It’s not unusual for the rancher to wake up early to tend to livestock, but at 5:45 a.m. this day his cattle wouldn’t come first. For the past 3½ years, three days a week, Pieper has made an early-morning commute to get dialysis at the nearest hospital.

Pieper lives outside Hay Springs, which has 599 residents, according to a sign at the edge of town. He makes sure not to forget his chocolate-brown cowboy hat before starting up his pickup truck for the half-hour drive to Chadron.

That February morning was one of his last dialysis sessions there before the hospital shuttered the service at the end of March.

“I guess I’ll just bloat up and die in a month,” Pieper remembered thinking when he learned the center was closing, eliminating the only option near his home.

He needs dialysis to survive after cancer treatment damaged his kidneys.

Pieper and 16 other patients relied on Chadron Hospital for the life-sustaining therapy that filters waste and fluid from their blood — a job their failing kidneys could no longer do. Treatment lasts about four hours.

The closure is just one example of the long decline of health care services in rural America, where people have higher rates of many chronic conditions but less access to care than elsewhere.

The Trump administration promised to address this problem, when it launched the $50 billion federal Rural Health Transformation Program in September. It may not be enough to stop the trend.

“[President Donald] Trump says he is going to help the rural health care,” Pieper said. Dialysis “is one thing that we really need here.”

Some patients have moved to live closer to care, including several nursing home residents. Their new facilities may be farther from their families.

Others are making long drives to dialysis centers. Pieper eventually found treatment in Scottsbluff, which, with about 14,000 residents, is the biggest city in the rural Panhandle region of western Nebraska. The hour-and-a-half drive will triple his time on the road to more than nine hours each week.

Jim Wright and his wife reduced their drive time — but are spending more money — by renting a small home near Rapid City, South Dakota, and living there on weekdays so he can get dialysis. Wright said he understands that rural hospitals face financial challenges.

“But we’re talking about something that’s lifesaving. It’s not a matter of, ‘Oh, I would like to be there’” getting treatment, he said. “It’s a case that if you don’t, you die.”

An Influx of Money That’s Out of Reach

Jon Reiners, CEO of the independent, nonprofit Chadron Hospital, wrestled with the decision to end dialysis services. He and several patients said that the closure was announced as the $219 million the state will receive in first-year funding from the Rural Health Transformation Program.

But the five-year program is aimed at exploring new, creative ways to improve rural health, not to help existing services stay afloat. States can use only up to 15% of their funding to pay providers for patient care.

At least 11 states — Nebraska is not among them — have mentioned using funding for rural dialysis programs, according to a �������ýҕ�l Health News review of applications. Their ideas include starting a mobile dialysis unit and helping people get treatment at home or in long-term care facilities.

Reiners said Chadron Hospital lost $1 million a year on its dialysis service due to low reimbursement rates that didn’t cover operational costs.

The facility is a critical access hospital, a designation that allows certain small, mostly rural hospitals to get increased reimbursement rates for their Medicare patients. While most of the affected patients were on Medicare, the critical access program doesn’t cover outpatient dialysis, Reiners said.

Reiners said the hospital worked for more than a year to find solutions, such as reaching out to four private companies to potentially take over the center. But he said they all passed after realizing they would lose money.

Nephrologist Mark Unruh said the dialysis closure in Chadron reflects a wider trend of staffing and funding challenges.

“You do end up in situations where you have people who are displaced like this, and it’s just sad,” said Unruh, chair of the Internal Medicine Department at the University of New Mexico.

People in rural America face significant disparities in kidney health and treatment, published in 2024 in the American Journal of Nephrology. They’re and face after diagnosis, according to data from the National Institutes of Health.

that helps primary care doctors in rural and other underserved areas prevent end-stage renal failure.

Another idea, Unruh said, is boosting the rate of kidney transplantation for rural patients. He’s looking at whether it’s helpful to “fast-track” tests patients need to get approved for a transplant by scheduling all of them over a couple of days to limit travel time.

Unruh said the U.S. health system also needs to recruit more staff who can train patients and their caregivers to administer dialysis at home.

Exploring the Option of Home Dialysis

Rural dialysis patients are more likely than urban ones to get home dialysis, according to . In 2023, the rate was nearly 18% for rural patients and about 14% for urban ones.

One type of home dialysis requires surgery to get a catheter placed in the abdomen and . The other kind requires . The nearest facility to Chadron that offers training for the first option is in Scottsbluff. The nearest that offers training for the latter kind is three hours away in Cheyenne, Wyoming.

Pieper said doctors told him he’s not a candidate for home dialysis or a transplant. The Panhandle has a nonprofit, rural transit system, but its schedule won’t work for Pieper. He said that leaves him with no choice but to get treatment in Scottsbluff, a 200-mile round trip.

It takes Linda Simonson even longer — more than four hours round trip — to drive her husband, Alan, from their ranch to his treatment in Scottsbluff.

Linda sat in the waiting room with a yellow legal pad during one of Alan’s final treatments in Chadron. The paper was scrawled with phone numbers of politicians to call and driving distances to dialysis centers in the region. She said facilities closer to their ranch either don’t have room for new patients or lack good spots along the route to take a driving break in bad weather.

“It’s just unreal,” she said.

She said even if Alan took a bus, she’d have to ride along to support him during the trip and his treatment.

Jim and Carol Wright, the couple staying near Rapid City on weekdays, said they can’t afford to rent a second home forever. Their weekly commute is already taking a physical and emotional toll. They said they’ll eventually have to move to a bigger city, giving up the house they love in the scenic Nebraska National Forest.

Carol said she feels for the dialysis staffers in Chadron, who are wonderful.

“It just doesn’t seem right to sacrifice one unit that’s so vital,” she said while standing next to a pile of moving boxes stacked inside their rental.

The Wrights wrote letters to politicians and hospital leaders to share their concerns and ideas for keeping the unit open, including using the federal rural health funding.

Simonson said she spoke with aides for the governor and her state representatives but none of the leaders called her back.

“It feels like they don’t know that we exist at this end of the state,” she said.

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She and her husband, Charles, a former high school teacher who goes by Chaz, planned to retire comfortably in the three-bedroom house where they raised their kids about 60 miles northwest of Sacramento.

But early last year, the 63-year-old became unsteady on her feet. One morning in May, she woke up with slurred speech and landed in the hospital, then rapidly lost the ability to move the right side of her body.

In August, as doctors continued to puzzle over a possible diagnosis, the couple received a notice saying that on Jan. 1 their combined health care premium payments through the state insurance exchange would shoot up from $540 a month to $3,899 a month. The reason: Federal enhanced premium subsidies expiring at the end of last year would no longer offset their payment.

They immediately canceled a monthlong cruise they’d been planning with friends and looked through their retirement accounts.

“Now, instead of thinking about where we can go in our retirement, we’re asking the question, ‘Are we still going to be able to stay where we are because of the health care costs?’” said Chaz, who retired in 2021 at age 59.

Then they received more bad news. In October, at the age of 63, Jean was diagnosed with ALS, a debilitating disease that will eventually leave her unable to speak, swallow, or breathe on her own. But Jean’s condition allowed her to enroll in Medicare, the federal health insurance program that covers adults 65 and older and people with disabilities. The diagnosis saved them roughly $1,600 a month in premiums — little comfort as Jean lost her ability to walk, bathe, and dress herself.

“It’s kind of morbid that, because of my diagnosis, I got put on Medicare right away, so at least we don’t have to pay that out-of-pocket,” Jean said, sitting in a wheelchair in her living room, a quilt draped over her legs to guard against the intense chills she now often gets. “We’re not going to get buried under this.”

Yet the premiums for Chaz’s plan and her Medicare remain a significant strain on their finances. The $2,300 a month they now owe, which includes roughly $342 in premium payments for Jean’s Medicare supplemental insurance, is higher than their monthly mortgage and eats up more than a quarter of their budget.

The Franklins are among the across the nation facing greater financial pressure after Congress chose not to extend 2021 enhanced federal subsidies. That assistance helped more than double enrollment in Obamacare plans to over 24 million.

The Congressional Budget Office estimated in 2024 that, without an extension of the tax credits, the number of uninsured Americans would climb by 2.2 million this year alone. , nationwide enrollment in ACA plans was down about 1.2 million year over year, though experts say it could be months before the full effects of rising premiums are known, as people miss payments and lose coverage.

The groups hit hardest will be , , and people living in high-cost states, said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. The Franklins are all three.

“They fell off what we call a subsidy cliff,” Pogue said. “It’s very, very shocking, the amount that a person would have to absorb.”

That’s because the expanded tax credits made the biggest difference for people nearing retirement age who sat just above thresholds, Pogue said. People such as the Franklins, who likely wouldn’t have qualified for financial help before expanded credits were implemented, are now losing that support at a time when insurers have responded to the uncertainty by dramatically raising rates.

Roughly half of people who were expected to lose eligibility for premium tax credits were ages 50 to 64, according to an , a health information nonprofit that includes �������ýҕ�l Health News.

Republicans who opposed the extension have said the premium assistance went directly to insurance companies rather than consumers, incentivizing fraud and wasteful coverage. They also say the enhanced subsidies, which had no upper income limit for eligibility, were far too generous in capping premium payments at 8.5% of income, no matter how much an enrollee made.

“Most Americans would agree that taxpayers should not be subsidizing the health insurance of someone making $250,000,” U.S. Rep. , a California Republican who an extension in January, wrote in an . “I cannot accept the simple extension of a program that will line the pockets of insurers and is riddled with fraud at the expense of the American taxpayer.”

Patient advocates say the premium increases and expiration of subsidies have forced people into difficult choices. “The young people who are healthy are the first to say, I’m going to roll the dice” and forgo coverage, said , executive vice president of policy and programs at the National Patient Advocate Foundation. “Those who are remaining in the system — because they have no choice — are holding off care, they’re holding off their meds, they’re going without necessary food.”

While the Franklins are getting by, they have relied on their sons to pay for a motorized recliner to assist with lifting Jean and a handicap van to transport her. Chaz, who broke a tooth a year ago, delayed fixing it because a crown would cost him $1,000.

This year, the couple will draw $36,000 more than they had anticipated from their retirement savings, most of it to cover Chaz’s insurance premiums.

“I have a nest egg,” Chaz said. “But there’s a lot of people around here who don’t.”

For a while, he was outraged.

“I wish Congress would get off their butts and solve this issue,” said Chaz, who is a registered Republican but blames both sides of the aisle. “You’re so busy bickering over stupid crap and it’s both parties pointing fingers and blaming. Where was this discussion two years ago?”

Now, Chaz said, he’s focused on making Jean, his wife of 27 years, as comfortable as possible.

Before she got sick, they did practically everything together — hiking, traveling, tai chi, amateur photography, and bug-hunting. One of her favorite specimens was the rain beetle, a fuzzy scarab-like insect that can’t feed as an adult, relying solely on fat stores from its larval stages.

In the mornings, Chaz and their sons, Charlie and Louis, take turns lifting Jean, dressing her, and helping her use the bathroom. It’ll be fodder for the counselor, she jokes to her sons, when they inevitably need therapy later in life.

Most days, Jean’s outdoor adventures rarely extend beyond being wheeled to her back patio, where she loves to watch their backyard chickens bobble around. Chaz’s stubbornness makes him a great patient advocate. Charlie always seems to know exactly when she needs a big hug, and Louis tells jokes that can still make her snort with laughter.

“I don’t know what I would do without my boys making me laugh,” she said.

In December, Chaz will turn 65, old enough to qualify for Medicare himself. “After this year — knock on wood — we should be OK,” Jean said, before pausing and shooting her husband a wry smile.

“Well, you’re gonna be OK.”

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It was a contrast to how Cole, 18, spent part of the 2024 holiday season. She was in the hospital — a frequent occurrence with sickle cell disease, a genetic condition that damages oxygen-carrying red blood cells and for years caused debilitating pain in her arms and legs. Flare-ups often would force her to cancel plans or miss school.

“With sickle cell it hurts every day,” she said. “It might be more tolerable some days, but it’s a constant thing.”

In May, Cole completed a several-months-long that helps reprogram the body’s stem cells to produce healthy red blood cells.

She was one of the first Medicaid enrollees nationally to benefit from a in which the federal government negotiates the cost of a cell or gene therapy with pharmaceutical companies on behalf of state Medicaid programs — and then holds them accountable for the treatment’s success.

Under the agreement, participating states will receive “discounts and rebates” from the drugmakers if the treatments don’t work as promised, according to the Centers for Medicare & Medicaid Services.

That’s a stark difference from how Medicaid and other health plans typically pay for drugs and therapies — the bill usually gets paid regardless of the treatments’ benefits for patients. But CMS has not disclosed the full terms of the contract, including how much the drug companies will repay if the therapy doesn’t work.

The treatment Cole received offers a potential cure for many of the 100,000 primarily Black Americans with sickle cell disease, which is estimated to shorten lifespans by more than two decades. But the treatment’s cost presents a steep financial challenge for Medicaid, the joint state-federal government insurer for people with low incomes or disabilities. Medicaid covers roughly half of Americans with the condition.

There are two gene therapies approved by the Food and Drug Administration on the market, one costing $2.2 million per patient and the other $3.1 million, with neither cost including the expense of the long hospital stay.

The CMS program is one of the rare health initiatives started under President Joe Biden and continued during the Trump administration. The Biden administration with the two manufacturers, Vertex Pharmaceuticals and Bluebird Bio, in December 2024, opening the door for states to join voluntarily.

“This model is a game changer,” Mehmet Oz, the CMS administrator, said announcing that 33 states, Washington, D.C., and Puerto Rico had signed onto the initiative.

Asked for further details on the contracts, Catherine Howden, a CMS spokesperson, said in a statement that the terms of the agreements are “confidential and have only been disclosed to state Medicaid agencies.”

“Tackling the high cost of drugs in the United States is a priority of the current administration,” the statement said.

Citing confidentiality, two state Medicaid directors and the two manufacturers declined to reveal the financial terms of agreements.

New Therapies

The gene therapies, approved for people 12 or older with sickle cell disease, offer a chance to live without pain and complications, which can include strokes and organ damage, and avoid hospitalizations, emergency room visits, and other costly care. The Biden administration estimated that sickle cell care already costs the health system almost $3 billion a year.

With many more expensive gene therapies on the horizon, the cost of the sickle cell therapies presages financial challenges for Medicaid. Hundreds of cell and gene therapies are in clinical trials, and dozens could get federal approval in the next few years.

If the sickle cell payment model works, it will probably lead to similar arrangements for other pricey therapies, particularly for those that treat rare diseases, said Sarah Emond, president and CEO of the Institute for Clinical and Economic Review, an independent research institute that evaluates new medical treatments. “This is a worthy experiment,” she said.

Setting up payment for drugs based on outcomes makes sense when dealing with high treatment costs and uncertainty about their long-term benefits, Emond said.

“The juice has to be worth the squeeze,” she said.

Clinical trials for the gene therapies included fewer than 100 patients and followed them for only two years, leaving some state Medicaid officials eager for reassurance they were getting a good deal.

“What we care about is whether services actually improve health,” said Djinge Lindsay, chief medical officer for the Maryland Department of Health, which runs the state’s Medicaid program. Maryland is expected to begin accepting patients for the new sickle cell program this month.

Medicaid is already required to cover almost all FDA-approved drugs and therapies, but states have leeway to limit access by restricting which patients are eligible, setting up a lengthy prior authorization process, or requiring enrollees to first undergo other treatments.

While the gene therapy treatments are limited to certain hospitals around the country, state Medicaid officials say the federal model means more enrollees will have access to the therapies without other restrictions.

The manufacturers also pay for fertility preservation such as freezing reproductive cells, which could be damaged by chemotherapy during the treatment. Typically, Medicaid doesn’t cover that cost, said Margaret Scott, a principal with the consulting firm Avalere Health.

Emond said pharmaceutical companies were interested in the federal deal because it could lead to quicker acceptance of the therapy by Medicaid, compared with signing individual contracts with each state.

States are attracted to the federal program because it offers help monitoring patients in addition to negotiating the cost, she said. Despite some secrecy around the new model, Emond said she expects a federally funded evaluation will track the number of patients in the program and their results, allowing states to seek rebates if the treatment is not working.

The program could run for as long as 11 years, according to CMS.

“This therapy can benefit many sickle cell patients,” said Edward Donnell Ivy, chief medical officer for the Sickle Cell Disease Association of America.

He said the federal model will help more patients access the treatment, though he noted utilization will depend in part on the limited number of hospitals that offer the multimonth therapy.

Hope for Sickle Cell Patients

Before gene therapy, the only potential cure for sickle cell patients was a bone marrow transplant — an option available only to those who could find a suitable donor, about 25% of patients, Ivy said. For others, lifelong management includes medications to reduce the disease’s effects and manage pain, as well as blood transfusions.

About 30 of Missouri’s 1,000 Medicaid enrollees with sickle cell disease will get the therapy in the first three years, said Josh Moore, director of the state’s Medicaid program. So far, fewer than 10 enrollees have received it since the state began offering it in 2025, he said.

Less than a year into the federal program, Moore said it’s too early to tell its rate of success — defined as an absence of painful episodes that lead to a hospital visit. But he hopes it will be close to the 90% rate seen over the course of a couple of years in clinical trials.

Moore said the federal program based on how well the treatment works was preferred over cutting fees for a new and promising therapy, which would put the manufacturers’ ability to develop new drugs at risk. “We want to be good stewards of taxpayer dollars,” he said.

He declined to comment on how much the state may save from the arrangement or disclose other details, such as how much the drug companies might have to pay back, citing confidentiality of the contracts.

Lately Cole, who underwent gene therapy at St. Louis Children’s Hospital, has been able to focus on her hobbies — playing video games, drawing, and painting – and earning her high school diploma.

She said she was glad to get the treatment. The worst part was the chemotherapy, she said, which left her unable to talk or eat — and entailed getting stuck with needles.

She said that her condition is “way better” and that she has had no pain episodes leading to a hospital stay since completing the therapy last spring. “I’m just grateful I was able to get it.”

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Cuando cae la noche y bajan las temperaturas, arma una tienda de campaña y enciende una fogata bajo un grupo de pinos, abetos y cedros.

Evita a las autoridades rotando el uso de tres tiendas de distintos colores en tres campamentos diferentes. Al amanecer, desmonta su refugio, enrolla sus pertenencias y las esconde para la noche siguiente. “No te ven si estás en el bosque”, dijo este hombre de 32 años. “Pero asegúrate de tener todo desmontado por la mañana o te van a encontrar”.

Durante el día, deambula, haciendo paradas en una biblioteca pública para calentarse o en un comedor comunitario para comer. Lo importante es no llamar la atención por no tener hogar.

“La policía quiere que no estorbemos”, dijo, vestido con una chaqueta gris y sin cargar ninguna de sus pertenencias. “Fuera de la vista, fuera de sus mentes”.

Ibrahim ha buscado intencionalmente pasar desapercibido desde agosto, cuando el presidente Donald Trump puso a la policía del distrito y ordenó que soldados de la Guardia Nacional patrullaran las calles. También ordenó el de las personas sin hogar. “No habrá ningún señor amable”, .

La administración Trump argumenta que los operativos para desmantelar campamentos han reducido la visibilidad del problema de personas sin hogar, mejorando así la ciudad. “Es innegable que Washington, D.C., es una ciudad más segura, limpia y hermosa gracias a las acciones históricas del presidente Trump para restaurar la capital del país”, dijo la vocera de la Casa Blanca, Taylor Rogers.

Aunque puede parecer que hay menos personas sin hogar en la capital del país, no han desaparecido.

En entrevistas, personas sin hogar dijeron que cambian de lugar constantemente, escondiéndose a plena vista.

Durante el día, se mantienen en movimiento, comen en comedores comunitarios y descansan de vez en cuando en bibliotecas públicas, bancos de parques o paradas de autobús. Por la noche, muchos duermen en entradas de negocios, aceras de parques y escalinatas de iglesias. Algunos pasan la noche en el autobús, otras se refugian en salas de emergencia, y algunas buscan cobijo en áreas boscosas o se van a suburbios en Virginia o Maryland.

Hay aproximadamente 5.100 personas sin hogar en Washington, D.C., incluyendo aquellas en albergues temporales, según realizado a inicios de 2025. Después de que Trump ordenara la ofensiva contra la falta de vivienda en espacios públicos, las personas que vivían en comunidades improvisadas se dispersaron y ahora viven en las sombras. En agosto, funcionarios de la ciudad estimaron que cerca de 700 personas vivían al aire libre sin tiendas ni ningún tipo de refugio.

Con la llegada del invierno, estas personas están expuestas al clima extremo y se enferman más, ya que afecciones crónicas como la diabetes o enfermedades cardíacas no se tratan. Proveedores de atención médica en la calle afirman que, desde el despliegue de la Guardia Nacional, ha sido sumamente difícil localizar a sus pacientes.

Muchos afectados por los operativos han perdido medicamentos esenciales y son más propensos a faltar a citas médicas porque viven en constante desplazamiento.

Los equipos médicos no logran entregar medicamentos ni transportar a pacientes a sus consultas. Este caos permanente también puede hundir aún más a quienes padecen enfermedades mentales o adicciones, aumentando el riesgo de sobredosis.

Trabajadores sociales reportan las mismas dificultades: cuando pierden el rastro de sus clientes, se rompe la conexión esencial para conseguir documentos clave como identificaciones oficiales o tarjetas del Seguro Social.

Funcionarios del distrito y proveedores de salud advierten que esta cadena de efectos puede empeorar la situación de las personas sin hogar, poner en riesgo la salud pública y la seguridad, y generar costos enormes para el sistema de salud.

“Ya era difícil encontrar a las personas, pero la presencia federal lo empeoró”, dijo la doctora Tobie Smith, médica de atención en la calle y directora ejecutiva de Street Health D.C.

El ir y venir de los sin techo

Chris Jones nació y creció en Washington, D.C., pero ahora vive en la calle, luego de ser desplazado de su tienda de campaña cerca de la Casa Blanca en los primeros días de la ofensiva federal.

Dijo que durante los operativos le confiscaron dos tiendas. Ahora duerme en una acera frente a una iglesia y ya no intenta conseguir otra. “¿Para qué? ¿Cuál es el punto? Igual la van a tirar a la basura”.

Jones, de 57 años, tiene una lesión grave en la rodilla que a veces le impide caminar y tiene programada una cirugía de reemplazo de rodilla en diciembre. Dice que necesita quedarse en esa zona porque depende de una farmacia cercana para surtir sus medicamentos para el trastorno bipolar, la diabetes y la presión alta. Cuando tiene hambre, va al comedor comunitario o trata de conseguir una hamburguesa con refresco en un local de comida rápida enfrente de donde está.

También se mantiene en ese lugar para que su trabajadora social lo pueda encontrar si se libera una plaza de vivienda permanente. Si hace demasiado frío, cruza la calle y duerme en la entrada de un negocio, que le da un poco más de protección. Quiere estar bajo techo, pero por ahora espera.

Desde que tomó el control de la policía del distrito, la administración Trump sobre ciudades y condados en todo el país para desmantelar campamentos de personas sin hogar, bajo amenaza de arresto, citaciones o detenciones. Ha ordenado o amenazado con desplegar la Guardia Nacional en ciudades con grandes poblaciones sin hogar como Los Ángeles y .

Rogers, la vocera de la Casa Blanca, dijo que el presidente mantiene la presencia de la Guardia Nacional y fuerzas federales del orden en la capital para “garantizar el éxito a largo plazo de la operación federal”.

Desde marzo, funcionarios federales y del distrito han eliminado más de 130 campamentos, según dijo. Sin embargo, algunos expertos en temas de personas sin hogar creen que esa cifra está inflada.

La Corte Suprema facilitó el año pasado que funcionarios y agentes del orden impusieran multas o arrestaran a personas sin hogar por vivir en la calle. Luego, en julio de este año, el presidente emitió una orden ejecutiva que exige una ofensiva nacional contra los campamentos urbanos, incluyendo el desalojo masivo de personas que viven al aire libre y tratamientos forzados para la salud mental o adicciones.

Trump también lidera una reforma de la política federal de vivienda, con planes de para vivienda permanente y servicios para personas sin hogar.

Esta medida limitaría el uso de una política federal conocida como “Primero la Vivienda” (Housing First), que ofrece vivienda sin exigir tratamiento para salud mental o adicciones.

La Alianza Nacional para Terminar con la Falta de Vivienda (National Alliance to End Homelessness) advierte que este cambio podría dejar sin hogar a por lo menos actualmente en viviendas de apoyo permanente. El Departamento de Vivienda y Desarrollo Urbano (HUD, por sus siglas en inglés) suspendió el plan el 8 de diciembre para hacer revisiones, que “piensan” implementar.

Funcionarios del distrito dicen que están cumpliendo con la exigente campaña federal contra las personas sin hogar en espacios públicos. Bajo presión de la Casa Blanca, reconocen haber intensificado la disolución de campamentos. Defensores de personas sin hogar señalan que algunos operativos se han realizado de noche o sin previo aviso.

Líderes locales creen que se podrían hacer de manera más compasiva, ofreciendo servicios y refugio.

“Hemos pasado de permitir campamentos si no afectaban la salud o la seguridad pública, a decir: ‘No los queremos en la calle’”, dijo Wayne Turnage, vicealcalde para Salud y Servicios Humanos del distrito, quien supervisa el desmantelamiento de campamentos. “Es inseguro, insalubre y peligroso”. Sin embargo, reconoce que los operativos pueden desperdiciar recursos públicos, ya que los trabajadores sociales y equipos médicos deben volver a buscar a sus pacientes y clientes.

Defensores afirman que la administración Trump está generando miedo y desconfianza entre personas sin hogar y quienes tratan de ayudarlas, a la vez que malgasta fondos públicos que podrían utilizarse para brindar atención o ubicar a estas personas en viviendas. Eso sí, ahora hay muchas menos tiendas de campaña y campamentos visibles para turistas y residentes.

“Las personas encontraban seguridad en esas comunidades, y los proveedores de servicios podían localizarlas. Ahora hay gente armada y luces que destellan sacando a la fuerza a personas sin hogar sin previo aviso y tirando sus cosas”, dijo Jesse Rabinowitz, director de campaña y comunicaciones del Centro Nacional de Leyes sobre Personas sin Hogar (National Homelessness Law Center).

Funcionarios del distrito dicen que algunas personas han aceptado ir a refugios de emergencia. Pero incluso mientras la ciudad trata de ampliar la capacidad de albergues y conectar a la gente con servicios, reconoce que no hay suficientes camas ni viviendas permanentes para todos.

Y habrá menos lugares disponibles para quienes viven en la calle.

El presupuesto del distrito para el año fiscal 2026 concentró los fondos para personas sin hogar en las familias, con 336 nuevos vales para viviendas de apoyo permanente.

Sin embargo, se recortó el financiamiento para albergues temporales tanto para familias como para personas solas, y no se asignaron nuevos vales de vivienda permanente para individuos.

Eso significa menos espacios disponibles para adultos solos, que representan la mayoría de quienes deambulan por las calles. No obstante, las autoridades locales señalaron que han incluido 260 nuevas unidades de vivienda permanente para personas sin hogar, ya sean familias o individuos, en sus planes de construcción.

Empeorando la atención médica

La situación ha saturado los comedores comunitarios, como Miriam’s Kitchen en Foggy Bottom. Esta institución local ofrece comidas calientes, asistencia para vivienda y cobijas a personas en situación de necesidad.

Trabajadores sociales dicen que cada vez es más difícil ayudar a los clientes a obtener identificaciones y otros documentos necesarios para servicios sociales y de vivienda.

“Estoy buscando por todos lados, pero no puedo encontrarlos”, dijo Cyria Knight, trabajadora social de Miriam’s Kitchen. “La mayoría de mis clientes se fue a Virginia”.

No está claro cuántas personas se han trasladado a comunidades vecinas en Virginia o Maryland. En enero, antes de la ofensiva de Trump, se estimaba que había unas en la región. Cuatro de los seis condados que rodean Washington vieron un aumento en la falta de vivienda desde 2024, mientras que en el distrito .

“No veo a mis pacientes por un mes o más, y cuando los encuentro, sus enfermedades crónicas están fuera de control. Han entrado y salido de la sala de emergencia, y tienen más probabilidades de ser hospitalizados”, dijo Anna Graham, enfermera especializada en medicina callejera de , una red de clínicas en Washington. “Esto nos hace retroceder”.

El equipo de Graham estaciona su unidad médica móvil afuera de Miriam’s Kitchen durante la hora de la cena para tener más probabilidades de encontrar pacientes.

Willie Taylor, de 63 años, buscaba dónde dormir esa noche tras recibir la cena. Vio a Graham para recibir medicamentos para una enfermedad pulmonar avanzada, convulsiones, dolor crónico y otros padecimientos.

Le cuesta caminar y necesita una silla de ruedas, lo cual es complicado porque no tiene una dirección fija. Sus proveedores médicos dicen que le han robado sillas de ruedas antes mientras dormía en la calle.

Taylor usa un carrito de compras para mantenerse en pie durante el día, caminando sin rumbo hasta que cae la noche.

En una fría noche de noviembre, Graham lo ayudó a organizar sus medicamentos y revisó sus signos vitales. El equipo le dio un abrigo y calentadores de manos antes de que volviera a irse.

Después de caminar unos 45 minutos, encontró un rincón de pavimento en un parque donde pudo armar su cama con lonas y sacos de dormir.

“Mi cuerpo ya no aguanta esto”, dijo Taylor mientras se preparaba para dormir. “Hay hielo en el concreto. Me duele muchísimo más cuando hace frío”.

Las personas sin hogar  y les cuesta más al sistema de salud que quienes tienen vivienda, en gran parte porque no reciben tratamiento en la calle y, cuando buscan atención, suelen ir a la sala de emergencia.

Se estima que, entre las personas inscritas en Medicaid, quienes no tienen hogar generan un gasto anual de $18.764, frente a $7.561 de otros beneficiarios.

Más temprano ese día, en el comedor comunitario So Others Might Eat, Tyree Kelley terminaba su desayuno: un sándwich de salchicha y huevos duros. Estaba considerando ir a un refugio. Dijo que las calles se estaban volviendo demasiado peligrosas, en referencia a la presencia policial y de la Guardia Nacional. Extrañaba la comunidad de su antiguo campamento, que lo ayudaba a mantenerse seguro.

Este año ha ido al hospital al menos siete veces por una fractura en el tobillo tras caer de un scooter eléctrico. El accidente le hizo perder su trabajo y su seguro médico como recolector de basura, contó. Dijo que su situación lo ha hundido en una depresión que comenzó hace tres años, cuando murió su madre.

Después, este año murieron su padre y su hermana. Para adormecer el dolor, comenzó a beber.

“Uno se deprime mucho estando aquí”, dijo Kelley, de 42 años. “Se vuelve adictivo. Empiezas a no preocuparte ni por cambiarte de ropa”.

Esa depresión lo llevó a buscar marihuana. Luego fumó un cigarro mezclado con fentanilo. La sobredosis lo mantuvo en el hospital durante varios días.

“En realidad morí y volví”, dijo, agradeciendo a otras personas sin hogar que le administraron naloxona y le salvaron la vida. “Necesito salir de esto, pero me siento atrapado”.

A unas cuadras al oeste de la Casa Blanca hay un terreno baldío en donde hasta hace poco había más de una docena de tiendas de campaña. Quienes trabajan en la zona perciben lo que ya no se ve.

“Estuve aquí cuando limpiaron todo. Llegó una topadora y tiraron todo a un camión de basura”, dijo Ray Szemborski, quien trabaja frente a ese lote. “Las personas siguen sin hogar. Las sigo viendo debajo del puente. A veces están en las paradas de bus, otras solo caminando. Las tiendas ya no están, pero ellos siguen aquí”.

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As night falls and temperatures drop, he erects a tent and builds a fire beneath a canopy of pine, hemlock, and cedar trees.

He evades authorities by rotating use of three tents of different colors at three campsites. As day breaks, he dismantles his shelter, rolls up his belongings, and hides them for the next night. “They don’t see you if you’re in the woods,” the 32-year-old said. “But make sure it’s broken down by morning or they’ll find you.”

During the day, he wanders, stopping at a public library to warm up or a soup kitchen to eat. What’s important is to not draw attention to himself for being homeless.

Ibrahim has been deliberate about blending in since August, when President Donald Trump placed the district’s police under and ordered National Guard soldiers to patrol its streets. The president homeless people to leave immediately. “There will be no ‘MR. NICE GUY,’” .

The Trump administration says encampment sweeps have reduced the visibility of homelessness, thereby enhancing the city. “There is no disputing that Washington, DC is a safer, cleaner, and more beautiful city thanks to President Trump’s historic actions to restore the nation’s capital,” White House spokesperson Taylor Rogers said.

While there may appear to be fewer homeless people in the nation’s capital now, they have not disappeared.

In interviews, homeless people said they are in a constant shuffle, hiding in plain sight. During the day, they stay on the move, grabbing meals at soup kitchens and resting on occasion in public libraries, on park benches, or at bus stops. At night, many unsheltered people bed down in business doorways, on park sidewalks, and on church stoops. Some ride the bus all night, while a few shelter in emergency rooms. Others find respite in the woods or flee to suburbs in Virginia or Maryland.

There are about 5,100 homeless people in Washington, D.C., including in temporary shelters, according to an . After Trump ordered the crackdown on public homelessness, people living in makeshift communities scattered and are now living in the shadows. City officials estimated in August that nearly 700 homeless people were living outdoors without tents or other shelter.

As winter draws near, they are exposed to the elements and grow sicker as chronic ailments such as diabetes and heart disease go untreated. Street medicine providers say that, since the National Guard was deployed, they have faced enormous difficulty finding patients. Many caught up in sweeps have had their lifesaving medications thrown away, and they are more likely to miss medical appointments because they are constantly on the move. Street medicine providers say they can’t find their patients to deliver medication or transport them to medical appointments. The constant chaos can suck patients with mental illness and substance use deeper into drug and alcohol addiction, raising the risk of overdose.

Caseworkers report similar disruptions, saying as clients get lost, they break connections essential for obtaining housing documents, particularly IDs and Social Security cards.

District officials and health providers say this cascade will make homelessness worse, threatening public health and public safety and racking up enormous costs for the health care system.

“It was already hard locating people, but the federal presence just made it worse,” said Tobie Smith, a street medicine doctor and the executive director of Street Health D.C.

The Homeless Shuffle

Chris Jones was born and raised in Washington, D.C., but now is homeless, having been pushed out of his tent near the White House in the initial days of the federal homelessness crackdown. He said two of his tents were taken during sweeps. Now, sleeping on a sidewalk outside a church, he doesn’t bother trying to get another one. “Why? What’s the point? It’ll just get thrown away again.”

Jones, 57, has a severe knee injury that prevents him from walking some days and said he was scheduled for a knee replacement in December. He said it’s important to stay where he is — he relies on a nearby drugstore to refill his medications for bipolar disorder, diabetes, and high blood pressure. When he’s hungry, he goes to a soup kitchen for a meal or tries to get a cheeseburger and a soda from a fast-food joint across the street.

It’s important for him to stay outside the church, he said, so his case manager can find him when a permanent housing slot opens up. If it gets too cold, he said, he will cross the street and sleep in the doorway of a business, which can provide a bit more shelter. He wants to get indoors, but for now, he waits.

Since taking control of Washington’s police force, the Trump administration has on cities and counties across the nation to clear homeless encampments under threat of arrest, citation, or detention. It has ordered or threatened similar National Guard deployments in Los Angeles; ; and other cities with large homeless populations.

Rogers, the White House spokesperson, said the president is maintaining National Guard and federal law enforcement presence in the nation’s capital “to ensure the long-term success of the federal operation.” Since March, city and federal officials have removed more than 130 homeless encampments, she said, though some local homelessness experts say that number could be inflated.

The Supreme Court last year made it easier for elected officials and law enforcement to fine or arrest homeless people for living outside. Then, in July of this year, the president issued an executive order calling for a nationwide crackdown on urban camping, including a massive removal of people living outdoors and forced mental health or substance use treatment.

Trump is also spearheading an overhaul of homelessness policy, moving to and services for homeless people. The move would limit the use of a long-standing federal policy known as “Housing First” that offers housing without mandating mental health or addiction treatment. The National Alliance to End Homelessness warns the move risks displacing in permanent supportive housing. The Department of Housing and Urban Development paused the plan on Dec. 8 to make revisions, which it “intends” to do, .

City officials say they are complying with the Trump administration’s forceful campaign against homeless people sheltering outside. Pressured by the White House, local officials said they’ve gotten more aggressive in breaking up camps. Advocates for homeless people say some of the sweeps have been conducted at night and others with little or no notice to move. City leaders believe they could be done more compassionately by offering services and shelter.

“We’ve pivoted from the notion of allowing encampments if they didn’t violate public health or safety to a position of, ‘We don’t want you in the streets,’” said Wayne Turnage, deputy mayor for District of Columbia Health and Human Services, who oversees encampment cleanups. “It’s unsafe, it’s unhealthy, and it’s dangerous.” Yet he acknowledges the encampment sweeps can waste city resources as caseworkers and street medicine providers scramble to find their clients and patients.

Advocates say the Trump administration is inciting fear and mistrust between homeless people and those working to help them while wasting taxpayer dollars used to provide care and place people into housing. There are, however, far fewer tents and large-scale encampments visible to tourists and residents.

“People found safety in those communities and service providers could find them. Now there are people with guns and flashing lights dislocating folks experiencing homelessness without notice and just throwing stuff away,” said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

District officials say some people have accepted emergency shelter. But even as the city works to connect people with services and expand shelter capacity, officials acknowledge there isn’t enough permanent housing or temporary beds for everyone.

And there will be fewer places for people living outside to go.

The city, in its fiscal year 2026 budget, concentrated its homelessness funding on families, funding 336 new permanent supportive housing vouchers. Yet it cut funding for temporary housing for both families and individuals and provided no new permanent supportive housing vouchers for individuals. That means fewer housing slots for single adults, who make up most of those wandering the streets. City officials said, however, that they have slotted 260 more permanent housing units for homeless individuals or families into their construction pipeline.

Worsening Health Care

The fallout is inundating local soup kitchens with demand, including Miriam’s Kitchen in Foggy Bottom. The local institution provides hot meals, housing assistance, and warm blankets to people in need.

Caseworkers say it’s becoming increasingly difficult to help clients secure IDs and other documents needed for housing and other social services.

“I’m looking everywhere, but I can’t find people,” said Cyria Knight, a caseworker at Miriam’s Kitchen. “Most of my clients went to Virginia.”

It’s unclear how much of the district’s homeless population has fanned out to neighboring Virginia and Maryland communities. There were an estimated in the region in January, months before Trump’s crackdown. Four of six counties around Washington saw homelessness rise from 2024, while it .

“I’m not seeing my patients for a month or more, and then when I do, their chronic conditions are uncontrolled. They’ve been in and out of the ER, and they’re more likely to be hospitalized,” said Anna Graham, a street medicine nurse practitioner for , a network of clinics in Washington. “It’s just setting us back.”

Graham’s team stations its mobile medical van outside Miriam’s Kitchen at dinnertime to better find patients.

Willie Taylor, 63, was figuring out where to sleep for the night after grabbing dinner from Miriam’s. He saw Graham to receive his medications for advanced lung disease, seizures, chronic pain, and other health disorders.

He has difficulty walking and needs a wheelchair, which is complicated because he doesn’t have a permanent address. Taylor and his medical providers say his previous wheelchairs have been stolen while he slept outdoors at night. He uses a shopping cart to keep him steady, walking around all day, until nightfall.

On a cold November night, Graham helped Taylor figure out his daily medications and checked his vitals. The team handed him a warm coat and hand warmers before sending him back outside.

After walking for about 45 minutes, he found a piece of park pavement where he could build a bed out of tarps and sleeping bags.

“My body can’t take this,” Taylor said, preparing to sleep. “There’s ice on the concrete. I’m in so much pain; it hurts so much worse when it’s cold.”

Homeless people and cost the health care system more than housed people, largely because conditions go untreated on the streets, and when they do seek care, many go to the ER. Among Medicaid enrollees, homeless people have been estimated to incur $18,764 a year in spending, compared with $7,561 for other enrollees.

Over at the So Others Might Eat soup kitchen earlier that day, Tyree Kelley was finishing his breakfast of a sausage sandwich and hard-boiled eggs. He was considering going into a shelter. The streets were becoming too dangerous for someone like him, he said, referring to the police and National Guard presence. He was feeling the loss of an encampment community that would watch his back.

He’s been to the ER at least seven times this year to get care for a broken ankle he sustained falling off an electric scooter. The accident caused him to lose his job and health insurance as a garbageman, he said. His situation has caused him to sink deeper into a depression that began three years ago after his mother died, he said.

Then his father and sister died this year. He began to numb his pain with beer.

“You get so depressed, being out here,” said Kelley, 42. “It gets addictive. You start to not care about even changing your clothes.”

His depression also led him to seek out marijuana. Then he smoked a joint laced with fentanyl. The overdose sent him to the hospital for days.

“I actually died and came back,” he said, crediting other homeless people with administering naloxone and saving his life. “I need to get out of this, but I feel so stuck.”

A few blocks west of the White House sits a vacant plot of land that earlier this year held more than a dozen tents. Workers in the area sense what they don’t always see.

“I was here when this was all cleared. A bulldozer came in, and all their stuff was thrown in a garbage truck,” said Ray Szemborski, who works across the street from the now-empty lot. “People are still homeless. I still see them around underneath the bridge. Sometimes they’re at bus stops, sometimes just walking around. Their tents are gone but they’re still here.”

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Bynum, then in his second year of residency training as a family medicine physician, was wrapping up a long shift when he was called into an emergency delivery. To save the baby’s life, he used a vacuum device, which applies suction to assist with rapid delivery.

The baby emerged unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon afterward, Bynum retreated to an empty hospital room, trying to process his feelings about the unexpected complication.

“I didn’t want to see anybody. I didn’t want anybody to find me,” said Bynum, now an at Duke University School of Medicine in North Carolina. “It was a really primitive response.”

The U.S. political environment presents an additional obstacle. Health and Human Services Secretary Robert F. Kennedy Jr. and other top Trump administration health officials have publicly blamed autism, diabetes, attention-deficit/hyperactivity disorder, and other chronic issues in large part on the lifestyle choices of people with the conditions — or their parents. For instance, FDA Commissioner Marty Makary suggested in a Fox News interview that diabetes could be better treated with cooking classes than “.”

Even before the political shift, that attitude was reflected at doctors’ offices as well. A 2023 study found that when treating patients with Type 2 diabetes. About 44% viewed those patients as lacking motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like feeling shame. We want to avoid it. It’s very uncomfortable,” said , a nurse at the University of Wisconsin-Madison, who has of related studies, published in 2024. And if the source of shame is from the clinician, the patient may ask, “‘Why would I go back?’ In some cases, that patient may generalize that to the whole health care system.”

Indeed, Christa Reed dropped out of regular medical care for two decades, weary of weight-related lectures. “I was told when I was pregnant that my morning sickness was because I was a plus-size, overweight woman,” she said.

Except for a few urgent medical issues, such as an infected cut, Reed avoided health care providers. “Because going into a doctor for an annual visit would be pointless,” said the now 45-year-old Minneapolis-area wedding photographer. “They would only just tell me to lose weight.”

Then, last year, severe jaw pain drove Reed to seek specialty care. A routine blood pressure check showed a sky-high reading, sending her to the emergency room. “They said, ‘We don’t know how you’re walking around normal,’” she recounted.

Since then, Reed has found supportive physicians with expertise in nutrition. Her blood pressure remains under control with medication. She’s also nearly 100 pounds below her heaviest weight, and she hikes, bikes, and lifts weights to build muscle.

, a California psychiatrist, is among a group of physicians trying to bring attention to the detrimental effects of shame and develop strategies to prevent and mitigate it. While this effort is in the early stages, she co-led a session on the spiral of shame at the American Psychiatric Association’s annual meeting in May.

If physicians don’t acknowledge shame in themselves, they can be at risk of depression, , sleeping difficulties, and other ripple effects that erode patient care, she said.

“We often don’t talk about how important the human connection is in medicine,” Woodward said. “But if your doctor is burned out or feeling like they don’t deserve to be your doctor, patients feel that. They can tell.”

In a survey conducted this year, 37% of graduating students at some point in medical school. And nearly 20% described public humiliation, according to the annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, along with an almost “masochistic” work ethic, as Woodward described it. Then they’re run through a gantlet of exams and years of training, amid constant scrutiny and with patients’ lives on the line.

During training, physicians work in teams and make presentations to teaching faculty about a patient’s medical issues and their recommended treatment approach. “You trip over your words. You miss things. You get things out of order. You go blank,” Bynum said. And then shame creeps in, he said, leading to other debilitating thoughts, such as “‘I’m no good at this. I’m an idiot. Everyone around me would have done this so much better.’”

Yet shame remains “a crack in your armor that you don’t want to show,” said , a family medicine physician at the University of Utah who has taught medical students about the potential for shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “Heaven forbid that you act like you’re not capable or you show fear.”

When students are taught about shame, the goal is to help future physicians recognize the emotion in themselves and others, so they don’t perpetuate the cycle, Pippitt said. “If you felt shamed throughout your medical education, it normalizes that as the experience,” she said.

Above all, physicians-in-training can work to reframe their mindset when they receive a poor grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they’ve failed as a physician, they can focus on what they got wrong and ways to improve.

Last year, Bynum started teaching Duke physicians about shame competence, beginning with roughly 20 OB-GYN residents. This year, he launched a larger initiative with , a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people across Duke’s Department of Family Medicine and Community Health, including faculty and residents.

This sort of training is rare among Duke OB-GYN resident ’s peers in other programs. Dancel, who completed the training, now strives to support students as they learn skills such as how to suture. She hopes they will pay that approach forward in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would following delivery. “I was too scared of how she was going to react to me,” he said.

“It was a little devastating,” he said, when a colleague later told him that the mother wished he had stopped by. “She had passed a message along to thank me for saving her baby’s life. If I had just given myself a chance to hear that, that would have really helped in my recovery, to be forgiven.”

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Permanent changes to the Supplemental Nutrition Assistance Program are coming regardless of the outcome of at least two federal lawsuits that seek to prevent the government from cutting off November SNAP benefits. The lawsuits challenge the Trump administration’s refusal to release emergency funds to keep the program operating during the government shutdown.

A federal judge in Rhode Island ordered the government to use those funds to keep SNAP going. A Massachusetts judge in a separate lawsuit also said the government must use its food aid contingency funds to pay for SNAP, but gave the Trump administration until Nov. 3 to come up with a plan.

Amid that uncertainty, food banks across the U.S. braced for a surge in demand, with the possibility that millions of people will be cut off from the food program that helps them buy groceries.

On Oct. 28, a vanload of SpaghettiOs, tuna, and other groceries arrived at Gateway Food Pantry in Arnold, Missouri. It may be Gateway’s last shipment for a while. The food pantry south of St. Louis largely serves families with school-age children, but it has already exhausted its yearly food budget because of the surge in demand, said Executive Director Patrick McKelvey.

New Disabled South, a Georgia-based nonprofit that advocates for people with disabilities, announced that it was offering one-time payments of $100 to $250 to individuals and families who were expected to lose SNAP benefits in the 14 states it serves.

Less than 48 hours later, the nonprofit had received more than 16,000 requests totaling $3.6 million, largely from families, far more than the organization had funding for.

“It’s unreal,” co-founder Dom Kelly said.

The threat of a SNAP funding lapse is a preview of what’s to come when changes to the program that were included in the One Big Beautiful Bill Act that President Donald Trump signed in July take effect.

The domestic tax-and-spending law cuts $187 billion within the next decade from SNAP. That’s a nearly 20% decrease from current funding levels, according to the Congressional Budget Office.

The new rules shift many food and administrative costs to states, which may lead some to consider withdrawing from the program, which helped about 42 million people buy groceries last year. Separate from the new law, the administration is also pushing states to limit SNAP purchases by barring such things as candy and soda.

All that “puts us in uncharted territory for SNAP,” said Cindy Long, a former deputy undersecretary at the Department of Agriculture who is now a national adviser at the law firm Manatt, Phelps & Phillips.

The country’s first food stamps were issued at the end of the Great Depression, when the poverty-stricken population couldn’t afford farmers’ products. Today, instead of stamps, recipients use debit cards. But the program still buoys farmers and food retailers and prevents hunger during economic downturns.

The CBO estimates that will lose food assistance as a result of in the budget law, including applying work requirements to more people and shifting more costs to states. Trump administration leaders have backed the changes as a way to limit waste, to , and to .

This is the biggest cut to SNAP in its history, and it is coming against the backdrop of rising food prices and a fragile labor market.

The exact toll of the cuts will be difficult to measure, because the Trump administration that measures food insecurity.

Here are five big changes that are coming to SNAP and what they mean for Americans’ health:

1. Want food benefits? They will be harder to get.

Under the new law, people will have to file more paperwork to access SNAP benefits.

Many recipients are already required to work, volunteer, or participate in other eligible activities for 80 hours a month to get money on their benefit cards. The new law to previously exempted groups, including homeless people, veterans, and young people who were in foster care when they turned 18. The expanded work requirements also apply to parents with children 14 or older and adults ages 55 to 64.

, if recipients fail to document each month that they meet the requirements, they will be limited to three months of SNAP benefits in a .

“That is draconian,” said Elaine Waxman, a senior fellow at the Urban Institute, a nonprofit research group. About 1 in 8 adults reported having lost SNAP benefits because they had problems filing their paperwork, according to .

Certain refugees, asylum-seekers, and other lawful immigrants are cut out of SNAP entirely under the new law.

2. States will have to chip in more money and resources.

The federal law drastically increases what each state will have to pay to keep the program.

Until now, states have needed to pay for only half the administrative costs and none of the food costs, with the rest covered by the federal government.

Under the new law, states are on the hook for 75% of the administrative costs and must cover a portion of the food costs. That amounts to an estimated median cost increase for states of more than 200%, according to by the Georgetown Center on Poverty and Inequality.

A �������ýҕ�l Health News analysis shows that a single funding shift related to the cost of food could put states on the hook for an additional $11 billion.

All states participate in the SNAP program, but they could opt out. In June, nearly wrote to congressional leaders warning that some states wouldn’t be able to come up with the money to continue the program.

“If states are forced to end their SNAP programs, hunger and poverty will increase, children and adults will get sicker, grocery stores in rural areas will struggle to stay open, people in agriculture and the food industry will lose jobs, and state and local economies will suffer,” the governors wrote.

3. Will the changes lead to more healthy eating?

The Trump administration, through its “Make America Healthy Again” platform, has made healthy eating a priority.

Health and Human Services Secretary Robert F. Kennedy Jr. has championed the restrictions on soda and candy purchases within the food aid program. To date, to limit what people can buy with SNAP dollars.

Federal officials previously blocked such restrictions, because they were difficult for states and stores to implement and they boost stigma around SNAP, according to . In 2018, the first Trump administration to ban sugar-sweetened drinks and candy.

A store may decide that hassle isn’t worth participating in the program and drop out of it, leaving SNAP recipients fewer places to shop.

People who receive SNAP are no more likely to buy sweets or salty snacks than people who shop without the benefits, . Research shows that encouraging healthy food choices is than regulating purchases.

When people have less money to spend on food, they often resort to cheaper, unhealthier alternatives that keep them sated longer rather than paying for more expensive food that is healthy and fresh but quick to perish.

4. How will SNAP cuts affect health?

Advocacy organizations working to end hunger in the nation say the cuts will have long-term health effects.

Research has found that kids in households with limited access to food to have a mental disorder. Similarly, food insecurity is linked to .

Working-age people with food insecurity to experience chronic disease. That high blood pressure, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

Those health issues come with costs for individuals. Low-income adults who aren’t on SNAP more a year on health care than those who are.

lived in households with limited or uncertain access to food in 2023.

5. What does this mean for the nation’s food supply chain?

SNAP spending directly boosts grocery stores, their suppliers, and the transportation and farming industries. Additionally, when low-income households have help accessing food, they’re more likely to spend money on other needs, such as prescriptions or car repairs. All that means that every dollar spent through SNAP generates at least $1.50 in economic activity, .

A report by associations representing convenience stores, grocers, and the food industry estimated it to comply with the new SNAP restrictions.

Advocates warn stores may pass the costs on to shoppers, or they may close.

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Richards has heard Trump administration officials suggest that and cause autism and ADHD. That stance, she said, unfairly blames parents.

“There’s no evidence to support it,” said Richards, 44, a marketing director in Richmond, Virginia. “As a parent, it’s infuriating.”

In their zeal to “Make America Healthy Again,” Trump administration officials are making statements that some advocacy and medical groups say depict patients and the doctors who treat them as partly responsible for whatever ails them.

Health and Human Services Secretary Robert F. Kennedy Jr. and agency leaders have attributed a panoply of chronic diseases and other medical issues — such as autism, attention-deficit/hyperactivity disorder, depression, diabetes, and obesity — to consumers and their lifestyle choices, according to a review of 15 hours of recorded interviews, social media statements, and federal reports.

He said at a news conference on April 16 that and that rates are rising because of toxic substances in the environment, despite a lack of evidence there is any link.

“These are kids who will never pay taxes. They’ll never hold a job. They’ll never play baseball. They’ll never write a poem. They’ll never go out on a date,” he said. “Many of them will never use a toilet unassisted.”

The vast majority of people on the spectrum do not have those severe challenges.

The statements are more than rhetoric. These attitudes, ranging from judgments about individual behaviors to criticism of the chronically poor, are shaping policies that affect millions of people. The sentiments have been a factor behind decisions to cut Medicaid, keep federal insurance programs from covering anti-obesity drugs, and impose new barriers to covid vaccines for healthy people, say public health leaders and doctors. GOP lawmakers and federal health officials, they say, hold a reproachful stance toward chronic illnesses and the estimated 129 million people in the U.S. affected by them.

“This is at the heart of so much of our national problem with health,” said Robert Califf, who led the Food and Drug Administration during the Obama and Biden administrations. “It’s these two extreme views. It’s every health decision is up to the ‘rugged individual,’ versus the other extreme view that it’s all controlled by environment and social determinants of health. The truth is, it’s on a continuum.”

The Blame Game

Self-reliance is a common theme among adherents of MAHA, an informal movement for which Kennedy has fashioned himself the figurehead that promotes medical freedom, skepticism of vaccines, and a focus on nontraditional medicine to treat disease.

Taking medication to manage diabetes? FDA Commissioner Marty Makary suggested on in late May that it would be effective to “treat more diabetes with cooking classes” instead of “just throwing insulin at people.”

People with Type 1 diabetes must take insulin because their pancreases don’t produce it, according to the , which also notes that many with Type 2 diabetes “need to take diabetes medicines as well.”

Taking birth control pills? Casey Means, President Donald Trump’s nominee to be U.S. surgeon general, has said that’s a “disrespect of life” for short-term gain and efficiency.

“We are prescribing them like candy,” she said last year on “,” adding that birth control medications “are literally shutting down the hormones in the female body that create this cyclical, life-giving nature of women.”

Have a child on ADHD meds? , who is an adviser to Kennedy and is Casey Means’ brother, said on the same show that Adderall is prescribed as the standard of care when children get a little fidgety because they’re in sedentary environments with limited sunlight and eat too much ultraprocessed food.

As a society, he said, “we’re really committing mass child abuse in many ways, and we’re normalizing that and we’re not speaking out about that. And then we’re giving people stimulants developed by Nazi Germany.”

Calley Means was probably referring to Pervitin, a drug administered to Adolf Hitler’s forces in World War II. Adderall is a prescription drug containing amphetamine, a stimulant that’s as methamphetamine.

The Department of Health and Human Services didn’t respond to messages seeking comment from Means.

Some conservatives and MAHA adherents argue that people need to take more responsibility for their health. But comments that shift blame to patients and physicians risk perpetuating stigmas, fostering the spread of misinformation, and eroding trust in modern medicine, say medical groups, doctors, and patient advocacy groups.

The statements assume consumers and patients have control over improving their health and preventing chronic disease when the reality is more complex, according to some public health leaders. Lower-income people, they say, often lack access to grocery stores and healthy food, may juggle too many jobs to have time to cook from scratch, and may live in dangerous areas where it’s harder to get outside and exercise.

, surgeon general during the previous Trump administration, told �������ýҕ�l Health News that he worries efforts to promote health will be undone by “the return of vaccine-preventable diseases, increasing mistrust in the health care system, and the tearing down of social supports which are critical for making healthy choices.”

Tough Talk

The attitudes held by top Trump health officials have affected policy decisions, some doctors and public health leaders say.

Kennedy and other Trump administration health leaders have been especially outspoken, targeting issues they consider especially egregious in recent federal actions, research, or policy.

For example, the Biden administration proposed in November that would let Medicare cover weight loss medications such as Wegovy and Zepbound. But Kennedy and other political appointees at HHS and its agencies have criticized the drugs and the people who take them.

“I think it’s very dark,” Calley Means , referring to the weight loss drugs. “I think it’s a stranglehold on the U.S. population, almost like solidifying this idea that there is a magic pill.”

He added: “Where is the urgency on saying ‘Hey parents, maybe we shouldn’t feed our kids toxic food?’”

Kennedy, too, has criticized the medications and people who use them, saying in October on that drugmakers “are counting on selling it to Americans because we’re so stupid and so addicted to drugs.”

In April, the Trump administration announced it would not finalize the Biden-era coverage rule.

“It’s impacting the kind of care and treatments patients will have,” said Andrea Love, a biomedical scientist and founder of ImmunoLogic, a science communication organization. “It sends the message that it’s your fault. It’s very much victim-blaming. It creates the idea that scientific progress is the devil, demonizes things that aren’t individually harming health, while avoiding addressing systemic issues that play a much larger role in health.”

Kennedy and HHS didn’t return messages seeking comment.

Data shows that the medications are effective. People who took the in clinical trials lost an average of 48 pounds, and 1 in 3 on that dose lost more than 58 pounds, or 25% of their body weight.

Kennedy and other agency leaders also oppose many covid-era health restrictions and rules. Some physicians and public health leaders note these officials downplayed covid risks while criticizing vaccines developed during the previous Trump administration.

Kennedy has said that people who died from covid actually fell victim to chronic diseases such as obesity, diabetes, or asthma.

“That’s really what killed them,” Kennedy said on “” in April. “These were people who were so sick they were basically hanging from a cliff, and covid came along and stamped on their fingers and dropped them off. But they were already living lives that were burdened by sickness.”

Covid was the underlying cause of death for more than in the U.S. from Aug. 1, 2021, to July 31, 2022, according to a 2023 report in JAMA Network, an open-access journal on biomedical sciences published by the American Medical Association.

Covid ranked first among deaths caused by infectious or respiratory diseases for youths under age 19, based on the report. Infants under a year old may be at higher risk of experiencing severe illness from covid compared with older children, , and risks are also higher for infants under 6 months and those with underlying medical conditions.

“ can help protect infants after birth,” according to the CDC.

But Kennedy announced in May that the federal government would no longer recommend covid vaccines for pregnant people and children who are healthy. Medical groups such as the American Academy of Pediatrics opposed this decision and filed a lawsuit. 

Kennedy also helped promote beliefs that many childless adults on Medicaid, the federal-state program for low-income people, don’t work and thereby drain resources from the program.

At a May hearing of the House Energy and Commerce Committee, Kennedy said the program was in jeopardy because of “all the able-bodied people who are not working [or] looking for jobs.”

It’s a view embraced by Republican lawmakers who portrayed adults enrolled in Medicaid as lazy or shirking work as they advanced a budget bill estimated to cut federal spending on the program by about $1 trillion over a decade, in part by imposing work requirements on many adult beneficiaries.

“Thirty-five-year-olds sitting at home playing video games, they’re going to now have to go get a job,” said House Majority Leader Steve Scalise of Louisiana.

The legislation, which Trump signed into law this month, will cause about 10 million more people to be without health insurance by 2034, .

Some health leaders who criticized the legislation say the statements inaccurately maligned Medicaid enrollees, who by law cannot hold high-paying jobs and remain in the program.

Nonetheless, nearly two-thirds of adults ages 19 to 64 covered by Medicaid in 2023 were working. For about 3 in 10, caregiving responsibilities, an illness or disability, or school attendance prevented them from working, , a health information nonprofit that includes �������ýҕ�l Health News.

“It’s using anti-welfare tropes for something that is basic health care, not a cash benefit,” said Anthony Wright, executive director at Families USA, which supports the Affordable Care Act and expanded health coverage. He summarized the Republican message: “We’re going to make it harder to get the help you need by imposing a bunch of paperwork, and if you don’t get it, it’s your fault.”

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Sounding the Alarm for Ambulances

Thank you for shedding much-needed light on the exorbitant costs and lack of reimbursement that have become a harsh reality for many ambulance services across Colorado and the nation (“Insurers Fight State Laws Restricting Surprise Ambulance Bills,” July 9). While it’s vital to protect patients from “surprise” bills — something your coverage highlights — it’s equally important to acknowledge the other side of the equation.

Ambulance providers often receive reimbursements well below the actual cost of delivering care. A recent found that ambulance services are under‑reimbursed by an average of $1,526 per transport, with Medicare alone paying nearly $2,334 less than the cost incurred. These shortfalls are unsustainable and threaten the financial viability of emergency responders.

It’s crucial that ambulance companies have a stronger voice in this conversation. Reimbursement rates aren’t just numbers — they determine whether crews can stay on the road, maintain readiness, and invest in vital mobile health care services. Emergency preparedness relies on stable funding, and when that funding falls short, communities suffer.

By spotlighting the reimbursement crisis, this article helps lay the groundwork for policy solutions. But let’s go a step further: We need to elevate the voice of ambulance agencies themselves, so lawmakers and insurers understand that fair payment isn’t a bonus — it’s essential to keep us safe.

— Patrick Fahey, Weymouth, Massachusetts

A DevOps engineer shared the NPR version of the article on social media:

Families hit hard by surprise ambulance bills-some see debts soar even with insurance. More states are acting, but a national solution may be needed for real protection.

— Michael Bennett (@M1keB_77)

— Michael Bennett, Denver

‘Congress Is Playing Political Hot Potato With My Health’

I’m 60, self-employed, and living with congestive heart failure. My ejection fraction is dangerously low, and the Affordable Care Act is the reason I can see a doctor, take my medication, and stay alive.

Now Congress is playing political hot potato with my health. If they don’t extend the ACA’s enhanced subsidies by August, my $30 premium could jump to over $800. That’s over 25 times as much. I’m not a hedge fund manager — I’m an independent contractor. Unless I start selling organs (not ideal when your heart’s the issue), I can’t keep up.

I’m too young for Medicare and have no employer plan. I’ve worked, paid taxes, and managed my condition responsibly. So why am I being priced out of care?

If Congress won’t listen, I’m asking you — the press — to help. Tell this story, or one just like it. Millions of Americans are quietly panicking, walking the same tightrope. These policy changes aren’t just math — they’re about human lives.

Because if nothing changes, a lot of us won’t be around to write letters next year.

— Kevin Bahn, Tamarac, Florida

Americans Pay the Price for a Sick Health Care System

I am sure your readers would be interested in how American health care costs compare with those of the European Union and Switzerland (“Bill of the Month: A Texas Boy Needed Protection From Measles. The Vaccine Cost $1,400,” June 30).

In France, the private price for the MMR vaccine is around $13 (in U.S. dollars), provided you have a prescription. Any pharmacy can administer the jab for about the same.

Here in Switzerland, the most expensive country in Europe, this vaccine costs under $40, as a private purchase.

I’ve moved 18 times with family across Western and Eastern Europe and have had expat staff in 35 countries on four continents.

It’s very clear to me now that most national attempts at health care are a costly failure, with few notable exceptions: Germany and, surprisingly, Spain. Then there’s Switzerland, which has among the best health care systems in the world — close to perfect. Basic coverage terms are federally mandated and cost around $430 a month with a $2,500 annual deductible, irrespective of age, after 26. And with a $300 yearly deductible, the premiums are about 40% higher.

Something is very off in the USA. It’s not that complicated.

— Clement Cohen, Geneva, Switzerland

A registered nurse shared his solution for taming Medicaid fraud in a post on X:

“They’ll give you a bone if you stay in the mud.It’s relatively easy to fix the benefit cliff: just phase in a graduated premium for Medicaid based on income above the threshold. If we had political will to do this, it would prompted self-sufficiency.

— Jacob Larsen 🇺🇸 🇩🇰 🇺🇦 (@SLCPaladin)

— Jacob Larsen, St. George, Utah

Why ‘Start From Scratch’ Vaccine Testing Can Be Dangerous

I anticipate we’ll be hearing more discussion around the use of “inert” placebos — like saline solutions — as the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention approach new vaccine recommendations (“Kennedy’s Vaccine Advisers Sow Doubts as Scientists Protest US Pivot on Shots,” June 27). This type of messaging seems poised to gain traction with the public, despite its ethical implications.

Increasingly, I’m seeing criticism that vaccine development doesn’t rely on inert placebos. This argument is often used to advocate for new clinical trials — even for vaccines already proven effective — and to justify beginning booster development from scratch.

While inert placebos may have been used and were appropriate in early stages of research for vaccines, their use becomes ethically problematic when a safe, effective vaccine already exists. In such cases, withholding protection from participants in a placebo group can put them at real risk, especially during the development of updated or booster doses of vaccines.

I believe it’s critical that organizations like �������ýҕ�l Health News help clarify this issue for the public. KFF is a highly respected, nonpartisan source with powerful communication reach. I’m a subscriber to �������ýҕ�l Health News and appreciate the way your reporting draws in readers with accessible, engaging headlines — and that your articles are available for syndication to other outlets.

Two key points I found buried in an stood out:

• “Many childhood vaccines were tested originally in randomized clinical trials that included placebo or comparison groups. If the vaccine is for a disease that currently has no vaccine, the placebo may be saline or another substance known to be safe. If the vaccine is a potential replacement for an existing, older vaccine, the comparator group may receive the older vaccine that has already been tested rather than an inert placebo.”
• “When a safe, effective vaccine already exists against a disease, giving children in the placebo group no protection against that disease is unethical. Unvaccinated children can contract dangerous illnesses. Parents of children in the placebo group would not know they didn’t get the vaccine and that their child is unprotected.”

That brings up another important question: Who would volunteer for a randomized, double-blind, controlled trial involving an inert placebo for an existing vaccine? People hesitant about vaccines are unlikely to participate, for fear they will receive the vaccine. And those who support vaccination may be reluctant to risk receiving an inert placebo instead of testing the current, older proven version against a new proposed version.

— Alice Henneman, Lincoln, Nebraska

A virologist and podcaster chimed in on the June installment of our “Bill of the Month” series:

A post doctoral fellow at UTMB couldn’t afford the university’s insurance option for his family so he bought a separate plan. It cost him $1400 to get his child the measles vaccine. During an outbreak. Get your vaccines now, before they are not covered.

— Heather McSharry, PhD (@PathogenScribe)

— Heather McSharry, Austin, Texas

A Premium Shell Game?

I read Michelle Andrews’ article today, published in the San Francisco Chronicle (“Have Job-Based Health Coverage at 65? You May Still Want To Sign Up for Medicare,” June 18). Thanks for reporting on this important issue.

You describe as contributing factors: ignorance of the employee, the lack of any requirement that Medicare notify the employee, and the failure of the broker to notify.

Perhaps I missed it, but I believe there’s an important additional factor you didn’t mention: the profit of the commercial insurance carrier. In my experience, folks don’t notice that their primary insurance has changed to Medicare primarily because their employer is still deducting the premium for their commercial group health insurance.

Isn’t it fraud for the insurance carrier to collect premiums for a policy for which the subscriber is visibly no longer eligible by law?

There’s a financial incentive for the commercial carrier not to tell the subscriber that their coverage has ended, and they are now eligible for a Medicare Advantage supplemental policy (with a much lower premium) if they sign up for Medicare: The commercial carrier can collect high premiums, then decline to pay benefits.

You mention that Medicare representatives note they are not required to notify subscribers. Why? Coincidence? More likely, the commercial insurance companies actively lobby against notification.

Also, there’s a financial incentive for hospitals to perform procedures on patients who are 65 or older and still on a commercial plan. Pretty sure the hospital billing office knows quite well they will eventually be able to bill the patient the retail fee, which is typically 10 times as much (or more) than the Medicare-discounted fee.

In my experience, this is not a doctor issue, as the physician rarely pays any attention to insurance details. But it’s very much a billing office issue.

— John S. Smolowe, Menlo Park, California

A reader in Connecticut tweeted his opinion on the risks of cannabis for an aging population:

Normalized cannabis use now will yield a big public health problem later and all the data points in that direction…👇🏼“As Cannabis Users Age, Health Risks Appear To Grow” via

— Brandon M. Macsata 🎗️ (@Purple_Strategy)

— Brandon M. Macsata, New Haven, Connecticut

Getting Ahead of Known and Unknown Threats

As highlighted in your article “‘MAHA Report’ Calls for Fighting Chronic Disease, but Trump and Kennedy Have Yanked Funding” (July 2), proposals to eliminate the National Center for Chronic Disease Prevention and Health Promotion do not align with efforts to address our country’s chronic disease crisis. These plans also further underscore the importance of strengthening America’s public health infrastructure not only to save lives, but also to ensure taxpayer dollars are used wisely.

For each dollar invested in disease prevention, the estimates, $5.60 in downstream costs can be saved nationwide — and this figure is even higher in some states.

But just as cuts to chronic health research will hamper the federal government’s goals of preventing diabetes, heart disease, and obesity, so too do cuts to broader public health funding streams inhibit state and local health departments’ ability to stop outbreaks of measles, drug overdoses, or hepatitis, among many other preventable conditions.

Investments in public health have saved lives and strengthened our country. Identifying emerging threats quickly — whether they come from infectious diseases, zoonotic illnesses, accidents, or injuries — is vital to mitigating them. Unfortunately, federal cuts to vital public health funding streams and programs make it increasingly difficult for our nation’s leaders to understand the threats facing their communities and make the most informed decisions possible to help their communities.

Across the country, public health departments are scaling back staff and delaying plans to adopt better technology due to funding constraints; therefore, many departments lack the resources to detect and respond to threats in a timely manner. Rural and underserved communities that have fewer resources to sustain or replace federal investment are at greatest risk.

Without continued investment in public health infrastructure — from the federal government as well as state, territorial, local, and tribal governments — the impact of future health risks will be multiples higher on both the national health care system and the resources (including government investment) needed to address whatever may be coming next.

To truly improve public health, our leaders at every level of government should be doubling down on public health systems, both infrastructure and technology, as the foundation and path to keep America healthy.

— Eric Whitworth, CEO of InductiveHealth, Atlanta

The CEO of 4sight Health had this advice, posted on X:

Don't listen to what the regime says. Watch what it does. What this story calls "contradictions" and "inconsistencies" are lies and diversions from its anti-health agenda. The market must pick up the chronic disease prevention torch. 

— David Johnson (@4sighthealth_)

— David Johnson, Chicago

Preventive Physical Therapy Can Spare You From Injury — And Rehab

Thank you for recently highlighting the critical need for quality physical therapy (“How To Find the Right Medical Rehab Services,” July 15) and providing a comprehensive guide on navigating rehabilitation services after hospitalization. It is also important to note the preventive power physical therapy has before an acute injury strikes.

Physical and occupational therapy services are not just a form of post-accident care but are also proactive, non-pharmaceutical strategies to preserve strength, balance, and independence — especially for our aging population. And research shows that when physical therapy is the for certain conditions like lower back pain — rather than injections or surgery — Medicare Part A/B costs drop by 19% compared with patients choosing injections first and by 75% compared with surgery-first cases.

Moreover, physical therapist-led have been shown to reduce fall risk, while also cutting emergency room visits, hospitalizations, and opioid use among older adults. These numbers matter deeply in an aging America where 30 million older adults fall each year and the lifetime medical cost of treating falls is over . And yet, the Medicare system often prioritizes post‑injury treatment over preventive care, delaying access to essential physical therapy until after damage occurs.

In light of our nation’s need for more preventive care, it is time for our Congress to enable easier, earlier access to physical therapy. One way lawmakers can help is by supporting and passing the bipartisan Stopping Addiction and Falls for the Elderly, or SAFE, Act (). This commonsense legislation would allow Medicare beneficiaries to access no-cost falls risk assessments from the fall prevention experts: physical and occupational therapists.

Incorporating physical therapy into primary and preventive care has the potential to decrease hospital visits, lower health care spending, and preserve our seniors’ independence — goals we all share. It’s time to shift the policy spotlight upstream. Physical therapy has already proved it saves money and improves lives.

— Nikesh Patel, executive director of the Alliance for Physical Therapy Quality and Innovation (), Sugar Land, Texas

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

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ALBANY, Ga. — Belinda McLoyd has been thinking about peanut butter.

McLoyd, 64, receives a small monthly payment through the federal Supplemental Nutrition Assistance Program, previously known as food stamps.

“They don’t give you that much to work with,” she said. To fit her tight budget, she eats ramen noodles — high on sodium and low on nutrition — multiple times a week.

If she had more money, said McLoyd, who has been diagnosed with multiple sclerosis and heart problems, she’d buy more grapes, melons, chuck roast, ground turkey, cabbage, and turnip greens. That’s what she did when lawmakers nearly doubled her SNAP benefit during the pandemic.

But now that a GOP-led Congress has approved $186 billion in cuts to the food assistance program through 2034, McLoyd, who worked in retail until she retired in 2016, isn’t sure how she will be able to eat any healthy food if her benefits get reduced again.

McLoyd said her only hope for healthy eating might be to resort to peanut butter, which she heard “has everything” in it.

“I get whatever I can get,” said McLoyd, who uses a walker to get around her senior community in southwestern Georgia. “I try to eat healthy, but some things I can’t, because I don’t have enough money to take care of that.”

The second Trump administration has said that healthy eating is a priority. It released a “Make America Healthy Again” report citing poor diet as a cause of childhood illnesses and chronic diseases. And it’s allowing states — including Arkansas, Idaho, and Utah — to limit purchases of unhealthy food with federal SNAP benefits for the first time in the history of the century-old anti-hunger program.

President Donald Trump also signed a tax and spending law on July 4 that will shift costs to states and make it harder for people to qualify for SNAP by expanding existing work requirements. The bill cuts about 20% of SNAP’s budget, the deepest cut the program has faced. About 40 million people now receive SNAP payments, but 3 million of them will lose their nutrition assistance completely, and millions more will see their benefits reduced, according to an analysis of an earlier version of the bill by the nonpartisan Congressional Budget Office.

Researchers say SNAP cuts run counter to efforts to help people prevent chronic illness through healthy food.

“People are going to have to rely on cheaper food, which we know is more likely to be processed, less healthy,” said Kate Bauer, an associate professor of nutritional sciences at the University of Michigan School of Public Health.

“It’s, ‘Oh, we care about health — but for the rich people,’” she said.

About 47 million people lived in households with limited or uncertain access to food in 2023, . The agency’s research shows that people living in food-insecure households are hypertension, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

The Trump administration counters that the funding cuts would not harm people who receive benefits.

“This is total fearmongering,” said White House spokesperson Anna Kelly in an email. “The bill will ultimately strengthen SNAP for those who need it by implementing cost-sharing measures with states and commonsense work requirements.”

McLoyd and other residents in Georgia’s Dougherty County, where Albany is located, already face steep barriers to accessing healthy food, from tight budgets and high rates of poverty to a lack of grocery stores and transportation, said Tiffany Terrell, who founded A Better Way Grocers in 2017 to bring fresh food to people who can’t travel to a grocery store.

More than a third of residents receive SNAP benefits in the rural, majority-Black county that W.E.B. Du Bois described as “the heart of the Black Belt” and a place “of curiously mingled hope and pain,” where people struggled to get ahead in a land of former cotton plantations, in his 1903 book, “The Souls of Black Folk.”

Terrell said that a healthier diet could mitigate many of the illnesses she sees in her community. In 2017, she replaced school bus seats with shelves stocked with fruits, vegetables, meats, and eggs and drove her mobile grocery store around to senior communities, public housing developments, and rural areas.

But cuts to food assistance will devastate the region, setting back efforts to help residents boost their diet with fruits, vegetables, and other nutritious food and tackle chronic disease, she said.

Terrell saw how SNAP recipients like McLoyd ate healthier when food assistance rose during the pandemic. They got eggs, instead of ramen noodles, and fresh meat and produce, instead of canned sausages.

Starting in 2020, SNAP recipients received extra pandemic assistance, which corresponded to a 9% decrease in people saying there was sometimes or often not enough food to eat, according to the . Once those payments ended in 2023, more families had trouble purchasing enough food, according to a in October. Non-Hispanic Black families, in particular, saw an increase in anxiety, the study found.

“We know that even short periods of food insecurity for kids can really significantly harm their long-term health and cognitive development,” said Katie Bergh, a senior policy analyst on the food assistance team at the Center on Budget Policy and Priorities. Cuts to SNAP “will put a healthy diet even farther out of reach for these families.”

The Trump administration said it’s boosting healthy eating for low-income Americans through restrictions on what they can buy with SNAP benefits. It has begun approving state requests to limit the purchase of soda and candy with SNAP benefits.

“Thank you to the governors of Indiana, Arkansas, Idaho, Utah, Iowa, and Nebraska for their bold leadership and unwavering commitment to Make America Healthy Again,” said Health and Human Services Secretary Robert F. Kennedy Jr. in about the requests. “I call on every governor in the nation to submit a SNAP waiver to eliminate sugary drinks — taxpayer dollars should never bankroll products that fuel the chronic disease epidemic.”

Although states have asked for such restrictions in the past, previous administrations, including the first Trump administration, never approved them.

Research shows that are more effective than regulating what they can buy. Such limits increase stigma on families that receive benefits, are burdensome to retailers, and often difficult to implement, researchers say.

“People make incredibly tough choices to survive,” said Gina Plata-Nino, the deputy director of SNAP at the Food Research & Action Center, a nonprofit advocacy group, and a former senior policy adviser in the Biden administration.

“It’s not about soda and candy,” she said. “It’s about access.”

Terrell said she is unsure how people will survive if their food benefits are further trimmed.

“What are we thinking people are going to do?” said Terrell of A Better Way Grocers, who also opened a bustling community market last year that sells fresh juices, smoothies, and wellness shots in downtown Albany. “We’ll have people choosing between food and bills.”

That’s true for Stephen Harrison, 22, whose monthly SNAP benefit supports him, along with his parents and younger brother. During the pandemic, he used the extra assistance to buy strawberries and grapes, but now he comes into A Better Way Grocers to buy an orange when he can.

Harrison, who is studying culinary arts at Albany Technical College, said his family budgets carefully to afford meals like pork chops with cornbread and collard greens, but he said that, if his benefits are cut, the family will have to resort to cheaper foods.

“I’d buy hot dogs,” he said with a shrug.

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