settle on the bill that Republican Senate Majority Leader John Thune has promised they could bring to the upper chamber for a vote.

As much as she favors a permanent extension of the enhanced credits, if the Democrats go that route, “we know it will go down, and it will be on a pretty much a partisan vote,” Baldwin said.

“I want results, so that probably dictates towards supporting something that conceivably does respond to some of the concerns Republicans have raised,” she said. “I’d like to pick the path most reasonably likely to succeed on behalf of the people who sent me to Washington to fight for them.”

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Blister packs of hormone replacement therapy medication. (Getty photos)

WASHINGTON — The U.S. Food and Drug Administration announced Monday it plans to remove warnings from hormone replacement therapy drugs that can be used to address symptoms of menopause, saying the statements are no longer needed. 

The black box warning, the strongest caution possible from the FDA, was added in the early 2000s after a study from the Women’s Health Initiative showed an uptick in rates of blood clots, breast cancer, heart attacks and strokes for women who used certain types of hormone replacement therapy. 

FDA Commissioner Marty Makary said during a press conference the change for estrogen-related products “is based on a robust review of the latest scientific evidence.”

Makary rebuked the medical establishment for not putting enough effort into researching women’s health conditions, including menopause. 

“A male-dominated medical profession, let’s be honest, has minimized the symptoms of menopause, and as a result, women’s health issues have not received the attention that they deserve. More than 80% of women have notable severe symptoms lasting up to eight years. How could the medical establishment get it so wrong for so long?” Makary said. “Women deserve the same rigorous sciences as is used for men.”

Study criticized

Department of Health and Human Services Advanced Research Projects Agency for Health Director Alicia Jackson said the black box warning on estrogen was based on “the flawed, overgeneralized and misinterpreted WHI study.” 

Jackson said menopause leads to a series of complicated and often painful experiences for women, including “sleepless nights, derailed careers, painful sex, broken bones and a loss of wellbeing.”

Jackson explained that when the level of estrogen drops throughout and after menopause, “a cascade of disease and aging begins.”

“A preponderance of data now shows that estrogen, when started early, acts as a protective shield for the brain, lowering risks of memory loss, mental health decline and neurodegenerative disease, even Alzheimer’s,” Jackson said.  

Makary said women should talk with their doctors and can request their estrogen levels be monitored as they approach the age where menopause typically begins and throughout that years-long process. 

He said that sometimes doctors can prescribe microdosing for hormone replacement therapy, followed by a half-dose and eventually a full dose as a woman’s estrogen levels decrease over time. 

Makary didn’t say how many of the companies that produce hormone replacement therapies plan to remove the black box warning but said he expects nearly all will do so. 

“Companies are, generally speaking, very excited when the FDA tells them they can remove a scary warning on your product,” he said. 

Review by panel

The FDA’s process for removing the black box warning requirement, Makary said, began with an expert panel earlier this year. The FDA’s subject-matter experts then conducted a “comprehensive review of the literature” and recommended the agency remove the requirement, which Makary accepted. 

The scientists who were part of the expert panel, he said, have written an article that will be published in the Journal of the American Medical Association.

President of the American College of Obstetricians & Gynecologists Steven J. Fleischman wrote in a statement that he “commends the HHS leadership for improving the lives of perimenopausal women by making the estrogen products they need more accessible to them.”

“The modifications to certain warning labels for estrogen products are years in the making, reflecting the dedicated advocacy of physicians and patients across the country,” Fleischman wrote. “The updated labels will better allow patients and clinicians to engage in a shared decision-making process, without an unnecessary barrier, when it comes to treatment of menopausal symptoms. ACOG has long advised clinicians to counsel patients based on an individual’s unique risk factors and treatment goals; this announcement does not change ACOG’s guidance on estrogen therapy.”

Deysi Camacho shops at the Feeding South Florida food pantry on Oct. 27, 2025 in Pembroke Park, Florida. Feeding South Florida was preparing for a possible surge in demand as SNAP benefits were delayed and reduced due to the government shutdown. (Photo by Joe Raedle/Getty Images)

WASHINGTON —  Senate Democrats left their Thursday caucus lunch tight-lipped as an agreement to end the government shutdown, now the longest in U.S. history at 37 days, remained elusive.

Republicans have floated a deal that includes the reinstatement of federal workers laid off by President Donald Trump, but no votes were scheduled on a spending bill as of late Thursday afternoon. There was some speculation senators could work through the weekend.

The chair of the Senate Appropriations Committee, GOP Sen. Susan Collins of Maine, said negotiations are still underway. But she said as part of a deal, she supported the rehiring of the thousands of federal workers the Trump administration fired in its Reductions in Force, or RIFs, during the government shutdown that began Oct. 1.

“Those who were RIF’d during the shutdown should be recalled,” she said. “We’re still negotiating that language.”

Emboldened by this week’s Election Day victories, where Democrats swept major local and state races, Senate Democrats are seeking to use that momentum as leverage to get Republicans to also agree to a health care deal to end the government shutdown.

While Democrats have pushed to extend tax credits for health care, Senate Majority Leader John Thune told reporters Thursday that the best he can offer is a vote on extending those subsidies, which expire this year. 

The coming expiration has resulted in millions of people who buy their health insurance through the Affordable Care Act Marketplace receiving notices of a drastic spike in premium costs.

“I can’t speak for the House, and obviously I can’t guarantee an outcome here, and they know that,” Thune, a South Dakota Republican, said. “I think the clear path forward here, with regard to the ACA issue, is they get a vote, and we open up the government, and we head down to the White House and sit down with the president and talk about it.”

Democrats that represent states with a high population of federal employees, such as Sen. Tim Kaine of Virginia, are also seeking to strike a deal on RIFs. A federal judge blocked those Reductions in Force last month.

Kaine told reporters Wednesday that those negotiations are occurring with the White House.

“It is an item that is being discussed with the president, with the White House,” Kaine said.

The progressive wing of the Democratic Party has stressed that unless there is a commitment from House Speaker Mike Johnson and President Donald Trump to extend health care tax credits, Democrats should not agree to pass a stopgap spending bill to reopen the government. 

In session next week?

Senators are still scheduled to leave Capitol Hill late Thursday and be out next week on recess for the Veterans Day holiday.

But a couple Senate Republicans said late Thursday afternoon that lawmakers might stay in Washington, D.C. into Friday or later.

“I think they’re trying to work towards a vote tomorrow, maybe through the weekend. I’m pro-through the weekend,” Sen. Thom Tillis, R-N.C., said in an interview following a GOP lunch meeting.

Sen. John Kennedy, R-La., likened the situation to a “goat rodeo,” which is a hyperbolic phrase to refer to a disaster.

“We’re probably going to have a vote tomorrow, and then we will get on, and then we will know where we are, and we’ll know whether the Democrats are serious or not,” Kennedy said, adding that he was unsure exactly what they were voting on.

Democrats quiet about any deal

Following their Thursday caucus lunch, Democrats did not seem closer to an internal agreement on how to move forward with resolving the government shutdown as they left their huddle. 

Senate Minority Leader Chuck Schumer said Democrats had a “very good, productive meeting.”

One of the top negotiators for Democrats on finding a deal, New Hampshire Sen. Jeanne Shaheen, declined to comment.

Pennsylvania Democratic Sen. John Fetterman threw his hands up as he left the room.

“I don’t know how productive it was,” Fetterman, who has voted with Republicans to move legislation to reopen the government, said. 

Some Democrats said they were unified, such as New Jersey Sen. Andy Kim, Michigan’s Gary Peters and Connecticut’s Chris Murphy, a top appropriator. 

Peters did not specify what issue Democrats were unified on. 

“I don’t want to get into that, but it was an encouraging caucus (meeting) because there’s a great deal of unity as we came out,” he said.

Revised stopgap?

Additionally, a new continuing resolution, or CR, is needed, as the stopgap funding measure would have funded the government until Nov. 21, now just two weeks away. 

The House, which Johnson has kept in recess since September, would also need to be called back to pass a new version of a CR.

As the government shutdown continues, Transportation Secretary Sean Duffy warned this week that if funding is not restored, flights will need to be reduced by 10% in some air spaces due to a shortage of air traffic controllers, who have worked without pay for weeks.

The government shutdown has led to millions of federal workers furloughed or required to work without pay and has created uncertainty for vulnerable people who rely on food assistance and  heating services, as well as stoppages in vital child development and nutrition programs. 

In an effort to force Democrats to vote to reopen the government, the Trump administration has tried to withhold Supplemental Nutrition Assistance Program, or SNAP, benefits for 42 million people, until a court ordered the U.S. Department of Agriculture to release those benefits. 

Frustrated with the government shutdown, Trump has also tried to pressure Republicans into doing away with the Senate’s filibuster, which requires a 60-vote threshold, but Thune has resisted those calls. 

Progressives: ‘Do not cave’

Johnson, a Louisiana Republican, said during a Thursday press conference that he’s “not promising anyone anything” when it comes to a House vote on extending health care tax subsidies.  

Johnson criticized Senate Democrats for wanting a guarantee that the House would also take a vote on extending the ACA taxes.

“That’s ridiculous,” he said. 

House progressives said they have one message for Senate Democrats: “Do not cave,” as Rep. Pramila Jayapal put it during a Thursday morning press conference outside the U.S. House.

“Any deal must secure the extension of the ACA tax credits and ensure health care for the American people with agreement from the House, the Senate and the White House, full stop. We have the momentum,” the Washington state Democrat said.

Rep. Chrissy Houlahan, D-Pa., who publicly confronted Johnson during a press conference Wednesday, said, “We require a deal that actually addresses the health care crisis, not that promises to think about addressing it down the road in two weeks, with concepts of a plan.”

“Sadly, at this point in time, even I say it’s impossible to trust our Republican colleagues to honor their promises and their obligations,” Houlahan said.

April Verette, president of the labor union SEIU, which represents roughly 2 million members, spoke alongside Jayapal and Houlahan and praised Democrats as “courageous.”

“We are determined to say ‘Stick with this fight’ because righteousness, morality is on our side,” Verette said.

Patients have their blood pressure checked and other vitals taken at an intake triage at a Remote Area Medical mobile dental and medical clinic on Oct. 07, 2023 in Grundy, Virginia. (Photo by Spencer Platt/Getty Images)

WASHINGTON — All 50 states have applied for the $50 billion Rural Health Transformation Program in Republicans’ “big, beautiful” law, the Centers for Medicare and Medicaid Services said Thursday.

States had from Sept. 15 through Wednesday to apply for the program, which was authorized under the mega tax and spending cut package passed by Republicans and signed into law by President Donald Trump. The fund is intended to offset the budget impacts on rural areas due to sweeping Medicaid cuts. 

However, the temporary fund could only offset a little more than one-third of the package’s estimated $137 billion cut to federal Medicaid spending in rural areas over the next decade, according to the nonpartisan health research organization KFF.

Administrator of the Centers for Medicare and Medicaid Services Dr. Mehmet Oz said the program “moves us from a system that has too often failed rural America to one built on dignity, prevention, and sustainability” in a Thursday statement alongside the announcement. 

Oz said “every state with an approved application will receive funding so it can design what works best for its communities — and CMS will be there providing support every step of the way.”

Each state was asked to “design a plan for transforming its rural health care system” and outline in proposals how they “intend to expand access, enhance quality, and improve outcomes for patients through sustainable, state-driven innovation.” 

The program allocates $25 billion equally to approved states between fiscal years 2026 and 2030. CMS said states meeting the baseline criteria will then “undergo a rigorous, data-driven merit review” for the remaining half of the funds. 

In September, when announcing the application opening, CMS said the remaining half of funds would be administered to approved states based on “individual state metrics and applications that reflect the greatest potential for and scale of impact on the health of rural communities.” 

CMS said approved awardees will be notified by Dec. 31. 

Senate Minority Leader Chuck Schumer, D-N.Y., speaks to reporters during a news conference on Nov. 5, 2025 on Capitol Hill in Washington, D.C. (Photo by Tom Brenner/Getty Images)

WASHINGTON — Following major Democratic wins in local and state elections across the country on Election Day, top Democratic congressional leaders pushed for a meeting with the president to end the federal government shutdown, which on Wednesday became the longest in U.S. history at day 36.

“The election results ought to send a much-needed bolt of lightning to Donald Trump that he should meet with us to end this crisis, his shutdown,” Senate Minority Leader Chuck Schumer said on the Senate floor Wednesday. “It’s time to hold a bipartisan meeting. The takeaway from last night was simply unmistakable.” 

Schumer and House Minority Leader Hakeem Jeffries, both New York Democrats, sent a Wednesday letter to President Donald Trump, calling for a bipartisan meeting at the White House to end the government shutdown and to address the spike in individual health care premiums.

“Last night, Republicans felt political repercussions,” Schumer said after Tuesday’s Election Day wins for Democrats. They included passage of a redistricting measure in California to offset partisan gerrymandering by GOP states, governorships in New Jersey and Virginia and local races across the country.

For more than a month, Democrats have voted against approving the House-passed GOP stopgap spending measure over concerns that health care tax subsidies will expire at the end of the year. As open enrollment begins, people who buy their health insurance through the Affordable Care Act Marketplace are seeing a drastic increase in premium costs. 

Sanders pushes back on dealmaking

Schumer did not detail what kind of deal Democrats would accept, but said any negotiation “must address the health care needs of the American people.”

However, independent Sen. Bernie Sanders of Vermont said that Democrats should not accept any agreement with the GOP unless there is a commitment from House Speaker Mike Johnson and the president to pass legislation to extend those tax credits.

“Bottom line is, we need to be successful in protecting the health care of the American people, and if it’s just a piece of legislation that passes the Senate … so what? Where does it go? Then it becomes just a meaningless gesture,” Sanders said. 

Republicans have maintained that they will only have a discussion on health care after Democrats agree to resume government funding. 

This week, the Senate failed for the 14th time to pass a stopgap spending measure that would fund the government until Nov. 21. 

Lawmakers have acknowledged that a new stopgap spending bill will need to be extended past the Nov. 21 deadline, but have not come to an agreement on a new deadline.

Thune plays down Democratic victories

Senate Majority Leader John Thune told reporters Wednesday that he was skeptical the government shutdown played into major wins for Democrats across the country. 

“The shutdown doesn’t benefit anyone,” he said.

The South Dakota Republican noted the shutdown may have played a role in suburban Virginia, where a large share of federal workers live and are furloughed due to the government shutdown.

“In Northern Virginia, that has a lot of federal workers, so it certainly could have been a factor in the elections,” Thune said. “But I think it’s hard to draw conclusions.”

But Thune said he’s focused on ending the government shutdown, and hopes progress can continue to be made before senators are scheduled to be out next week for recess due to the Veterans Day holiday. 

Transportation Secretary Sean Duffy this week warned that if the shutdown continues into next week, it could lead to certain airspace needing to be closed due to a shortage of air traffic controllers who have continued to work amid the shutdown.

Trump, in a social media post, blamed two factors for Republicans not performing well on Tuesday: his absence from the ballot, and the government shutdown.

“I think if you read the pollsters, the shutdown was a big factor, negative for the Republicans, and that was a big factor, and they say that I wasn’t on the ballot was the biggest factor,” Trump said during a Wednesday press conference.

Withholding SNAP benefits

As the government shutdown has continued, the Trump administration has tried to get Senate Democrats to agree to the stopgap spending measure by directing the U.S. Department of Agriculture to not tap into its contingency fund to provide food assistance to 42 million people.

Two federal courts found that the Trump administration acted unlawfully in holding back those Supplemental Nutrition Assistance Program, or SNAP, benefits, and USDA agreed that it would partially release SNAP benefits. 

Trump earlier this week wrote on his social media platform that SNAP benefits would only be released when Democrats vote to reopen the government, a move that would likely violate the two court orders.

“SNAP BENEFITS, which increased by Billions and Billions of Dollars (MANY FOLD!) during Crooked Joe Biden’s disastrous term in office (Due to the fact that they were haphazardly ‘handed’ to anyone for the asking, as opposed to just those in need, which is the purpose of SNAP!), will be given only when the Radical Left Democrats open up government, which they can easily do, and not before!,” he wrote.

However, White House press secretary Karoline Leavitt seemed to walk back that statement on Tuesday, arguing that the president’s social media post did not refer to the court order, but to future SNAP payments.

“The president doesn’t want to tap into this (contingency) fund in the future and that’s what he was referring to,” Leavitt said.

Volunteers with the Capital Area Food Bank distribute items to furloughed federal workers in partnership with No Limits Outreach Ministries in Hyattsville, Maryland, on Oct. 28, 2025. (Photo by Ashley Murray/States Newsroom)

This report has been updated.

WASHINGTON — The U.S. Senate Tuesday failed for the 14th time to advance a stopgap spending bill to fund the government, as the ongoing shutdown hit 35 days and is now tied with the shutdown of 2018-2019 as the longest ever.

The 54-44 vote was nearly identical to the previous 13 votes, as Republicans and Democrats remained unwilling to change positions. The legislation extending funding to Nov. 21 needed at least 60 votes to advance, per the Senate’s legislative filibuster. 

Even though the upper chamber has been unable to pass a stopgap spending measure for more than a month, Senate Majority Leader John Thune, R-S.D., told reporters Tuesday that he believes senators are “making progress.” 

He floated keeping the Senate in session next week. The chamber is scheduled to be in recess for the Veterans Day holiday. 

“We’ll think through that as the week progresses, but I guess my hope would be we’ll make some progress,” he said.

Thune added that any stopgap spending bill will need to be extended past Nov. 21, “because we’re almost up against the November deadline right now.”

Duffy warns of flight ‘chaos’ due to staff shortages

Transportation Secretary Sean Duffy warned during a Tuesday press conference at the Department of Transportation that if the government shutdown continues into next week, it would lead to “chaos” and certain airspace would need to be closed due to a shortage of air traffic controllers who have continued to work amid the shutdown.

House Speaker Mike Johnson, R-La., said at a separate press conference at the Capitol that he would bring the House back to vote on a stopgap spending measure if the Senate extends the funding date.

“If the Senate passes something, of course we’ll come back,” Johnson said. “We’re running out of (the) clock.”

Johnson said he is “not a fan” of extending the bill to December and would prefer a January deadline. 

He said extending a stopgap funding bill “into January makes sense, but we got to, obviously, build consensus around that.” 

Senators at odds

On Tuesday’s Senate vote, Nevada Sen. Catherine Cortez Masto and Pennsylvania Sen. John Fetterman, both Democrats, and Maine independent Sen. Angus King voted with Republicans to advance the legislation. Kentucky GOP Sen. Rand Paul voted no.

Senate Democrats have refused to support the House-passed GOP measure over concerns about the expiration of health care tax subsidies. As open enrollment begins, people who buy their health insurance through the Affordable Care Act Marketplace are seeing a drastic spike in premium costs. 

Republicans have maintained that any negotiations on health care must occur after Democrats agree to fund the government. 

The Trump administration has also tried to pressure Democrats to accept the House stopgap spending measure by instructing the U.S. Department of Agriculture to not tap into its contingency fund to provide critical food assistance to 42 million Americans. 

SNAP fight

Two federal courts have found the Trump administration acted unlawfully in holding back those benefits, and on Monday USDA announced it would partially release Supplemental Nutrition Assistance Program, or SNAP, benefits. 

However, President Donald Trump Tuesday morning wrote on his social media platform that SNAP benefits would only be released when Democrats vote to reopen the government, a move that would likely violate the two court orders.

“SNAP BENEFITS, which increased by Billions and Billions of Dollars (MANY FOLD!) during Crooked Joe Biden’s disastrous term in office (Due to the fact that they were haphazardly ‘handed’ to anyone for the asking, as opposed to just those in need, which is the purpose of SNAP!), will be given only when the Radical Left Democrats open up government, which they can easily do, and not before!,” he wrote.

White House press secretary Karoline Leavitt said during a Tuesday briefing that the president’s social media post did not refer to the court order, but was referring to future SNAP payments.

“The president doesn’t want to tap into this (contingency) fund in the future and that’s what he was referring to,” she said.

‘Republican health care crisis’ 

House Minority Leader Hakeem Jeffries of New York stood firm in his party’s demands over extending health care tax credits in order to back a stopgap spending bill during a Tuesday press conference at the Capitol.

“We want to reopen the government — we want to find a bipartisan path forward toward enacting a spending agreement that actually makes life better for the American people, that lowers costs for the American people, as opposed to the Trump economy where things are getting more expensive by the day,” Jeffries said. 

“And, of course, we have to decisively address the Republican health care crisis that is crushing the American people all across the land.” 

He noted that Republicans’ refusal to extend the enhanced Affordable Care Act tax credits would result in “tens of millions of Americans experiencing dramatically increased premiums, co-pays and deductibles.” 

An analysis by KFF shows that those enrollees in the Affordable Care Act marketplace who currently receive a tax credit are likely to see their monthly premium payments more than double by about 114% on average.

Senate Minority Leader Chuck Schumer said the spike in health care premiums will cause some people to choose to forgo health care insurance.

“It’s a five-alarm health care emergency,” Schumer said. 

Johnson’s January CR rationale 

Meanwhile, Johnson said at his press conference that “a lot of people around here have PTSD about Christmas omnibus spending bills,” when speaking out against a December extension of the stopgap spending bill. 

GOP leaders have sought to do away with the practice of bundling at the end of the year the final versions of the dozen annual government funding bills into what’s known as an omnibus package. 

“We don’t want to do that. It gets too close, and we don’t want to have that risk,” Johnson said. “We’re not doing that.” 

However, it’s unclear how long the new stopgap spending bill will extend. Thune, during a Tuesday press conference, said a year-long continuing resolution, or CR, was not on the table. 

“There’s a conversation around what that next deadline would be,” Thune said, adding that there is not an agreement yet.

The Trump Administration yanked more than $65 million in Title X funding from clinics nationwide in April, and some of that funding is still frozen, leaving clinics struggling to offer free or low-cost contraception and other family planning services. Some states are suing to get the funding back, but Idaho officials chose to forego it due to a conflict with state law. (Getty Images)

The Idaho Department of Health and Welfare quietly declined the entirety of its annual $1.5 million federal Title X funding, leaving patients statewide without free and low-cost contraception and reproductive health care services from a key family planning program. 

Though thousands of Idahoans relied on the health care provided through Title X for over 50 years, the state made no public announcements as the decision took effect in April, leading to the closure of 28 out of 43 — about 65% — Title X-funded family planning clinics in public health districts throughout the state, according to the Idaho Department of Health and Welfare. 

After turning down the Title X money entirely, Health and Welfare said there are no plans for the state to make up the difference by increasing the family planning budget. 

In one district, Eastern Idaho Public Health, spokesperson Brenna Christofferson said contraception services are no longer available at all, which has only been communicated to existing Title X patients. Sexually transmitted infection testing and treatment, and breast and cervical cancer screenings are still provided using different funding sources.

Many of the clinics closed in eastern Idaho, including more populated cities such as Twin Falls and Idaho Falls, and more rural areas such as Salmon, Rexburg and Rigby. Title X services also ended at clinics like Terry Reilly Health Services in one of southwestern Idaho’s most populous areas of Nampa and Caldwell. 

The decision to forego the funds came at the same time the Trump administration yanked more than $65 million in Title X funding from Planned Parenthood clinics and some independent reproductive health clinics across the country, much of which is still frozen, including for Idaho’s last remaining Planned Parenthood in Meridian. Spokesperson Nicole Erwin said Planned Parenthood continues to fundraise to help offset costs and keep family planning services affordable on a sliding scale.

Although Idaho’s move came at the same time national attention was focused on the frozen funds, it was a separate decision, according to Health and Welfare.

“The discontinuation of Title X funding … was not related to the federal administration’s Title X policy changes earlier this year,” said AJ McWhorter, spokesperson for the Health and Welfare Department. “The department made the decision to decline the funding to remain compliant with current Idaho laws concerning parental rights and counseling on pregnancy options.”

Nationally, seven out of 16 grantees have had their funding restored, while others have been waiting nearly seven months for resolution, said Clare Coleman, president and CEO of the National Family Planning and Reproductive Health Association.

“For Idaho to walk away from the money doesn’t just disadvantage and imperil young people, it imperils all the people in the state,” she said. “It hurts women, it hurts men, and it hurts young people.”

Coleman’s organization sued the U.S. Department of Health and Human Services over the frozen funds, and the case is still pending. A coalition of 20 Democratic-led states sued federal government agencies in July to halt its actions related to several social safety net programs, including Title X. That case is paused while the government is shut down.

In 2023, U.S. Health and Human Services reported Title X provided care to nearly 3 million people nationwide, a 7% increase from the prior year. Under the program guidelines, people with family income levels at or below 100% of the federal poverty level can receive services free of charge, while those making up to 250% of the federal poverty level pay a discounted rate on a sliding scale.  

The program, established by Congress and signed by former Republican President Richard Nixon in 1970, is intended to prioritize low-income or uninsured people, including those who make too much to qualify for Medicaid, who may not otherwise have access to family planning and reproductive health services. Abortion services cannot be covered by Title X dollars.

Pregnancy options and parental consent 

The federal statute guiding the administration of Title X funds includes a section on adolescent services that says grantees cannot require the consent of parents or guardians before or after the minor has requested or received family planning services. Another section directs grantees to allow pregnant patients the opportunity to receive information and counseling regarding prenatal care and delivery, infant care, foster care, adoption and pregnancy termination. Idaho has a near-total abortion ban with few exceptions.

Idaho’s Legislature passed Senate Bill 1329 in 2024, requiring parental consent for “the furnishing of health care services” to a child, with the exception of lifesaving care. Idaho Capital Sun reported the law has also created difficulties for the state’s suicide hotline, because some minors need permission from a parent to receive certain services.

Coleman said the adolescent and pregnancy options requirements have long been part of Title X guidance, and it has not conflicted with state law because federal law should take precedence under the U.S. Constitution.

Idaho is one of at least two states that currently has no Title X funding, Coleman said, after Utah lost all of its Title X money when the Trump administration withheld funding from Planned Parenthood clinics, which were the only places offering those low-cost or free services. Planned Parenthood of Utah closed two of its centers — in Logan and St. George — in the wake of the decision to freeze funding. Logan is less than an hour away from eastern Idaho’s border.

Some states were temporarily left without Title X providers after the Trump administration’s actions in April, but the funding was restored at later dates for certain states, including Missouri and Mississippi. The federal health agency also restored funds in May for two states with abortion bans, Tennessee and Oklahoma, whose grants were revoked under Democratic President Joe Biden’s administration because of their refusal to include abortion among the options during pregnancy counseling. 

In a letter from HHS to Tennessee state officials providing notice of the award, the acting chief grants management officer wrote, “Tennessee is one of only two states to have lost funding for failure to comply with the Title X 2021 regulations requiring counseling and referral for abortion. The department is declining to enforce this provision against the state, and you may rely on this letter to that effect.” 

A total of 7,528 Title X clients were served across Idaho in 2024, McWhorter said. The 15 remaining family planning clinics are supported by other funds, and additional service sites may be added as funding becomes available. Those clinics are in two out of the state’s seven public health districts, which served about 1,400 people combined in 2024. 

The closures add another challenge in an already difficult landscape for sexual and reproductive health care in Idaho. A recent study found that 94 of 268 practicing OB-GYNs left Idaho between August 2022 and December 2024, and care is becoming harder to obtain, according to residents, who say wait times are longer and certain treatment is unavailable locally. 

Coleman said under Biden’s administration, when an entity lost Title X dollars for noncompliance or other reasons, there was an effort to reallocate the funding to another willing participant. Without that action, it would revert back to the U.S. Treasury, and the next opportunity for another Idaho entity to apply for Title X funding will be late 2026. 

Preventing unplanned pregnancies 

Amy Klingler, a clinician in rural eastern Idaho, told States Newsroom she was devastated by the closure of Eastern Idaho Public Health’s family planning clinic. She worked there in addition to another clinical job since 2006 and said there aren’t many other options for family planning care in that area of the state.

“Idahoans don’t trust doctors, but they trust their doctor,” Klingler said. “So when we see rural health care being eroded and doctors leaving Idaho or not coming to Idaho, I think that is really going to impact the health of people in our communities.”

The additional cuts to Planned Parenthood through Medicaid, along with overall Medicaid cuts that may force the closure of more rural hospitals and clinics, will force people to delay care until they are sicker and require more expensive medical care, Klingler said.

The minor consent for treatment bill had good intentions, she said, and in an ideal world, every child would feel comfortable talking to their family members about birth control. But she said she is confident there are young women who don’t get birth control because they don’t want to have that conversation with their parents. 

And with Idaho’s abortion ban, unplanned pregnancies either have to be carried to term or the person must go to another state where abortion is legal. It’s also a felony in Idaho for someone to take a minor to another state for an abortion without parental permission.

“Providing free birth control is really powerful if you’re trying to prevent unplanned pregnancies,” Klingler said.

On her last day at the family planning clinic in June, Klingler said the staffers cried together.

“We often ended the day by saying, ‘We did some really good work today,’” she said. “And to not be able to do that good work kind of hurts the heart.”

Sarah Donald of Pearl, Miss., left, who has been in recovery for nine years, receives naloxone nasal spray from an organizer at the state’s Save a Life Day in September. Overdose awareness is continuing to save lives, but overdoses and deaths have spiked in some areas this year. (Photo by Vickie D. King/Mississippi Today)

Illicit drug overdoses and the deaths they cause are trending down this year, despite spikes in a handful of states, according to a Stateline analysis of data from the federal Centers for Disease Control and Prevention.

A handful of places with rising overdoses are responding to the problem with cooperation, they say, by sharing information about overdose surges and distributing emergency medication.

“The national conversation is just about warships in the Caribbean and drones and borders,” said Nabarun Dasgupta, who studies overdose trends at the University of North Carolina. “It discounts this huge groundswell of Americans taking care of Americans. There’s a huge amount of caregiving and tending to the needs of local communities that is being done in a non-flashy way because this is hard, slow work.”

Overdose deaths have been dropping steadily since 2023. As of April, the latest date available, deaths were at 76,500 for the previous 12 months — their lowest level since March 2020. A pandemic spike in overdose deaths drove the number as high as almost 113,000 in the summer of 2023, according to federal statistics.

President Donald Trump has ordered more than a dozen military strikes against boats in the open waters of the Caribbean and the Pacific Ocean since Sept. 2, claiming without publicized evidence that their occupants were drug runners bringing narcotics to the United States. Nearly 60 people have been killed.

The bulk of deadly fentanyl is smuggled over the border with Mexico in passenger cars, according to a September report by the federal Government Accountability Office. Chemicals and equipment, mostly from China, are smuggled in via cargo trucks, commercial ships, airplanes and the mail, according to the report.

A more timely indicator of overdoses — nonfatal suspected overdose patients in hospital emergency departments — was down 7% this year through August compared with 2024, according to Stateline’s analysis of CDC statistics.

The nonfatal overdoses were up for the year in only a few states and the District of Columbia. The largest spikes were 17% in the district, 16% in Rhode Island, 15% in Delaware, 11% in Connecticut and 10% in New Mexico, with smaller increases in Colorado, Pennsylvania, Wyoming, South Dakota, Utah, New Jersey and Minnesota.

Other states saw drops in nonfatal overdoses: Maryland had the largest decrease through August, about 17%.

But Baltimore had an attention-grabbing cluster of 42 overdoses between July and October, all within the same neighborhood. No fatalities were reported. The cluster led the city to set aside $2 million in October for more mobile services, harm reduction and social supports to fight overdoses.

New Mexico is seeing more overdoses and more deaths than the previous year in three counties on the Colorado border. In response, New Mexico is distributing both warnings and naloxone, an opioid-overdose antidote.

Officials are giving naloxone to storekeepers near overdose sites and alerting those seeking services about the deadly threat in the local supply.

“We started planning naloxone saturation and different types of outreaches so we can hopefully stem this from getting even worse,” said David Daniels, harm reduction section manager in the New Mexico health department.

“Putting messaging directly into clients’ hands is extremely valuable. That might be, ‘If you’re choosing to use, don’t use the regular amount. Maybe you should use a quarter of it. Test it out first,’” Daniels said.

The three counties in New Mexico — which include the capital city Santa Fe, ski resort Taos and Española, the setting of the 2023 TV black comedy series “The Curse” — saw about 438 more deaths from July through September than they did during the third quarter of 2024, according to Stateline calculations. That’s more than double the 383 overdose deaths for the area during the same time period last year.

Roger Montoya, a former Democratic state representative who runs an arts nonprofit in Rio Arriba County, said most of the deaths there have been among homeless substance users.

A local hospital has responded with programs to get treatment for more people, and his own Moving Arts Española group concentrates on helping children and young people break a cycle of economic despair that often leads to addiction and homelessness, he said.

“We try to redirect and strengthen the resiliency of young people who largely are being raised by grandparents and kin because mom and dad are either dead, on the street or incarcerated,” Montoya said.

But most states with overdose increases are still showing fewer deaths, mostly because the drug supply in the eastern United States is more likely to be cut with sedatives that don’t have the same deadly effect as fentanyl, though they can cause overdose.

The drugs linked to Baltimore’s mass overdoses were cut with an unusual, powerful sedative, according to federal testing. The sedative can cause people to lose consciousness but can’t itself be treated with reversal medication such as naloxone.

By contrast New Mexico’s tests on this year’s clusters generally found more deadly fentanyl than usual in the local supply, said Phillip Fiuty, a technical adviser on adulterant testing in the state health department.

“We’re not seeing the type of adulteration they’re experiencing on the East Coast. Once something is in New Mexico, there’s little to no adulteration,” Fiuty said.

Some East Coast states are seeing more overdoses but fewer deaths. Rhode Island warned of spikes in nonfatal overdose in August and September, but deaths through September were still lower than during the same period last year, according to state figures.

That’s not always the case. Connecticut reported a surge of both fatal and nonfatal overdoses near interstate highways in May and June.

“One of the factors is change in the illicit drug supply or bad batches. I think that’s what’s playing out now. The drug supply is increasingly unpredictable,” said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials.

The association has a suggested framework for community response to spikes, but cities and counties may be hampered by a new aggressiveness on enforcement and more hostility to local efforts to stop deaths, she said.

The current Trump administration has shown some reluctance to support community harm reduction techniques, she said. That includes the temporary suspension of $140 million in funds for a program called Overdose Data to Action, known as OD2A, that the first Trump administration started to sound the alarm when spikes happen.

“Given recent cuts to health care and substance use and overdose prevention services that we’re seeing, that is impacting some of the work on the ground,” Freeman said. “It’s pushing people away from being able to make the changes they need to make to change their lives. It has the potential to create more of an overdose problem.”

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

Volunteers from No Limits Outreach Ministries in Hyattsville, Maryland, and the Capital Area Food Bank prepare for distribution on Oct. 28, 2025 to furloughed federal workers affected by the government shutdown. People with government employment ID began lining up hours ahead of time. (Photo by Ashley Murray/States Newsroom)

WASHINGTON — By Saturday, millions of Americans are expected to face a drastic spike in health care premium costs during open enrollment, though a hunger crisis may have been temporarily averted, both tied to the ongoing government shutdown.

A federal judge in Massachusetts Friday afternoon found that the U.S. Department of Agriculture acted unlawfully in deciding to withhold billions in emergency funding for 42 million people who rely on the Supplemental Nutrition Assistance Program, or SNAP, amid a government shutdown.

But while the ruling does not order USDA to immediately tap into its roughly $6 billion contingency fund, a separate ruling from a federal judge in Rhode Island ordered the agency to continue the payments after a coalition of religious and advocacy groups sued.

Prior to both rulings, Agriculture Secretary Brooke Rollins defended USDA’s decision to not use the contingency fund during a Friday press conference at the U.S. Capitol with House Speaker Mike Johnson on day 31 of the government shutdown. 

“We are here today because SNAP benefits run dry tomorrow, so the truth has finally revealed itself, hasn’t it?” Rollins said. “Democrats’ support for programs like SNAP is now reduced to cynical control over people’s lives.”

It was not yet clear midday Friday how the two court rulings would be carried out by the administration.

The move to cut off SNAP would leave millions hungry, nearly 40% of them children, and is an effort by the Trump administration to put pressure on Senate Democrats to accept the House-passed GOP stopgap spending bill to fund the government until Nov. 21. 

Senate Democrats have held out demanding action on tax credits that will expire at the end of the year for people who buy their health insurance through the Affordable Care Act marketplace, hugely driving up costs. 

They have tried to spark negotiations, but Republicans have maintained that talks on health care subsidies will only begin after the government is funded. 

Flight delays, filibuster fate 

As the government shutdown continues, millions of federal workers are furloughed, or have continued to work without pay, including air traffic controllers. 

Flight delays and cancellations are starting to mount, with 3,739 delays within, into or out of the United States and 364 cancellations within the United States by midday Friday, according to the FlightAware delays tracker.

Another shutdown complication emerged when President Donald Trump, who has spent most of the week abroad in Asia meeting with foreign leaders over trade and tariff talks, Thursday night urged Republicans to eliminate the Senate filibuster, which requires a 60-vote threshold. 

“Get rid of the Filibuster, and get rid of it, NOW!” Trump wrote on his social media platform. Senate Republicans have been lukewarm on the idea, since Democrats then could do the same if they regain control of the chamber now held by the GOP with 53 seats.

Lacking 60 votes, the Senate has failed 13 times to pass the House-passed stopgap spending measure and left Capitol Hill Thursday night. Democrat Sen. Jacky Rosen from Nevada tried to keep the Senate in session, but was overruled by Republicans. 

Another critical deadline approaching Friday was pay for active duty military members. Vice President JD Vance said the Trump administration would shuffle funds to ensure pay, but did not detail those plans. According to Axios, the Defense Department pulled billions from several accounts to ensure the troops could be paid. 

Rollins defends USDA refusal to pay benefits

Congress failed to fund SNAP and nearly every other discretionary federal program for the 2026 fiscal year that began Oct. 1.

In order to receive SNAP benefits, a household’s gross monthly income must be at or below 130% of the federal poverty guidelines. A family of four would receive a SNAP maximum monthly allotment of $994, according to USDA.

Rollins sought to justify her agency’s refusal to shuffle the contingency funds to pay for SNAP, saying that money “is only allowed to flow if the underlying program is funded,” and “by law, a contingency fund can only flow when the underlying fund is flowing.” 

The Agriculture secretary said that “even if it could flow, it doesn’t even cover half of the month of November.” 

USDA said in a memo earlier in October that it would not tap into the contingency fund to keep the program afloat in November, despite its since-deleted Sept. 30 shutdown plan saying it would tap into this reserve. 

The memo said the contingency fund “is a source of funds for contingencies, such as the Disaster SNAP program, which provides food purchasing benefits for individuals in disaster areas, including natural disasters like hurricanes, tornadoes, and floods, that can come on quickly and without notice.” 

Democrats have objected. Friday’s decision from a federal judge in Boston stems from a lawsuit brought by 25 states and the District of Columbia against the Trump administration to force USDA to use the contingency fund. 

USDA secretary recounts conversation with waiter

At the Capitol press conference, Rollins also recalled a recent encounter she had at a Louisiana restaurant with a “wonderful” waiter named Joe, who she said took on that job after being furloughed as a federal government employee due to the shutdown. 

“He didn’t know who I was. And I said, ‘Well, Joe, I can appreciate that. You know, I’m sort of in that world as well.’ And I said, ‘Where do you work?’ And he said, ‘Well, I work for the U.S. Department of Agriculture in their New Orleans office as part of the financial team.'”

Rollins said that encounter “just really brought home for me … to echo what Mike (Johnson) said, just thanking so many thousands of federal workers who are showing up, who are still doing their job, who aren’t getting paid, those that are now concerned about putting food on the table and making their mortgages and paying their rent.” 

Rollins, along with the rest of the president’s Cabinet, is still getting paid.

Health premiums skyrocket

As open enrollment begins Saturday, those enrollees in the Affordable Care Act marketplace who currently receive a tax credit are likely to see their monthly premium payments more than double to about 114% on average, according to an analysis by KFF. 

For the last month, Democrats have warned of this, as the tax credits that help pay for individual health insurance are set to expire at the end of the year. 

The top Democrat on the House Energy and Commerce Committee, Rep. Frank Pallone of New Jersey, said in a statement that many families will see an increase in their premiums on Nov. 1.

“The sticker shock many families will face when they shop for health coverage is unacceptable, and it’s why Congress must act,” Pallone said.

The nonpartisan Congressional Budget Office estimated that if Congress does not extend the tax credits, insurers expect healthy, younger people to drop their marketplace coverage plans, which will lead to increased premium costs. 

Anxiety over WIC program

Meanwhile, USDA’s Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, a program separate from SNAP, got a $300 million infusion from the agency, using tariff revenue, to keep the program running through October. 

The program provides nearly 7 million women, infants and children with healthy foods, breastfeeding support, nutrition education and other resources. 

Advocates are calling on the administration to supply additional emergency funds for WIC. 

Led by the National WIC Association, more than three dozen national organizations signed on to an Oct. 24 letter to the White House urging the administration to provide an additional $300 million in emergency funding. 

Head Start affected

The consequences of the shutdown are also hitting Head Start — a federal program that provides early childhood education, nutritious meals, health screenings and other support services to low-income families and served more than 790,000 children in the 2023-2024 program year. 

The National Head Start Association estimates that 140 programs across 41 states and Puerto Rico serving more than 65,000 children will not receive their operational funding if the shutdown continues past Nov. 1 — a reality that appears certain.

Six of those programs serving more than 6,500 children did not receive this funding on Oct. 1 and have had to look to outside resources and local funds to keep their programs afloat. 

SNAP, WIC and Native communities 

American Indian and Alaska Native communities are also scrambling to fill the anticipated gaps in food security and assistance due to funding uncertainties for SNAP and WIC. 

Advocates and U.S. senators across the aisle say these funding uncertainties for the key federal nutrition programs are putting particular pressure on Native communities. 

At an Oct. 29 Senate Indian Affairs Committee hearing on the shutdown’s impacts on tribal communities, Minnesota Democratic Sen. Tina Smith said she is hearing from tribal nations in her state about people switching from SNAP to the Food Distribution Program on Indian Reservations, or FDPIR, a separate USDA initiative.

FDPIR is an alternative to SNAP and, per USDA, provides foods “to income-eligible households living on Indian reservations, and to American Indian households residing in approved areas near reservations and in Oklahoma.” 

American Family Children's Hospital in Madison. An annual report from the Wisconsin Hospital Association says hospitals in the state are doing better financially, but face uncertainty. (Photo by Erik Gunn/Wisconsin Examiner)

Uncompensated health care at Wisconsin hospitals rose more then 30% in 2024 from the year before, according to a new report from the Wisconsin Hospital Association.

People without health insurance or regular health providers are using emergency rooms more, the report also finds.

The association annually assesses the state of Wisconsin hospitals, including their finances, utilization and staffing. The 2024 report was released Thursday.

“We are seeing a modest improvement in hospital financials across the state,” said Kyle O’Brien, president of the Wisconsin Hospital Association, in an interview. Nevertheless, he added, “there’s a lot of uncertainty in the health care market right now.”

While the state’s hospitals were doing better in 2024 than in the previous two years, 40 hospitals had a negative operating margin, O’Brien said, and many hospitals across the state where margins were positive, but narrow.

Uncompensated care includes charity care — provided by the hospital with the full knowledge that the cost won’t be covered — as well as bad debt: care for which the hospital expected to be paid but wasn’t.

In 2024, uncompensated care in both categories added up to $1.77 billion — a 30.5% increase over the 1.36 billion in uncompensated care in 2023.

O’Brien said several factors are responsible for that increase. One of those is generally higher deductibles on health insurance plans, requiring patients to spend more out of pocket before their insurance coverage kicks in.

“If that patient can’t pay for that higher out-of-pocket [expense], hospitals are the ones that either have to try to collect those dollars, or they are the ones that provide relief through charity care, bad debt policies, or things like that,” O’Brien said.

For hospitals, another top concern is how much Medicaid pays to cover the cost of care.

State budgets over the last decade have been increasing Medicaid hospital payments, O’Brien said, with the 2025-27 budget having the largest increases to date. Even so, he said, hospital Medicaid reimbursements fall short of fully covering the cost of the care that Medicaid is supposed to cover.

Decisions by health insurance to deny coverage are a source of “general consternation” for hospitals, O’Brien said — both with group health insurance policies but also for Medicare Advantage policies. Medicare Advantage policies are sold to people eligible for the federal Medicare program but are instead provided by private insurance companies.

O’Brien said the hospital association is also concerned about projected increases in people without health insurance as a result of higher premiums paid by people who buy their own insurance at the federal marketplace, HealthCare.gov, created under the Affordable Care Act.

Enhanced subsidies for HealthCare.gov policies enacted in 2021 will expire at the end of this year unless they are renewed. The subsidies are provided in the form of federal income tax credits for consumers who purchase insurance through HealthCare.gov

This week the state Office of the Commissioner of Insurance released projected rates for 2026 that reflected the loss of those enhanced subsidies.

Those higher costs have prompted widespread predictions that, after years in which enrollment in the marketplace plans has set new records, enrollment will drop off and more people with go without health insurance instead.

“We are certainly concerned anytime there’s a potential that somebody might lose coverage,” O’Brien said. Federal law requires hospitals to treat patients whether or not they are able to pay.

“We have been advocating with the congressional delegation to reauthorize those enhanced premium tax credits,” O’Brien said. He said members of Congress have been focused on “issues that are playing out right now [that] may be even bigger than hospital-related issues, but I think that they understand our concerns.”

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Idaho resident Lynlee Lord said she used nutrition assistance programs that helped ease some of the stress she was dealing with while pregnant in the aftermath of her partner’s death. Food insecurity can bring heightened risks of preeclampsia, preterm birth and NICU admission, research shows. (Courtesy of Lynlee Lord)

Millions nationwide could be cut off from access to government food assistance Saturday due to the shutdown, including those who are pregnant or have babies and young children.

That possibility brings back a lot of difficult memories for Lynlee Lord, a mom of three in rural Idaho. In 2014, when Lord was 24, her partner died by suicide. She was 11 weeks pregnant with his daughter and already had a 2-year-old son.

“I went from building my life with my best friend to not having anything, and having to move into income-based apartments,” Lord said.

She was also going to cosmetology school full-time in Boise, Idaho, nearly an hour away from where she lived, spending more than 12 hours away from home each day. She worked on her dad’s ranch and cleaned houses to earn gas money. She tried to keep her stress levels down, but the one thing she didn’t worry about was food, because she had benefits from the U.S. Department of Agriculture’s Supplemental Nutrition Assistance Program, or SNAP.

“It took a lot of pressure off of me,” she said.

Many studies have shown adequate nutrition is essential for a developing fetus, and a January study published in the Journal of the American Medical Association found food insecurity in pregnancy is associated with medical complications. The researchers defined food insecurity as being worried about running out of food before there’s money for more. Risks include preeclampsia, preterm birth and NICU admission. 

Those who did not have access to food assistance had the highest risk of complications, according to the January study. The increased rate was alleviated by food assistance. 

It’s unclear how many pregnant people use SNAP benefits on average, but the program helped feed 42 million Americans in 22 million households in the 2025 fiscal year, according to the USDA. A separate supplemental nutrition program for Women, Infants and Children — known as WIC — is often used simultaneously by participants. The federal government temporarily shored up WIC through October and promised more money, but whether the funding will last through November remains uncertain as the shutdown wears on.

The Trump administration has so far declined to use emergency funds to keep SNAP solvent while the government shutdown continues. Republican Senate Majority Leader John Thune said he won’t consider a Democrat-led standalone funding bill to keep the program going during the shutdown.

Though officials in some states are making moves to boost food assistance temporarily, others — including in Indiana and Tennessee — have refused to step in.

Lord doesn’t need food assistance anymore, but about 130,000 Idahoans still do and are set to lose their benefits starting on Saturday, Nov. 1. The Women, Infants and Children program, which helps families afford formula and other supplemental foods, could also soon run out of funds in certain states, including Idaho, the Idaho Capital Sun reported.

Instability and hard choices

Gestational diabetes — one of the more severe complications that can result from food insecurity — affects up to 10% of all pregnancies on average. The condition occurs when the placenta produces hormones that decrease insulin sensitivity, creating unstable blood sugars that necessitate a more strictly controlled diet and potentially the use of insulin or other medication to keep glucose levels in a normal range. Most cases are diagnosed in the third trimester, when the amount of insulin needed to keep blood sugars normal is at its peak.

Blood sugar can also be affected by stress, poor sleep, irregular meals and other physiological factors. If left untreated, or if glucose remains unstable through the last trimester of pregnancy, it can cause the fetus to grow too quickly, increasing the risk of stillbirth and other complications, like high blood pressure and low blood sugars in the baby after delivery.

Dr. Chloe Zera, chair of the Health Policy and Advocacy Committee for the Society of Maternal-Fetal Medicine, specializes in gestational diabetes and said she saw a patient on Tuesday who was worried about losing her SNAP benefits.

“Adding that on top of what is already a stressful diagnosis is incredibly challenging for people,” Zera said. “There’s so much guilt and shame and blame that goes along with gestational diabetes and diabetes in general in pregnancy.”

People with gestational diabetes who already have children and who are food insecure will also most often feed their children before themselves, Zera added.

“They’re going to make really hard choices that mean they have even less control over their nutrition,” she said.

Dr. Andrea Shields, an OB-GYN and maternal-fetal medicine specialist at the University of Connecticut, said uncontrolled gestational diabetes can cause low blood sugar in babies after delivery, which has been linked to neurodevelopmental issues later in life. If the SNAP benefits stop, she said, more people will have to get creative about finding ways to help pregnant patients without assistance from the federal government.

“This is a perfect example of why we pay taxes and why we want to help society in general, because we don’t need to create generational issues, which this will, because it impacts the unborn fetus,” Shields said.

Lord said if she was in the same situation today that she was 10 years ago, she might have had to consider an option that never crossed her mind at the time — an abortion. Even though it was her partner’s only child, and abortion is now banned in Idaho, Lord said she may have needed to find a way to end the pregnancy out of necessity, especially considering the costs of rent, child care, food and other expenses today.

“I would’ve probably picked my child that was living,” she said. “It was really scary for me back then, and I can’t even imagine in today’s world if that happened.”

UPDATE: This story was updated to include more information about WIC on Friday, Oct. 31. 

Democratic U.S. Sen. Chuck Schumer of New York, accompanied by Democratic U.S. Sen. Cory Booker of New Jersey, points to a poster depicting rising medical costs if Congress allows the Affordable Care Act tax credits to expire. (Photo by Andrew Harnik/Getty Images)

States are preparing for the possibility of a rapid shift in the cost of Obamacare health plans, depending on whether Congress extends the subsidies that are at the center of the federal government shutdown.

No matter what Congress does, the amount insurers charge for coverage sold on the marketplaces created by the Affordable Care Act will increase by an average of 26% in 2026, according to KFF, a health research nonprofit. In the 30 states that use the federal Healthcare.gov, premiums will rise by an average of 30%. In the states that run their own marketplaces, the average increase will be about 17%.

But 22 million of the 24 million people who are enrolled in marketplace plans receive a tax credit. If Congress extends the credits, the amount subsidized enrollees pay each month won’t significantly change, even as insurers charge more.

If Congress doesn’t act, people with incomes below 400% of the federal poverty level will receive less financial help, while people making more than that amount will not get any help at all. As a result, according to KFF, monthly premium payments for all enrollees will increase by an average of about 114%,

For a month, Republicans and Democrats have been in a stalemate over whether to extend these subsidies, leading to a government shutdown. The situation has created ambiguity for the states that run their own marketplaces, as many of them move this weekend into the open enrollment period for people to purchase health plans.

Some states, such as Maryland, are preparing for a scenario in which they would either extend state-funded subsidies to enrollees to help them keep their plans, or rapidly apply federal subsidies if Congress extends them.

“It’s going to vary state by state based on their technological abilities and if they need to do anything with their rates,” Michele Eberle, executive director of the Maryland Health Benefit Exchange, said in a phone interview.

Eberle said Maryland created a state subsidy program to make up for some of the federal subsidies that are in limbo. She said that if Congress extends the subsidies, enacting changes for the state’s 240,000 marketplace enrollees could take around three weeks.

Maryland would have to ask health insurers to resubmit their rates. The state also might have to send notices to enrollees to give them the opportunity to change their choice of plan, according to Eberle.

“We would change [enrollees’] premiums. We would have to back out the state subsidy [that we] put in, if there’s a new rate, put the new rates in, recalculate the new premium tax credit and apply that,” Eberle said.

In California, where two million people are enrolled in Covered California, residents are already reeling from sticker shock after seeing next year’s premiums on the state’s website.

“People are very stressed about what to do and what their options are with these cost changes,” Jessica Altman, executive director of California’s marketplace, said in an interview. “At the same time, we are very much ready, and we’ll move any mountain that we can possibly move if Congress does act.”

Altman said the state will automatically recalculate what enrollees would pay for their plans if Congress extends the credits, and is prepared for people to want to change their plans if federal lawmakers act.

“We’re also very much going to want to inform our consumers and give them the opportunity to make a different choice,” she said.

Altman said notifying enrollees’ of changes should take a few weeks, but changing information in the state’s system should only take about a week.

“Even when the enhanced tax credits passed the first time, it was in the middle of the year, in the spring,” Altman said.

“All the state exchanges had to build that, and it was done in a matter of weeks, right? So, that’s who we are, and that’s how we’re thinking about this challenge.”

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

Medications are stored on shelves at a pharmacy in Los Angeles. States have gotten creative in trying to lower patients’ prescription drug copays by targeting different parts of the drug supply chain. (Photo by Eric Thayer/Getty Images)

In the absence of much federal action, states have enacted dozens of laws this year to lower prescription drug costs for their residents — and many more are considering following suit.

States cannot lower drug prices directly, but they can go after different parts of the drug supply chain to try to lower patients’ out-of-pocket costs and reduce excessive spending in state-run health plans.

Nearly two-thirds of the new state laws are aimed at pharmacy benefit managers — the drug middlemen who negotiate deals among the manufacturers that make the drugs, the insurers that allow the drugs to be prescribed, and the pharmacies that sell them.

Several states are considering drug affordability review boards. Others have passed laws to hold manufacturers and PBMs to higher transparency standards.

“So a lot of states went into looking at drug costs — trying to understand and follow the dollar,” said Maureen Hensley-Quinn, a senior program director at the National Academy for State Health Policy, a nonpartisan group that works on health policy issues. “Is it the price that manufacturers are setting? Is it the supply chain where there are different entities?”

Advocates of these laws say it’s up to states to take the lead as the federal government lags in compelling drug companies and insurers to lower prices for patients. But critics say some state interventions could lead to local pharmacies shuttering and may stifle innovation in the pharmaceutical industry, leading to fewer new drugs.

Laws targeting PBMs are wide-ranging in scope, requiring PBMs to pass discounts on to consumers or to be more transparent in their drug purchasing activities. Some states have created drug affordability review boards to assess manufacturers’ prices. Some laws aim to place copay caps on critical medications like insulin.

So far this year, at least 31 states have enacted nearly 70 laws designed to lower drug costs, according to a state drug affordability law tracker from the National Academy for State Health Policy.

“States have no leverage, really, to put pressure on manufacturers to lower their prices, and that’s why I think most of the legislation at the state level has been on the intermediaries, the supply chain,” said Geoffrey Joyce, chair of the Department of Pharmaceutical and Health Economics at the University of Southern California.

Those interventions can go a long way in trying to reduce patients’ expenses, he said.

“The concern [is] about, well, ‘States really can’t lower drug prices, per se,’ but they can,” Joyce said. “I think there’s been evidence.”

California Democratic Gov. Gavin Newsom in October signed legislation to cap the cost of insulin for people covered by state-regulated health plans, including the state’s Affordable Care Act marketplace, private health plans and its Medicaid program. The state also plans to start offering its own generic version of insulin, costing just $11 a pen, in January.

Colorado’s drug affordability review board capped the cost of a widely used rheumatoid arthritis medication.

And Maryland Democratic Gov. Wes Moore signed a law in May to expand the authority of the state’s drug affordability review board to lower prescription drug prices for all residents, not just state employees.

Pointing fingers

The federal government has taken some steps to lower prescription drug prices. The Inflation Reduction Act under the Biden administration created annual caps on out-of-pocket drug costs and capped the cost of insulin at $35 a month for patients with Medicare, the health care program that primarily serves people over 65. The law also gave the federal government more power to negotiate drug prices for Medicare patients.

President Donald Trump has promised to slash drug prices by percentages that some experts say are mathematically impossible. He threatened tariffs on manufacturers that import their drugs if they didn’t lower their prices, which led to a deal with biopharmaceutical company Pfizer. And in May, he signed an executive order designed to ensure the U.S. government can secure drugs at prices on par with other nations.

Kush Desai, a spokesperson for the White House, said in a statement that the Trump administration’s website, TrumpRx, which hasn’t yet launched, will lower drug costs by allowing people to purchase drugs directly from the manufacturer.

But some states are going further.

In October, Colorado became the first state to cap the price of a prescription drug for all consumers. Starting in 2027, new insurers and patients will pay no more than $31,000 a year for Enbrel, a drug that treats rheumatoid arthritis and other autoimmune diseases — a sharp decrease from the average insurance payment of $53,049 in 2023. Nearly 2,600 Coloradans used Enbrel in 2022, according to state research.

Colorado Democratic state Sen. Julie Gonzales, who sponsored the bill creating the state’s drug oversight board, said states have to deal with a lot of competing interests in the drug supply chain. When it comes to establishing who is setting high drug prices, she said, “everyone is pointing the finger at everyone else.”

It took four years from the law’s passage to set up the board and approve its first payment limit because there were so many special interests involved, she said. “We had to overcome a tremendous amount of angst and fear.”

Maine, Maryland, Minnesota, Oregon and Washington also have prescription drug affordability boards. New Hampshire created a board but dissolved it in July because of budget cuts.

In California, Newsom signed a bill this year to cap the consumer copay of insulin at $35 per month for all state-regulated health plans, after vetoing similar legislation in 2023. More than two dozen other states had already opted to cap insulin for state health plans. He also signed a PBM regulation bill that, among other provisions, requires pharmacy benefit managers to pass drug discounts on to payers and patients.

California Democratic state Sen. Scott Wiener, who sponsored the PBM and insulin bills, said states have the power to lower patients’ out-of-pocket expenses, even if they can’t force manufacturers to lower drug prices.

“The federal government right now is a disaster zone when it comes to health care,” Wiener said. “That’s why it’s more important for the states to step up.”

Other states such as Illinois, Iowa and Louisiana enacted similar PBM laws this year, according to the National Academy for State Health Policy.

A complicated system

The system for developing, selling and distributing prescription drugs is complex.

Pharmaceutical companies determine the initial costs of drugs, but are often accused of setting prices too high. Pharmacy benefit managers say they exist to negotiate lower drug prices, but are often accused of pocketing discounts or engaging in predatory practices. Meanwhile, health insurers pay for the drugs and decide what copays patients may end up with, and are often accused of not reimbursing enough.

Experts note that three pharmacy benefit management companies — CVS Health, Cigna and United Health Group — dominate the PBM industry, which adds to concerns about their market power.

“There’s also some truth to the fact that this industry is very concentrated, and there’s not a lot of transparency around how much money they’re making and how they make their money, and if that’s being shared back with plans and with consumers,” said Pragya Kakani, a health economist specializing in drug policy at the Weill Cornell Medical College.

The pharmaceutical industry typically opposes drug affordability boards.

In Colorado, Amgen Inc., the manufacturer of Enbrel, sued the state in 2024 over its drug affordability review board, alleging that a price cap would cause economic harm to the company. A federal district court dismissed the challenge in March.

“Instead of fixing the root causes of patient affordability concerns, the board has rushed into a reckless experiment,” Reid Porter, senior director of state public affairs for PhRMA, a group that represents pharmaceutical companies, wrote in an email statement in regard to the board’s upper payment limit. “Colorado is risking patient access and jeopardizing the development of new medicines.”

Porter argued that PBMs and health insurers, not drugmakers, drive high costs.

But PBMs say their negotiations lower costs.

“Big Pharma sets the price — and the price is the problem when it comes to Americans facing difficulty affording their prescription drugs,” Mike Baldyga, a spokesperson for the Pharmaceutical Care Management Association, which represents pharmacy benefit managers, wrote in an email statement. “PBMs are the only entity in the drug supply chain that lower prescription drug costs on behalf of patients, and there is no correlation between the rebates they negotiate and list prices.”

Hensley-Quinn, of the National Academy for State Health Policy, noted the challenge of making drugs affordable and accessible.

“There is no silver bullet for lowering drug costs,” Hensley-Quinn said. “You have to balance being able to innovate and making sure that drugs are affordable so that what you have just created, which is life-changing, actually gets to the people that need it.”

But this challenge is in some ways expected and more evidence that states must take action, said Priya Telang, communications manager at the nonprofit advocacy group Colorado Consumer Health Initiative.

“Manufacturers point the finger at PBMs, and PBMs point the finger at insurers. And so it’s really hard to get a sense of who the actual bad players are all at the same time,” she said.

“And so that’s why it’s critical for affordability boards to exist, because they get to see the data, they get to see behind closed doors what the root causes are and really work to bring affordability to consumers.”

Drug affordability boards

When Mary Fowler Simmons, 54, was diagnosed with an advanced cancer three years ago, she had to give up her steady job as a state government worker in Virginia to go through months of expensive and painful treatment. Fowler Simmons survived and is cancer-free today, but is still reeling financially.

Fowler Simmons told Stateline that after being saddled with a hospital bill totaling over $323,000 and depleting her savings, she and her husband continue to pay around $300 a month — after insurance — for prescription medications to maintain her health.

Fowler Simmons, who also has Type 2 diabetes, says she wants her state and federal lawmakers to recognize that some Americans are having to choose between paying for their next meal or their necessary prescription drugs.

“They need to have more compassion for people. We’re not in the position that we are making millions, that we can afford this. We’re working-class people,” Fowler Simmons said. “I need them to actually consider what they are doing to the American people and just have affordable prescription drugs available.”

Otto Wachsmann, a Republican in the Virginia House of Delegates and a pharmacist, said that he doesn’t think there’s enough evidence yet that prescription drug affordability review boards work.

He said if states set upper payment limits on drugs, that doesn’t mean a pharmaceutical company would necessarily lower the cost. Rather, he says, pharmacies may just get reimbursed even less than the cost of the drug. This year Virginia lawmakers tried to create a drug affordability review board.

“There’s nothing to prevent the board from saying we’re only going to reimburse $100 for this prescription, although those pharmacies may have to pay $120 for the drug,” Wachsmann said in an interview.

He added that if review boards target expensive and rare drugs for which to set upper payment limits, they could stifle innovation.

“If those manufacturers think that those are the type of drugs that are going to get hit by these boards and they realize they’ll never get their investment back, they’re not going to develop those drugs anymore,” Wachsmann said.

Virginia Republican Gov. Glenn Youngkin vetoed a bill this year that would have created a drug affordability board in the state, saying in a statement, “This approach could limit access to treatments and hinder medical innovation, especially for life-threatening or rare diseases.”

Wachsmann had voted against the board. Instead, he says it’s better to target PBMs, because he said they are engaging in predatory practices that freeze out small pharmacies and leave consumers with nowhere to go.

Neighboring Maryland created the nation’s first drug affordability board in 2019; it got a boost of resources and revved up activities in 2023.

“It will not hurt pharmacists. It will help everybody except Big Pharma,” said Vincent DeMarco, president of health care advocacy group Maryland Health Care for All, in speaking about the state’s drug affordability review board.

The original bill creating the board only authorized the board to create upper payment limits for drugs purchased by states and local governments in Maryland. But this year, Moore signed a law to expand the authority of the board to create upper payment limits for everyone, except patients on health plans regulated by the federal government.

DeMarco said he’s hoping the board will move to create limits on two popular drugs prescribed for Type 2 diabetes, Jardiance and Farxiga.

“In addition to individuals who can’t afford their drugs, all of us pay the price in higher health insurance premiums, because a big part of our health insurance premiums is high-cost drugs,” DeMarco said.

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

Engineer and TV host Emily Calandrelli came to Capitol Hill Wednesday, Oct. 29, as part of an effort to require the U.S. Transportation Security Administration to enforce a policy that allows parents to bring breast milk, formula and supplies on planes. She is among many moms who say they have faced scrutiny traveling with breast milk and ice packs. (Photo by Sofia Resnick/States Newsroom)

Brinda Sen Gupta was traveling by plane for work last month without her infant but with gel packs she would need to keep her breast milk cool on the return flight. Knowing how hard it can be to get through airport security with breastmilk and infant-feeding supplies, Sen Gupta arrived extra early and prepared.

Sure enough, a U.S. Transportation Security Administration agent objected to Sen Gupta’s gel packs, she said. She took out her phone and showed a screenshot of TSA’s current policy. It stems from a 2016 law and states that breast milk, formula and toddler drinks are considered “medically necessary liquids” and are allowed in carry-on baggage in quantities greater than 3.4 ounces. The policy expressly allows breast milk and formula cooling accessories like ice and gel packs, and states a child does not have to be present for a parent to carry these supplies.

Despite the law, women continue to report issues with TSA security in airports across the country, saying many workers are not trained on their own policy.

“The TSA agent had to ask their supervisor to come,” Sen Gupta said. The supervisor reviewed the policy and allowed the gel packs through, she said, “but it was annoying to me, because I had to add extra time before I went to make sure that I could have this conversation with them.”

Sen Gupta was among several D.C. chapter leaders of the national nonprofit Chamber of Mothers who gathered in Washington, D.C., on Wednesday, Oct. 29, to advocate for the passage of the Bottles and Breastfeeding Equipment Screening (BABES) Enhancement Act. Introduced in the House by Democratic Rep. Eric Swalwell of California, the bill would require an audit by the inspector general of the Department of Homeland Security within one year of enactment to ensure the policy is being enforced and workers are being trained on how to inspect infant-feeding supplies in a way that is sanitary. 

The bill has been introduced in Congress three years in a row but failed to pass despite bipartisan support. In May for the first time the bill cleared the Senate, where it was cosponsored by Democratic Sens. Tammy Duckworth of Illinois and Mazie Hirono of Hawaii, and Republican Sens. Steve Daines of Montana and Ted Cruz of Texas. It has advanced in the House, where it has 26 cosponsors, including five Republicans.

“We don’t actually need to change the policies. We need to enforce them, to have some oversight for when the policy isn’t adhered to and how they’re held accountable for those missteps,” said Emily Calandrelli, an engineer and science TV host, who brought attention to the issue after her story of being escorted out of an airport security line because of her ice packs went viral.  

Calandrelli said she is unaware of major pushback to the bill in the U.S. House, but she is not certain there will be enough support to move the legislation anytime soon, especially as the federal government shutdown is about to enter its second month.

She said she is hopeful that Rep. Maria Elvira Salazar of Florida, one of the first Republicans to sign on, will recruit more members of her party. 

“At this point, we need Republicans to really lead the charge to help get to the finish line,” Calandrelli said.

In the meantime, moms who relayed their recent TSA experiences at the Chamber of Mothers event said parents traveling with infant-feeding supplies should prepare themselves for traveling — have TSA’s policy ready on their phones and arrive well ahead of time.

Travel security lines may be even slower or flights may be delayed during the shutdown, too, as federal workers like air traffic controllers and TSA agents work without pay.  

Bri Adams, another Chamber of Mothers D.C. chapter leader, said she has been dealing with the headache of nursing while frequently traveling for work for the past few years. A breast milk overproducer who had to pump frequently to maintain her supply, she said agents would handle her milk or supplies in ways that were not sanitary. Over time, she learned to advocate for herself. 

“I literally had it up on my phone, the regulations on the TSA website, ready to go, and I pretty much just acted a lot more confident,” Adams said. “This is what I’m doing, and I’m taking breast milk that’s thawed and frozen at the same time, and you’re going to let me on because you can.”

TSA has not yet responded to requests for comment. 

‘What would make motherhood easier for you?’

A driver parked the Chamber of Mothers’ black and red bus across the street from the U.S. Department of Labor, which ordinarily would have meant lots of foot traffic. But on the 29th day of the shutdown, the sidewalks and streets were largely empty of the typical tourists and federal workers, many who were either furloughed without pay or working without pay. 

The bus has stopped in nine cities over the last couple of months. Lexie Wooten said she has been to every stop, where the group’s been asking moms, “What would make motherhood easier for you?” Overwhelmingly, responses have been about economic support and paid family leave, she said. 

Wooten said she could feel the economic anxiety as Americans brace for cuts to health and food assistance programs for people with low incomes, exacerbated by the shutdown. As States Newsroom has reported, temporarily losing food assistance like the Supplemental Nutrition Assistance Program could lead to more pregnancy complications.

“People are broke, and it makes everything harder,” Wooten said.

Chamber of Mothers CEO Erin Erenberg said the organization now has 43 local chapters in 30 states and about 100,000 members nationwide, and focuses on policies meant to improve access to maternal health care, paid parental leave and affordable child care. Erenberg, who is also an intellectual property attorney, cofounded the nonprofit in 2021 with a group of fellow working moms after paid family leave was cut from former President Joe Biden’s Build Back Better plan. One of the state bills they’ve worked on since is Arizona’s HB 2332, a maternal mental health bill, which Gov. Katie Hobbs signed in May. 

Erenberg said the Trump administration, through the office of the vice president and the U.S. Department of Health and Human Services, has reached out to her organization to collaborate. But before the group would work with the White House, she said there are some nonnegotiable terms, which include preserving and expanding access to affordable health care, Medicaid and SNAP — all impacted by recent federal spending policies.

“So far, this administration hasn’t shown that they’re fully behind what we advocate for,” Erenberg said. “With pronatalism, we have repeatedly said, great, you want people to have more babies? … We need paid leave, we need affordable child care, and we need you to invest in what actually would make us healthy … and survive childbirth.”

An emergency room nurse tends to a patient at Houston Methodist The Woodlands Hospital in Texas. States, counties and nonprofits are striving to continue their work to close racial health disparity gaps but are struggling amid a loss of federal dollars. (Photo by Brandon Bell/Getty Images)

Racial health disparities may widen as states, universities and nonprofits grapple with federal funding cuts to programs that were aimed at filling gaps in care, public health experts say.

As part of its federal restructuring and crackdown on diversity, equity and inclusion (DEI) programs, the Trump administration has been shuttering federal offices and rescinding grants dedicated to addressing worse health care access and outcomes for racial minorities.

The shake-up has caused some state agencies and nonprofits to pause programs and some groups and universities to apply for foundation grants instead.

Hundreds of grants have been terminated for state, local and territorial health departments as well as nonprofits and universities, many of which addressed health equity across rural, low-income and communities of color.

The nation’s racial health disparities were laid bare during the COVID-19 pandemic, when the virus killed Black, Hispanic and Indigenous people at higher rates than white people. The police murder of George Floyd in May 2020 also fueled a racial reckoning across the nation, prompting efforts by states, universities, health systems and the federal government to address racial health disparities.

Those approaches ranged from targeted vaccine campaigns and efforts to enroll more people of color in clinical trials to corrections of diagnostic tests that relied on inaccurate information about race and biology.

Communities of color have long had less access to health care, increased exposure to environmental pollutants and higher rates of certain chronic illnesses and cancer deaths. They also have more diabetes-related amputations because of a lack of access to care. And specific genetic diseases, such as sickle cell disease, disproportionately affect Black people.

“COVID revealed the impact of health disparities to individual health — as well as how not addressing these disparities undermines the health system for everyone,” said Dr. Georges Benjamin, executive director of the American Public Health Association.

Now, many of the programs trying to address health disparities are being rolled back.

As a result, health policy experts, clinicians and researchers fear those disparities will widen as states, universities and nonprofits grapple with lost federal dollars while the administration continues to limit federal funding for DEI programs. In July, the U.S. Department of Justice released guidance saying such initiatives should not receive federal funding, alleging they are “discriminatory.”

Entities that receive federal funds “must ensure that their programs and activities comply with federal law and do not discriminate on the basis of race, color, national origin, sex, religion, or other protected characteristics—no matter the program’s labels, objectives, or intentions,” the news release said.

Several state and local health officials were reluctant to speak with Stateline on the record about how the federal administration’s DEI crackdown has left them in a bind, fearing retaliation or targeting by the federal government. The White House did not respond to Stateline’s request for comment.

“My concern about what the administration is doing is that they are, in effect, making these disparities worse,” Benjamin said. “Everybody’s health is not the same. … It’s important to know that the disparities are really profound.”

Benjamin added that the cumulative effect of disparities means more late-stage disease — costing both patients and health systems more.

“There’s a trope or misunderstanding out there that DEI is a ‘woke’-related agenda. DEI is not a ‘woke’ agenda. DEI is an American agenda, because it’s really one that is the same thing as ‘rising tides lift all boats,’” said Brandon Wilson, senior director of Health Innovation and Public Health at Community Catalyst, a health equity advocacy organization. “When you cut [resources] off, you’re actually disproportionately impacting those who are already impacted.”

‘Increasing need’

The administration canceled billions of dollars in grants from the National Institutes of Health (NIH), the Centers for Disease Control and Prevention, the Environmental Protection Agency and the Department of Health and Human Services.

Many of the grants helped recipients create solutions tailored to their communities’ needs and strengths.

At least three dozen state, local and territorial health departments have had pandemic-era grants that addressed health equity terminated. While originally focused on COVID-19, agencies have since used that grant money for other public health efforts: testing and contact tracing for a wide range of diseases, better data reporting, and community partnerships that address social and environmental effects on health.

The money was part of a $2.2 billion national health equity initiative that aimed to address vulnerabilities and protect those communities ahead of the next outbreak.

The Department of Health and Human Services told media such cancellations were due to the pandemic emergency ending in 2023.

At NIH, the administration terminated more than 5,400 NIH research grants, although about 2,800 were reinstated. Canceled grants included research toward illnesses like HIV and AIDS, which disproportionately affect Black and Hispanic people as well as gay and transgender people.

The Trump administration has also gutted federal offices dedicated to fighting disparities, including the Offices of Minority Health under the Centers for Medicare & Medicaid Services and the Department of Health and Human Services.

At the state level, the Arkansas Department of Health recently shut down its own minority health-focused office. Ashley Whitlow, a spokesperson for the department, said in a statement that it “relies on federal grant funding to support a variety of public health programs.”

“The recent reduction in program staff reflects the Arkansas Department of Health’s ongoing efforts to operate more efficiently with the resources available. Despite these changes, ADH remains fully committed to serving communities across the state,” the statement said.

Meanwhile, Maryland’s Department of Health said its minority health office is funded through state general funds and not directly impacted by the federal cuts.

The nation has seen a spike in congenital syphilis cases, which disproportionately occur among Black and Indigenous families.

“Regardless of whether you’re at the highest risk, any outbreak that’s not controlled can spread widely and broadly, and you can see that that’s what’s happening with measles,” said Dr. Julie Morita, former executive vice president of the Robert Wood Johnson Foundation and former health commissioner Chicago Department of Public Health.

But states likely can’t replace all the lost federal dollars.

“You’ve got declining capacity, and increasing need — which is a formula for problems,” said Richard Frank, director of the Brookings Institution Center on Health Policy.

“It’s impossible to make all that up with state and local dollars,” he continued. “You’re going to see programs that serve real people getting pulled back.”

Frank and Wilson also expressed concern about the Medicaid changes included in the broad tax and spending law President Donald Trump signed in July. The law is projected to cut federal Medicaid spending by an estimated $911 billion over the next decade, largely because new work requirements will push people off the rolls. Data shows the majority of Medicaid enrollees already work, and experts say many will be kicked off the rolls due to difficulties in states’ reporting processes. Black and Hispanic people are disproportionately represented on the Medicaid rolls.

OB-GYN Dr. Versha Pleasant, a clinical assistant professor at the University of Michigan, directs the Cancer Genetics and Breast Health Clinic at Von Voigtlander Women’s Hospital. She treats patients at high risk for breast and ovarian cancers. Black women have an almost 40% higher risk of death from breast cancer than white women.

“That, to me, is unacceptable,” she said, adding that such disparities speak to the need for ongoing programs to “provide everyone with a fair chance at leading a long and healthy life.”

“If we don’t make a special effort to save the most vulnerable lives … where does that leave us?” she continued. “The changes that we’re seeing are only going to magnify preexisting challenges.”

Data and dollars

Dr. Sarah Rudman, acting public health officer at the Santa Clara County Public Health Department in California, and others have told Stateline that federal officials are informing health agencies that race and ethnicity data are no longer required to be reported.

“We are being asked to change the way we collect our own data here and report it,” Rudman said, adding that her county is going to continue collecting data to “understand who is here, who’s experiencing what health outcome and what they need.”

Many families, in the shadow of the county’s Silicon Valley, still struggle with poverty — more than 27,000 children suffer food insecurity, United Way Bay Area says.

“It is sometimes surprising and striking to people to understand how much poverty and other types of vulnerability are hidden among the more visible wealth of Silicon Valley, and that’s where we’ve dedicated our resources,” Rudman said.

“It’s hard to even imagine what my colleagues in smaller areas of California or in other parts of the country are experiencing,” she added about lower-income counties. “We are feeling extremely strained and already in our second round of layoffs, knowing that many more are likely. So I think that the hits are going to be that much more significant in areas who have less resources than we do.”

Federal officials also canceled the county’s $5.7 million grant to address COVID-19-related disparities, used to shore up vulnerable communities ahead of the next disease outbreak, natural disaster or heat wave, Rudman said. The money helped the county conduct basic laboratory testing and vaccine outreach for a wide range of diseases, not just COVID-19.

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

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Affordable Care Act premiums, expected to skyrocket in 2026 unless enhanced subsidies are extended, have increased about 118% since coverage for individuals began in 2014.

That’s three times higher than inflation (39%).

U.S. Sen. Ron Johnson, R-Wis., made the three-times claim Oct. 21, as the federal government shutdown continued. 

To end the shutdown, Democrats want to extend the enhanced Obamacare subsidies, which made more people eligible. They expire Dec. 31. 

Without enhanced subsidies, Wisconsinites could see 2026 premium increases of up to 800%, according to the state. 

The average monthly premium for a benchmark Obamacare plan was $273 in 2014; it is expected to be at least $596 in 2026.

Premiums, initially so low that insurers lost money, jumped in 2017, stayed stable since 2018 but are expected to rise more than 18% in 2026, KFF Obamacare program director Cynthia Cox said.

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

Sources

• U.S. Bureau of Labor Statistics: CPI Inflation Calculator
• The Journalist's Resource: The battle over Affordable Care Act insurance subsidies: What to know as open enrollment looms
• Wisconsin Gov. Tony Evers: Healthcare Premiums for Wisconsinites to Skyrocket in 2026 if Republicans Fail to Extend Affordable Care Act Tax Credits
• KFF: Marketplace Average Benchmark Premiums
• Peterson-KFF: How much and why ACA Marketplace premiums are going up in 2026

Have Obamacare premiums increased three times the rate of inflation? 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.