On a weekday morning in a quiet Boston neighborhood, a kitchen bustled with activity. Volunteers sliced chicken breasts, stuffed bell peppers, filled trays, and carefully labeled each item. It was part of an experiment to offer nutritious and medically tailored meals to Medicaid patients who are unable to shop for groceries and cook for themselves.

“Once I started to eat these meals that were geared toward my illness, I built up my muscle mass again, built up my strength, built up my confidence in myself,” said Vanessa Georges, who is in remission from throat cancer and said she would struggle to consume enough calories without the deliveries. “These meals have given me a second chance.”

Georges said she noticed another benefit from the meals: She spends less time at the doctor’s office.

Researchers have found evidence backing her observation. About 1,900 Massachusetts residents who, like Georges, received medically tailored meals for at least three months needed less medical care, according to published in the journal Nature Medicine. They had 20% fewer emergency department visits and 31% fewer hospitalizations than similar patients who did not receive meals.

“It actually saves the healthcare system money,” said , a cardiologist and professor at Tufts University who led the study. “That’s a really big deal, because most things in healthcare don’t.”

The research from Massachusetts that medically tailored meals could save states money — in addition to improving health. Yet such programs could land on the chopping block as states look to tighten spending under Trump administration budget cuts, even as federal officials argue that food is a critical component of health.

Medicaid Budget Cuts Loom

The 2025 law known as the One Big Beautiful Bill Act slashed projected Medicaid funding by more than $900 billion. Many Republicans who backed the bill believe federal health spending is too high and riddled with fraud. Sen. John Kennedy, a Louisiana Republican, for example, has accused California of “outrageous fraud” for using Medicaid dollars to fund housing and nutrition programs.

, a policy analyst at KFF, said states will have to make tough choices in the next few years as they figure out how to fill funding gaps. “If states are not able to offset the loss of federal funds with new taxes or reductions in other state spending, they may have to make program cuts,” she said. (KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

Thirteen states have received federal waivers to use Medicaid dollars to pay for meals — part of an approach known as “food is medicine.” Three other programs are awaiting federal approval.

President Donald Trump’s support for social services has wavered. While the first Trump administration allowed states to pursue medically tailored meals and other social supports, the second Trump administration for Medicaid initiatives that address social needs. It hasn’t detailed a new policy. Administration officials have warned that they will be more focused on the budget impacts of such initiatives.

“They signaled they’re going to be a lot more skeptical,” said , an assistant professor at the University of Massachusetts Chan Medical School who studies nutrition programs and helped lead the Massachusetts study. “Instead of using a broad-based approach nationwide, they’re going to make decisions on a state-by-state basis.”

At the same time, health leaders in Trump’s administration have made nutrition a major focus, including by promoting . Robert F. Kennedy Jr., who leads the Department of Health and Human Services, and Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, have to serve healthier foods to boost patient outcomes.

The healthcare system is often willing to pay for surgeries, Oz said in a social media video in June, “but not always willing to pay for the nutrition that might help prevent those outcomes in the first place. That’s bothered me my whole career.” He added that the agency is , including medically tailored meals, to prevent illness and hospitalization. CMS officials did not respond to several emailed requests for comment for this article.

, who studies social determinants of health at Harvard Law School’s Center for Health Law and Policy Innovation, said the lack of federal guidance is stirring uncertainty for states that want to pursue nutrition programs in Medicaid. “We’re still waiting to see that big step forward around ‘food is medicine’ interventions,” she said. “We need to see that step forward to resolve some of the uncertainty.”

Lawmakers have had a hard time engaging administration officials on medically tailored meals, said U.S. Rep. Jim McGovern, a Massachusetts Democrat who sponsored a bill that would pilot meal deliveries for some . The legislation has yet to come up for a vote.

“I had thought, based on some of his rhetoric before he entered the Trump administration, that RFK Jr. would be a natural ally on this,” McGovern said. “But we can’t seem to get his attention.”

The Costs of Poor Nutrition

Some companies have been accused of for meals that were neither healthy nor nutritious, raising concerns about lax regulation of these programs.

But at in Boston, the food is prepared with specific attention to sugar, salt, fat, vitamins, and minerals and is based on a person’s health needs, said , chief executive of the nonprofit. Many recipients require food that is mild or low in fiber, for example.

“What we’re able to do is to work with your healthcare provider to understand your health realities — what your diagnoses are, what your medications are, side effects, food allergies, cultural norms — and then prescribe a diet for you that is scratch-made,” Waters said.

The Massachusetts researchers found that the meals — at a cost of $125 per person per week — essentially paid for themselves. Patients with heart disease used about $10,000 less in healthcare services over six months, and patients with kidney disease used $12,000 less in healthcare. There were also savings for people with diabetes, depression, and anxiety.

“Those are pretty big numbers when you think of how expensive those diseases can be and the prevalence in the population,” Waters said.

Nationally, , 10 million Americans would benefit from medically tailored meals, though only a small fraction are enrolled.

“Poor nutrition is the top cause of poor health in this country. It’s the top cause of preventable healthcare spending,” said Mozaffarian, director of the Food is Medicine Institute at Tufts. He has estimated that medically tailored meals could help patients avoid 1.6 million hospitalizations and in healthcare costs each year.

A Weekly Delivery That Makes a Difference

Steve Honyotski receives 10 meals at his Boston home each week, cooked fresh and delivered cold or flash-frozen. They’re ready to eat after just a couple of minutes in the microwave.

“The carrot ginger soup is my favorite,” Honyotski said.

Honyotski, 71, lives with several chronic conditions, including diabetes, obesity, and high blood pressure. He said he’s noticed improvements in his health since he started eating medically tailored meals. He needs less insulin to control his diabetes, and he’s lost enough weight to delay a knee replacement surgery.

For now, those meals will keep coming. And Massachusetts’ Medicaid director, Ryan Schwarz, said the state will seek federal approval to continue medically tailored meals in the coming years. “We feel very strongly committed to continuing these services,” he said.

In North Carolina, researchers found that food and housing supports lowered Medicaid spending over time. Yet even with federal approval for medically tailored meals, and evidence that the meals — along with housing and transportation support — were helping people, North Carolina state lawmakers suspended the services in 2025 over budget worries. After budget deliberations this summer, state legislators changed course and decided to the program.

“To me, that’s a signal of what might occur in other states as these Medicaid cuts hit,” said Hager, the UMass researcher. “Even though they have the authority to run these programs, it might be a lot harder for the states to actually implement them.”

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When Josh Fleig, Louisiana’s chief innovation officer, learned his state had set aside $20 million a year, for five years, to invest in startup rural health companies, his reaction was not surprising: “Wow!”

In rural America, where people are often reported to be sicker with poor access to healthcare, the cash influx is a relief. In the economic development space where Fleig operates, it’s an opportunity.

“Look, that’s a lot of money for what we do,” said Fleig, whose state-funded economic development office invests in corporate launches, ranging from software startups to shipbuilders.

Louisiana and a handful of other states set aside money from their share of the $50 billion federal Rural Health Transformation Program to quickly invest in new technologies, mirroring private industry moves. Lawmakers added the rural health program to offset more than $900 billion in reduced Medicaid spending expected over 10 years from Republicans’ sweeping 2025 tax and spending law.

But rather than filling the budget hole, the rural program’s assignment is to find new approaches for revitalizing rural communities where doctors are in short supply and hospitals have been downsizing and closing for decades. The federal government doled out the first-year rural health program awards to states this year, with pots ranging from $147 million in New Jersey to $281 million in Texas.

Modernizing technology infrastructure is a key pillar of the federal rural health program, and the catalyst money epitomizes the administration’s strategy to move fast and experiment with untested technology — much like the “move fast and break things” mantra during the heyday of Silicon Valley.

Instead of breaking things, though, the goal is to “move fast, fast-fail, innovate quickly, and move to sustainability,” said Aaron Bujnowski, a managing director with the healthcare industry group at the consultancy Alvarez & Marsal. “This is a transformation that is still meant to serve the people.”

Rigorous Rules and Tight Deadlines

Beyond Louisiana, Timothy Foster, a spokesperson for the Centers for Medicare & Medicaid Services, confirmed that Delaware, Georgia, Massachusetts, Nebraska, South Carolina, Virginia, and West Virginia are also creating rural health tech catalyst funds.

Every year, states must compete for rural funding in the five-year federal program. Federal regulators will take money away from states that do not meet the goals promised in their applications, including whether they designated money to companies for tech innovations.

CMS, which is overseeing the program, released a seven-step for states to follow when creating the tech catalyst operations. No more than 10% of each state’s award can be spent on a rural tech catalyst fund.

States’ initial annual progress reports for the rural fund were due at the end of August. CMS has declined to publicly post those reports; it plans to publish an annual report on state progress. States must show that first-year funds will be obligated — but not necessarily spent — by Oct. 30, according to the CMS guidance document.

Daniel X. O’Neil, a technology consultant who advocates for open data and open government, created a and parsed the original state applications to find dozens that mention catalyst awards and technology funds.

O’Neil said he is “looking forward to the clawbacks and the craziness of October because, you know, that’s serious stuff.”

For the rural health catalyst funds, CMS requires states to submit the list of finalists “at least 15 business days” before announcing winners, along with “sufficient information” for the agency to “assess each proposed project,” according to the guidance document.

The document outlines intellectual property and federal rights but does not provide guidance or standards for patient rights or protections. CMS spokesperson Foster stated in an email that the technology investments must comply with federal “privacy, security, interoperability, and patient safety” requirements.

Protecting Patients

Maya Sandalow, director of the health program at the Bipartisan Policy Center and one of the leading analysts watching the rural fund, said the catalyst funds are “public dollars” and has called for more transparency in the overall rural health program. The center is a nonprofit think tank in Washington, D.C.

Accurate and timely reporting must be done to ensure “the necessary guardrails are in place” to protect patients, she said, adding that the innovation needs to be “tested in a way that’s safe for the patients that they are going to be used on.”

To apply, startups must be less than 10 years old and have raised less than $50 million in early funding. Companies that win a portion of state catalyst funds must meet predetermined milestones before being paid — and federal officials will make “targeted reviews as needed,” according to the guidance document.

Louisiana officials announced the state’s tech catalyst fund with an event in rural Natchitoches, known as the filming location of the 1989 film Steel Magnolias. The fund quickly drew more than 200 companies competing for between $250,000 and $3 million in seed money.

Tiny startup Greens Health was invited to the event. The 2-year-old company analyzes Medicare claims to identify patients with chronic diseases, such as diabetes, and works with local home health nurses and senior facilities to improve care.

“We’ve been looking for a way to launch in Louisiana,” said Kehlin Swain, co-founder and chief executive of Greens Health. The company serves about 100 patients across Texas, Alabama, and Florida and hopes to get a $250,000 investment from Louisiana.

Louisiana’s Fleig said his state is “at a really interesting turning point.” The state secured $208.4 million for the first year of the rural health program and quickly created its catalyst fund using the state’s already established innovation department.

At the same time, nearly 1.1 million people live in Louisiana’s rural parishes and the state ranks as the “least healthy” in the nation, according to its own application. State rates of diabetes, obesity, and cardiovascular disease are among the highest in the nation.

Fleig believes Louisiana is an ideal place to test technology solutions. So, while Silicon Valley has “not needed much of what Louisiana has had to offer” for much of its existence, it does now, he said.

Caret Health is one of those companies. Co-founders Riya Pulicharam, who is a physician-researcher, and Kevin Zhao, an engineer, met in Silicon Valley. Together, they created a technology platform that identifies patients who need help getting to their appointments, having scans done, or picking up prescriptions. That technology flags a human, who then contacts the patient with a call or text.

Zhao said Caret had successful pilots at large health systems, but those places also had other vendors and “it was a pretty big uphill battle” to get in and scale. Then, in 2024, the company began paying attention to rural places.

“There wasn’t a lot of existing infrastructure. And that was really good for us because we were able to come in very quickly,” Zhao said. “A lot of the hospitals really needed this kind of service.”

Fast-forward to 2026: Caret Health is about 4 years old and has contracted with about 60 hospitals in 16 states. Pulicharam and Zhao hope to win $3 million to expand into Louisiana.

Louisiana’s Fleig said the state will take an equity stake in each company it invests in. “The dream” is that selected startup companies will also help the state make money to reinvest. If some companies fail — or fail fast — that’s to be expected, but the state should still make money because of “the law of averages,” he said.

“If we are good, we’ll make more money than we spent,” Fleig said. “Either way, it’s going to go back into improving healthcare outcomes.”

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If the state Office of Health Care Affordability adopts the fines next week, hospitals, medical groups, insurers, and others could face penalties that amount to as much as 125% of the total they spend above the state’s annual growth targets.

The penalty proposal comes after healthcare entities in California were asked to limit growth by 3.5% last year and ramp down to 3% by 2029. Seven hospitals that state officials consider particularly expensive face even smaller growth targets: 1.8% in 2026, dropping to 1.6% by 2029.

Consumer advocates argue that state financial deterrents are critical to bring relief to millions of Californians struggling with high insurance premiums and out-of-pocket expenses. Hospitals accounted for in U.S. health spending from 2022 to 2024, compared with 11% from retail prescription drugs. But adding teeth to those targets sets up a fight with the powerful hospital industry, which has a challenging the spending limits as unreasonable. Hospitals warned that they will cut back on vital services, including in emergency rooms, obstetrics, and behavioral health.

Healthcare industry representatives said the state affordability office hasn’t accounted for year-to-year volatility or other factors beyond the industry’s control, such as rising minimum wages, state earthquake retrofit requirements, and expensive new drugs.

“They’re building the plane while flying it,” said Ben Johnson, group vice president for financial policy at the California Hospital Association. “We know improvements in affordability are needed, but we have serious questions about how and about what the unintended consequences could be under OHCA’s rather stringent approaches.”

When calculating penalties, California regulators would consider various factors, including a healthcare entity’s financial situation, its market impact, and the gravity and number of offenses, according to a in June. And entities would first be given opportunities to implement performance improvement plans to bring their spending into line before penalties are imposed. For those that don’t comply, the board is considering penalties of $10,000 a day or a flat $500,000.

The penalties, which the affordability office’s eight-member board is required by to adopt, are slated for discussion, and a potential vote, at the board’s . The soonest healthcare providers would be subject to penalties is 2028, because it’s expected it will take two years to collect and publicly report spending data to measure against the 2026 targets. The state is still collecting data on how entities performed against the 2025 targets, which aren’t enforceable, according to Andrew DiLuccia, a spokesperson for the California Department of Health Care Access and Information.

States Set Targets

California is one of at least eight states that have set spending targets as part of an expanding effort to curb soaring healthcare spending across the nation. Connecticut, Massachusetts, Oregon, and Rhode Island have also authorized the use of some type of financial penalty. The specifics of each vary widely, although so far no state has applied them.

A by the California Health Care Foundation found that 4 out of 10 state residents said they had medical debt, and 6 in 10 reported that they or a family member had skipped or delayed medical care in the previous 12 months because of cost. Nationwide, about say it is difficult to afford healthcare costs.

After Rosalyn Book got stiches on her chin, the elementary school teacher received a $15,000 ER bill from a local hospital, despite having insurance. Many teachers in her district leave because they can’t afford the cost of healthcare and insurance premiums, she said.

“The healthcare charges are just insanity, and what we get as patients for the care, it’s not the best either,” said Book, president of the Monterey Bay Teachers Association. “If you’re a working, regular individual in terms of how much you make, the cost of living and especially the healthcare is just not doable.”

Meanwhile, hospitals are warning there’s a risk of more closures. According to Yale University’s , 17 hospitals have closed in the state since 2016, compared with only six openings.

Hospitals and other healthcare providers have said the proposed multimillion-dollar penalties are too steep and could destabilize their operations at a time when they’re facing funding challenges, including massive federal cuts to Medicaid, the end of enhanced federal subsidies for Affordable Care Act plans, and a sharp rise in uninsured patients. The One Big Beautiful Bill Act, passed by congressional Republicans and signed by President Donald Trump last summer, is expected to reduce federal Medicaid spending by more than — including by in California — and increase the rolls of the uninsured in the U.S. by over a decade.

Johnson said hospitals raise prices on commercial payers to offset the expense of treating uninsured patients, as well as patients on Medicaid and Medicare, which can reimburse care providers at rates that fall short of treatment costs.

In addition, said Anete Millers, vice president of legal and regulatory affairs at the California Association of Health Plans, tax increases on managed-care plans recently to offset federal Medicaid cuts will force plans to increase their prices for consumers.

“Some spending pressures originate outside of the control of health plans and are the result of public policy decisions rather than underlying changes in healthcare utilization or efficiency,” she told the affordability office’s .

Kristof Stremikis, the director of market analysis and insight at the nonprofit California Health Care Foundation, acknowledged that external forces can drive costs but said that plenty of unnecessary spending is within the healthcare system’s control, such as administrative waste and duplicative tests and procedures. of U.S. healthcare spending is considered wasteful, according to .

Elizabeth Mitchell, a former Office of Health Care Affordability board member whose term ended in May, agreed.

“Every business has external challenges,” said Mitchell, who is now president and CEO of Purchaser Business Group on Health, a nonprofit coalition representing large employers. “The hospital industry has not taken accountability to actually manage costs. I have heard those excuses for decades, and at some point, they have to make changes.”

First Step To Bring Down Costs

of five states with cost growth benchmarks, published in June, found that some have succeeded in modestly slowing healthcare spending, particularly those with enforcement mechanisms. However, spending growth in most states has still set. 

Jeremy Vandehey, a consultant with the Peterson-Milbank Program for Sustainable Health Care Costs, said setting benchmarks and collecting data to analyze which entities meet them is only a first step. Armed with information about what and who is driving up costs, states are more empowered to take additional action, such as imposing penalties or regulating prices, to bring down costs, he said.

“I don’t think anybody in any state is declaring victory on healthcare costs, but I wouldn’t say that that means the programs are a failure,” Vandehey said. “In all of these states, there’s much more robust conversations happening about, OK, we haven’t solved our cost crisis, so we need additional action.”

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“I’ve seen nurses get shoved, pushed, scratched. The biggest one is bitten,” said Dhooghe, who works at in Grand Blanc, Michigan.

The in healthcare has in states such as , , , , and , where Dhooghe and many of her co-workers have been on the picket line since Labor Day last year.

“People will question me and be like, ‘Why are you still working in a place if you’re treated like this?’” said Dhooghe, who gets by on strike benefits and working extra shifts at another hospital. The problem, she said, is that other hospitals aren’t any better. “It’s the same everywhere I go.”

In a statement, spokesperson Dana Jay acknowledged violence against healthcare workers is a “national epidemic” and said the health system’s efforts to address the problem include metal detectors, armed security officers trained to make “misdemeanor arrests,” and de-escalation training.

“We have zero tolerance for violence of any kind,” said Jay, asserting the strike is not about safety but is instead “simply an economic strike.”

Nationwide, hospital workers are seven times as likely to be injured on the job due to violent acts as members of the general working population, according to the available from the Bureau of Labor Statistics. The outcry over workplace violence in healthcare is pitting workers’ demands for better compensation and staffing against hospital operators pressured to cut costs.

‘A Powder Keg’

Violent outbursts are so common that they’ve been dramatized on the popular medical TV series . “Emergency rooms right now are like a powder keg,” said Rachel Odes, an assistant professor at the University of Wisconsin-Madison School of Nursing.

In hospitals, a combative or violent patient is known as a “.” Outbursts can be spontaneous and unpredictable, making some almost impossible to prevent. But research shows the increases when hospitals are understaffed or employees are insufficiently trained or experienced.

Mental health worker Andrew Kimball-Mirzaie said he got hurt in February 2024 at Butler Hospital in Providence, Rhode Island.

He’d been working at the private psychiatric hospital for about six weeks and said he hadn’t yet worked in the ER. He said he was sent there to “monitor” a man in his 20s who was waiting for an inpatient bed.

The patient was alone in a back room watching a Knicks basketball game on TV, he recalled. Kimball-Mirzaie said he got the patient a drink and a snack. They were watching the game when, suddenly, he said, the patient stood up and punched him in the face. He said the assault left him with a concussion and broken nose. His injuries were documented in the hospital’s.

“I understand that there is an inherent danger with the job,” Kimball-Mirzaie said. He doesn’t blame the patient, who was very ill at the time. “We should have had at least another staff member with us,” he said, “and I should have been adequately trained on the unit.”

The attack emboldened Kimball-Mirzaie to join some 700 other unionized Butler workers last spring and summer in a months-long strike, which forced the hospital to close . Service Employees International Union 1199 New England declared the strike a win.

Employees received wage increases that union leaders said would enable the hospital to attract and retain more staff. The hospital also agreed to provide financial support for workers violently injured on the job. And the hospital and union agreed to jointly fund a “time bank” to supplement workers’ compensation for injured workers who need more time to recover.

But five months later, a nurse supervisor at Butler had to call 911 because an unarmed patient in the hospital’s ER was assaulting staff. According to the police report, by the time police arrested the patient, he’d injured two nurses, a security guard, and a police officer.

“Butler recognizes the importance of being proactive in protecting those who provide care,” Mary Marran, Butler’s president and chief operating officer, said in a statement. She added that hospital leadership meets regularly with staff to review safety measures and “identify opportunities to strengthen protection for everyone.”

The patient was charged with four counts of , including against the two nurses.

The American Hospital Association has said punishment is key to preventing violence. It has been to make assaulting healthcare workers a that would carry in prison. At least , including and , have enacted similar laws. But workplace safety experts say there is no evidence that such laws have reduced the incidence of violence against healthcare workers.

Calls for ‘Safe Staffing’

Striking healthcare workers around the country often have demanded “safe staffing” instead of stronger punishments for patients who cause injuries.

The against healthcare workers has caught the attention of the , the accreditation organization for more than 80% of U.S. hospitals and health systems. The commission released national performance goals that and require hospitals to be and that staff be trained “to provide safe, quality care.”

But no federal law limits the number of patients in a nurse’s care across healthcare settings, despite the nation’s largest nurses union, National Nurses United, having pressed for a national standard . Hospitals must “safely staff all units” to enable nurses to “provide the care that patients need before they get agitated or disoriented,” said , lead industrial hygienist for .

Some states have passed their own staffing laws. Only has enacted broad mandatory nurse staffing ratios, which were associated with lower mortality rates and likely higher retention. Oregon enacted a staffing law, . Legislators in and have introduced similar bills, but they have failed to advance to floor votes.

The American Hospital Association opposes mandatory minimum nurse staffing ratios in hospitals, saying they would “remove real-time clinical judgment and flexibility,” , and potentially force some hospitals to turn away patients or delay care, spokesperson Colleen Kincaid said. And she pointed to California, whose for psychiatric hospitals reportedly in at least four counties.

“There are a lot of other things you can do to prevent workplace violence than just increasing staffing levels,” said , who was a deputy assistant secretary of labor for the Occupational Safety and Health Administration during the Obama administration and helped develop OSHA’s for healthcare and social service workers.

Barab said hospitals can, for example, train employees in de-escalation, install metal detectors, or have specially trained security guards on-site so staff don’t have to wait for police to arrive when an incident happens.

, a worker safety and health policy expert at Georgetown University, said the in congressional Republicans’ One Big Beautiful Bill Act will in the next few years.

When funding dries up, she said, “protecting workers is going to be the first thing that gets cut.”

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Carter’s specialty is reeling in grants to support students in the Omaha Nation school district, where she is a finance manager. One paid for the garden that sits next to the district’s campus. Another allowed the school system, in one of Nebraska’s lowest-income counties, to pay students to maintain it.

“They’re out in the sun. They’re watering plants,” she said. “It’s the first time they get a paycheck in their life.”

Carter, 41, is paralyzed from the chest down, an injury she’s lived with since a fall in her early 20s. It didn’t slow her down as she built her accounting career and got a master’s degree in human resource management.

But in November 2023, Carter — who lives in Sioux City, Iowa — got a letter from Iowa’s Department of Health and Human Services. It said that her income was too high for her to stay on Medicaid and that she might lose her benefits in two weeks if she didn’t take action.

States are scrambling to get ready for a new federal requirement to double-check that many people on Medicaid qualify for the benefit, by showing they are working, volunteering, or studying at least 80 hours per month. Politicians’ focus on requiring work has angered many people with disabilities who have Medicaid and say current policies that apply to them have the opposite effect — making them choose between working or receiving benefits.

‘I Have No Options’

When Carter got the letter, she was making $110,000 a year, well above Iowa’s 2023 income limit for working people with disabilities: $36,450 for a household of one.

“I had no time at all to prepare,” she said. “I had a decision to make.”

At the time, Carter got her health coverage through Iowa’s , a buy-in program that allows working disabled Iowans to pay part of their income to the state to maintain access to Medicaid benefits. Forty-seven states offer , but eligibility through limits on income and assets.

For years, disability rights advocates have pushed state legislatures to change the limits, arguing they prevent people like Carter from accepting raises or building savings, for fear of losing crucial medical benefits. Massachusetts, Minnesota, New Jersey, and Rhode Island have eliminated such limits over the past five years.

To keep her Medicaid coverage, Carter would’ve had to find a job paying her far less than she was making. Or she could drop her Medicaid coverage and enroll in the school district’s health plan. But that plan didn’t cover many of the disability-related expenses that Medicaid did.

Carter decided to keep her job and leave the Medicaid buy-in program. In the end, the decision felt like a no-brainer, she said.

“I like getting up and going to work every day, and I really like what I do,” she said. “Why would I throw that away?”

But it’s been hard on her finances. Carter said she now spends about $35,000 a year out-of-pocket for expenses her old plan covered, such as the nurse who visits her three times a week, modifications to her car, and wheelchair repairs.

“I had the motors go out on my wheelchair,” she said. “So that was like $4,000 to fix.”

Over the next year, Carter picked up extra jobs and cashed in some of her retirement savings.

“I want to pay my own way. I don’t mind paying taxes,” she said. She doesn’t want to hide her income, either. “I just want an option,” she said. “I have no options right now.”

A Program Intended To Encourage Work

Congress to create Medicaid buy-in programs in the 1990s, intending to incentivize more people with disabilities to work. Iowa was one of the first states to adopt the program.

According to state data, 11,640 Iowans were participating in the buy-in program as of late January, or 1.7% of all Medicaid recipients in Iowa.

The income caps have inched up since Carter got her letter. , set at 250% of the federal poverty level, is $39,900 for a household of one this year.

The rules also restrict recipients from accumulating too much in assets. The is $12,000 for an individual or $24,000 for a married couple, excluding some assets, such as a primary home or vehicle.

Carlyn Crowe, the public policy manager at the , said the limits can prevent disabled Iowans from reaching their goals. “Work full-time and be able to buy a house, live in the community, buy a car,” she said. “Those limits placed on what they can earn and save are keeping them from doing that.”

Crowe’s organization, which has counterparts in every state, is and advocates for people with disabilities. In Iowa, such advocates have asked legislators to drop the hard limits on income and assets. Instead, they suggest that disabled Iowans pay 6% of their income to buy into the Medicaid program, an approach modeled after a 2024 that created a Medicaid buy-in program with no income and asset limits. (Tennessee is waiting on federal approval before starting its program.)

In recent years, these efforts have built bipartisan support and gained traction. An Iowa House committee unanimously in 2025 to remove the income and asset caps, but the bill died after failing to move forward during this spring’s legislative session.

State legislatures now in Medicaid spending estimated at more than $900 billion over 10 years, as part of the One Big Beautiful Bill Act.

, an associate director of KFF’s Program on Medicaid and the Uninsured, said the specific worry is that buy-in programs, though they’re a small part of the larger Medicaid system, could increase overall Medicaid spending if eligibility changes.

“The premiums charged in buy-in programs are nowhere near close to the expected costs of covering people,” Burns said. (KFF is a health policy research, polling, and news organization that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

Focusing on initial cost increases is myopic, said , the director of disability policy at at Iowa’s Drake University. More workers mean additional income tax revenue for states. It also enables some people with disabilities to earn enough to transition off other government assistance programs, such as the Supplemental Nutrition Assistance Program.

“Three, five, seven years from now, you may be recouping those expenses by having people be able to work their way off,” Van Sant said.

Falling Through the Cracks

Iowa lawmakers tried a more modest adjustment during this year’s legislative session. Instead of removing the income limit entirely, they introduced legislation that would raise the cap to 300% of the federal poverty level and exempt pension accounts and a spouse’s income, among other things, from the asset cap.

In the end, the provision was stripped from a wide-ranging public assistance bill. If it had passed, the new income limit would have been one of the for a buy-in program, according to KFF.

, a former City Council member in Sioux City who was paralyzed from the chest down after a diving accident, told state lawmakers during a hearing in February that the proposal was a step in the right direction, but not enough.

“I fear that we’re going to lose people to other states,” said Watters, who added that he was considering moving to Minnesota, which never had an income cap and eliminated asset caps for its in 2024.

Even if Iowa had raised its income limit, Carter would still have been ineligible.

Carter remains committed to her primary job at the school district. She plans to keep working there and taking on additional jobs, seven days a week, so she can pay for her medical needs and continue helping students.

This article is from a partnership that includes , , and .

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If he wanted to learn more about an outbreak of measles or hantavirus, he would pore over the weekly CDC report that came by email. If a patient’s family was traveling to Africa or Asia, he would check the latest CDC vaccine recommendations for overseas travel. And if a family was worried about potential side effects from a shot, he could always send them to the CDC’s website to bolster his argument to get the immunization.

Public trust in the CDC has in the road , but for medical professionals, Snyder said, “the CDC used to be, worldwide, the most trusted source of information pertaining to public health and infectious disease.”

Yet even doctors began losing trust, Snyder said, after Donald Trump was elected president again. Trump quickly tapped longtime anti-vaccine activist Robert F. Kennedy Jr. as his nominee to lead the Department of Health and Human Services, which oversees the CDC.

Within months of his confirmation as secretary, Kennedy had of the CDC’s vaccine advisory board and replaced them with , some of them prominent vaccine skeptics.

“It turned into a completely unreputable source of information,” Snyder said.

This rupture of scientific trust in the CDC has put many pediatricians like Snyder in a bind, as they no longer turn to the country’s preeminent public health agency and instead search for ways to fill the information gap. Some doctors are launching their own vaccine education efforts, sometimes in collaboration with local public health departments.

On Jan. 5, the CDC from the recommended for all children — against the advice of major medical groups like the . The as the agency dropped rotavirus, covid-19, influenza, hepatitis A, hepatitis B, and meningococcal disease from the list. The agency did not respond to a request for comment for this article.

In March, after , a federal judge to revert to the previous guidelines. The administration the judge’s decision.

The back-and-forth “creates a whole bunch of confusion in the public,” Snyder said. “And it’s very confusing even for healthcare providers.”

So he’s trying to be clear to patients about what the evidence shows, even if that means going against the federal government. His practice, Amherst Pediatrics, to say: “The CDC is no longer considered to be a reliable or legitimate source of information.”

“It’s shocking that we have to say that,” Snyder said. Instead, the site directs families to get information from their own doctor, the state of Massachusetts, or nongovernmental medical organizations including the AAP.

In the exam room, Snyder is having more tense conversations with families. He said some parents are explicit that they want to hew to what the CDC recommends. “Even if they don’t say that, we have definitely seen increasing hesitancy and questions,” he said. “All of that interferes with us protecting children.”

On a spring afternoon, several of Snyder’s young patients came into Amherst Pediatrics for routine visits.

“Let’s talk about vaccines,” Snyder said to one mother, Tenzin Dekey, who was there with her 1-year-old. Snyder explained that her son was due for the , which protects against measles, mumps, and rubella, in addition to the chickenpox, hepatitis A, and flu vaccines.

“So that’s four shots, two in each leg,” he said, as he handed Dekey CDC information sheets about the vaccines. She glanced at them and agreed to the shots.

Ironically, the information sheets are stamped with the CDC’s logo — — even though Amherst Pediatrics has explicitly directed patients away from the CDC. Snyder said he hates that disconnect.

“This has been a source of heated discussion,” he said. “How can we be saying, ‘Do not trust the CDC when it comes to vaccines,’ yet here is the information we’re giving our own patients when they’re in the office about vaccines?”

Another mother brought her 14-year-old son for his annual physical. She asked to be identified by only her first name, Melissa, so she could freely discuss her family’s private health issues.

Snyder recommended the , which helps . Although Melissa had refused the HPV vaccine in a previous visit, this time she left the decision up to her son. He agreed to it. But for other vaccines, she wouldn’t budge.

“I’m a hard ‘no’ on the covid,” she told Snyder.

“We could talk about that if you want,” he suggested.

“I don’t need to talk about it,” she replied.

After the appointment, Melissa said she just doesn’t know whom to trust anymore when it comes to vaccine safety. She used to get information from the CDC but no longer does.

“I worry that it’s been politicized a lot, and I don’t like politics,” she said. “Now I prefer to hear things from people, healthcare professionals.”

Such distrust and confusion inspired Snyder to join an independent vaccine information campaign, along with other pediatric practices and health departments in the Connecticut River Valley of Western Massachusetts.

The campaign’s website, which is promoted in Snyder’s waiting room, is called . It sidesteps the CDC and highlights advice from local doctors and national medical groups, . Valley Vax bought ads on the sides of buses in Western Massachusetts to promote the site, with the faces and testimonials of local doctors including Snyder.

“We wanted something that felt familiar and appealing and that they might be more likely to trust,” said , director of Amherst’s public health department, who coordinates the Valley Vax effort.

She said the organizers decided not to criticize the CDC outright.

“Some information from the CDC is reasonable. Like they are doing a good job of tracking influenza-like illness rates in the country,” Malin said. “It’s important not to discount an organization completely.”

Still, she said it’s the first time she’s had to contradict health information from the CDC. “That’s not a comfortable place to be in at all,” she said.

Other health leaders are also banding together to get out evidence-based information. At the state level, California, ±á²¹·É²¹¾±â€˜i, Oregon, and Washington — frustrated with the CDC — operate the to “ensure the public has access to credible information.” And governors of 14 states and Guam set up the in response to declining trust in federal health agencies.

Locally, some public health departments are partnering with community leaders to reach people who have stopped listening to government institutions but “do have strong connections within their faith community or do have strong connections within their neighborhood,” said , a spokesperson for the .

Like Amherst, many local health departments now direct people to professional medical organizations instead of the CDC, Casalotti said, because advice from those groups may change slightly as the science evolves, but it’s unlikely to change with each lawsuit against the government.

This article is from a partnership that includes , , and Ñî¹óåú´«Ã½Ò•îl Health News.

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The Consumer Product Safety Commission, responsible for tracking and issuing recalls of dangerous products sold in the U.S., began discreetly pressuring hospital executives this year to share personally identifiable health data with a private contractor. But hospital lawyers and other industry experts have questioned the agency’s authority to collect, its ability to safeguard such a swath of sensitive information, and whether it has followed the legal process to overhaul its surveillance system.

After Ñî¹óåú´«Ã½Ò•îl Health News asked the CPSC about the new system, the the program on July 21. Left unmentioned, however, is the alarm it has raised among hospital executives, as well as the nature and extent of the agency’s data demands.

In a stark departure from its product-focused mission, the agency’s goal is to obtain millions of Americans’ medical records from emergency room visits for most injuries, from a broken bone to a childhood vaccine reaction or even a suicide attempt, according to documents and emails obtained by Ñî¹óåú´«Ã½Ò•îl Health News, as well as interviews with five people involved or familiar with the discussions.

A CPSC official also insisted in the emails that the institutions provide all ER patients’ identifiable information — such as names, addresses, diagnoses, and other personal details — to the contractor, Konza Health, for analysis. In correspondence with , Konza representatives described participation as “mandatory” or “required.”

As a condition of viewing the correspondence, Ñî¹óåú´«Ã½Ò•îl Health News agreed not to republish some of the emails it obtained.

The CPSC wants at least 100 hospitals to start sending detailed medical records by the end of this year, according to an .

“The whole thing is troubling,” said Sharona Hoffman, a professor of health law at Case Western Reserve University who noted that giving a private entity access to a sweeping collection of data will introduce risks to patient privacy. “If this company really is collecting identifiable information, that is worrisome for patients.”

The new project was launched amid upheaval at the traditionally independent agency, which is without a governing board since President Donald Trump fired the CPSC’s three Democratic board members. Nearly 1 in 5 career staffers left the CPSC in the first 16 months of the new administration, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of federal workforce data.

The initiative also comes as the Trump administration has sought unprecedented access to millions of Americans’ medical records, with the Office of Personnel Management requesting federal workers’ sensitive health information and Health and Human Services Secretary Robert F. Kennedy Jr. using a private organization to collect more medical records for his studies on vaccines and autism.

Steve Roney, CPSC spokesperson, said in an emailed statement on July 10 that the CPSC is “modernizing” its surveillance system. Asked whether the CPSC will file complaints against hospitals that do not participate, he said only that while the previous system “operated as a voluntary program, the ability of hospitals to opt out limited the sample size and usefulness of the data.”

Roney also acknowledged that the agency had not yet notified the public, as “required by law.”

Federal law requires the agency to provide notice and a public comment period before requesting information from 10 or more entities, a step it has not taken despite plans for 100 hospitals to join the surveillance system. Ñî¹óåú´«Ã½Ò•îl Health News independently confirmed with over a dozen hospitals that they had been approached.

Federal public health authorities that private health data be reported. But CPSC officials have that if hospitals decline to share data with the new surveillance system, they could be subject to strict penalties from a data-sharing regulation known as “information blocking.”

Yet some hospital executives say they are reluctant to share patients’ sensitive data because they’re concerned about a different violation — that of .

AI Takes Over

Dozens of ERs across the country already participate in the CPSC’s voluntary National Electronic Injury Surveillance System, or NEISS, through which trained hospital workers report injuries involving consumer products, almost always stripped of patients’ identifiable information. The system helps the CPSC identify products, such as baby loungers, toys, and household appliances, with a pattern of injuring consumers.

The new injury surveillance program goes much further.

At a toy industry trade event in February, acting CPSC Chairman Peter Feldman said the agency is “investing in AI-enabled workflows that improve the quality and quantity of injury surveillance data, while also building up digital infrastructure to handle a massive new volume of electronic health records.”

Konza Health, a Kansas-based organization that runs the state’s health data exchange, will automatically pull and analyze medical records of all patient visits from ERs nationwide. Konza won a worth up to $15.9 million with the CPSC last fall.

In email correspondence with hospital technology officials, Konza Health President and CEO Laura McCrary also has described ERs’ participation as “required,” stipulating that they share patients’ records with identifying information.

McCrary told Ñî¹óåú´«Ã½Ò•îl Health News by email that the company is not using AI to process the records it receives, saying instead that Konza will use “advanced analytic parsing and filtering capabilities.” Roney, the CPSC spokesperson, did not answer questions about the .

For years, agency officials moving away from human contractors and automating NEISS to save time and money.

But without workers on-site, hospital staffers may no longer receive training to determine what clinical information is important to include for the CPSC. In short, the changes could dilute the quality of the product safety data the agency collects.

“They want to suck in as much data as possible, but I’m not sure how thoughtful they’re being about what is collected and what is actually needed by the agency,” said former CPSC chair Alexander Hoehn-Saric, one of the Democratic appointees Trump fired last year.

Record Number of Career Staff Left CPSC Last Year

The Consumer Product Safety Commission overhauled its National Electronic Injury Surveillance System on the heels of its largest exodus of career employees in at least a decade.

Source: <a href=” of Personnel Management</a>

Wanted: Injuries From Vaccines and Stingrays

The CPSC’s new data collection appears to contradict its own 214-page , which instructs hospitals not to include identifiable information “such as names, birthdates, or addresses” when reporting cases.

The agency is supposed to receive patients’ identifying information only when needed for follow-up investigations, which happens in fewer than 1% of reported cases, according to the manual.

The CPSC has also historically limited the records it collects to minimize privacy violations in case of a data breach.

The risk is not hypothetical: From 2017 to 2019, the agency improperly released personal health information of around 30,000 people, a disclosure that a top Republican at the time

Konza, however, will receive even more sensitive information on many more people. McCrary said in a statement that Konza will remove patients’ names, addresses, and medical information “not needed by CPSC” before sharing records with the agency.

Leaving a private organization to collect sensitive information introduces risks, including that it could be stolen or used for business purposes, said Hoffman, the Case Western professor.

“Very often, they will use information for marketing because now they’re going to know what conditions people have,” she said.

Roney said that its contract with Konza, which has not been made public, prohibits the organization from selling or marketing the data it collects.

The CPSC’s manual also identifies types of ER visits that should not be reported to the CPSC, which has jurisdiction over only certain consumer products. Excluded injuries are those caused by food, illegal drugs, medical devices, alcohol, or plants, as well as injuries that did not involve consumer products — such as a cut from a rock or broken bones from a fall on the ground — and suicide attempts by adults.

But in a to one hospital and reviewed by Ñî¹óåú´«Ã½Ò•îl Health News, Konza set no such limits on the information it would gather from ER records and said it would hold on to patient health information for at least 30 days.

In an email sent to hospital technology officials, McCrary wrote that Konza would provide the CPSC with records when a patient is treated in the ER for any of more than 10,000 conditions. The expansive list of diagnostic codes Konza provided in the email includes injuries that do not involve consumer products.

Child injuries resulting from “poisoning by” vaccines or contact with stingrays, neither of which is regulated by the CPSC, are included in the list.

A limited number of hospitals once shared deidentified data on all injuries — regardless of product involvement — through the NEISS using the Centers for Disease Control and Prevention’s injury-tracking program. But the CDC halted that data collection, after funding and staffing were cut last year, and has not restarted it.

Pressure on Hospitals

CPSC Chief Data Officer Elizabeth Puchek, who joined the agency late last year after engineering U.S. Citizenship and Immigration Services’ data system, has told hospitals in emails that they must seek an exemption from the program if they decline to share patients’ emergency room records with Konza.

The CPSC’s targeted outreach has included some of the nation’s largest urban and rural health systems, as well as small, publicly owned hospitals.

Staff members at Mary Greeley Medical Center in Ames, Iowa, said that Konza and federal officials told them their participation in the new program was mandatory. The hospital, which has long participated in NEISS, signed a new contract in April to share its ER records with Konza.

Yet the hospital is reevaluating its participation after being notified that the funds it received to participate in NEISS were “no longer available,” spokesperson Steve Sullivan said.

Several hospital executives, lawyers, and others have raised doubts about the CPSC’s claimed authority.

Harborview Medical Center spokesperson Susan Gregg said the Seattle hospital’s emergency room has “voluntarily submitted de-identified data for many years, but we are not obligated to report this information.”

In Boston, Mass General Brigham has declined to participate in the new program, with spokesperson Kelly Mitchell saying that “to protect patient privacy, we are unable to provide these medical records.”

Henry Ford Health in Detroit; St. Luke’s in Boise, Idaho; and Sanford Health based in Sioux Falls, South Dakota — which together handle over a million ER visits a year — are among the health systems that have been approached but not yet entered into an agreement with Konza, according to representatives. Several of the nation’s busiest hospital systems targeted for the program — including the Mayo Clinic in Minnesota, Yale New Haven Hospital in Connecticut, Nationwide Children’s Hospital and the Cleveland Clinic in Ohio, and Baylor Scott & White Health in Texas — declined to answer questions about whether they’re participating.

Hoehn-Saric, the agency’s former chairman, said he was surprised that the CPSC would insist that hospitals provide identifiable records from all emergency room visits.

“This idea that they can simply demand patient information from a hospital and that the hospital would provide it — I really don’t understand the basis for that,” he said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Source: <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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Ñî¹óåú´«Ã½Ò•îl Health News will update this database as more states respond to emails and public records requests for their documents.

Note: Data collected as of Sept. 11, 2026. Ñî¹óåú´«Ã½Ò•îl Health News reporters searched state websites, requested documents, and filed public records requests. Ñî¹óåú´«Ã½Ò•îl Health News continues to collect documents.

Sources: Documents publicly posted online or released in response to Ñî¹óåú´«Ã½Ò•îl Health News requests; <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Homes that once belonged to friends, family, and neighbors had siding covered in mold. Some were boarded up. Others had holes in their roofs.

Black churches once used Oquina Creek, which runs along the border of the neighborhood, to baptize their congregants. Today, fecal bacteria and other contaminants have made the water unsafe due to an aging wastewater system.

“Sometimes you get the feeling like you’re in a Third World country,” Williams said. After three decades in Washington, D.C., he returned four years ago with a mission to revitalize communities such as Dewey City, which he said are “part of what makes Thomasville, Thomasville.”

A $19.8 million Community Change Grant from the Environmental Protection Agency was supposed to shift the tides of the neighborhood Williams grew up in.

The city and the , where Williams formerly served as community development director, applied for the grant in 2024. It was part of a $2 billion effort to help disadvantaged communities address environmental health risks and create clean energy and climate resiliency projects.

But three months after winning the grant, Thomasville became one of across the country — from to to — to see the funding stripped as priorities shifted in Donald Trump’s second presidency.

On the first day of his second term, Trump signed an executive order titled “.” It stated that the Biden administration “forced illegal and immoral discrimination” through diversity, equity, and inclusion programs.

In an emailed statement, EPA spokesperson Mike Bastasch said the administration is “fully committed to being a great steward of taxpayer dollars.” He added that the “radical agenda” of DEI and environmental justice “preferencing” are not within the agency’s core mission of protecting human health and the environment.

Environmental health advocates argue, though, that the decision to cut the grants was not rooted in science. They say that equating environmental justice to DEI is an act of bad faith and that withholding the money forces disenfranchised communities to delay long-overdue updates needed to protect public health for marginalized populations.

“I unfortunately believe we’re going to see a reversal in the health profile of this country,” said , an associate professor at the University of Michigan who served in the Biden administration as the first federal chief environmental justice officer.

“This current federal regime has decided that humanity and public health and justice don’t mean anything,” she said.

‘Why Us?’

Thomasville, near Georgia’s southwestern border, is home to just over 18,600 people.

The city had hoped to improve health outcomes in neighborhoods on its southern and western sides where, according to the grant proposal, “historical redlining created a legacy of disinvestment.”

Those areas have a deep history: Dewey City, for example, was the first neighborhood in the city where Blacks could build homes after the Civil War. It’s also home to the closed Douglass High School — the first public school for Blacks in Thomasville, established in 1902.

“This place has been neglected,” said Williams, who occasionally hosts historical walks through the community. “But it’s worth bringing it back online.”

The proposed “Restoring Resiliency” project featured a plan to remove toxic substances such as mold, lead paint, and asbestos from homes, repair a nearly 82-year-old wastewater system, and convert part of a shuttered high school band room into a health clinic.

“This was a long and storied attempt to bend the arc of justice closer,” said Jeremy Rich, a Thomas County commissioner and the pastor at First Missionary Baptist Church. “Justice in healthcare. Justice in environmental impact.”

Having a clinic in the community would be a “game changer,” Rich said. During the covid pandemic, he said, older residents who rely on public transit were reluctant to go to the nearby hospital or the county health department to get vaccinated. When his church offered shots from Black nurses, he said, vaccination rates improved.

Many residents don’t have the financial means to remove mold, lead paint, and other toxic materials, said Thomasville Mayor Pro Tem Lucinda Brown. “They just have money to live with every day. That’s it,” she said. “If they can make that happen.”

The grant meant hope, and its reversal left many asking, “Why us?” Williams said.

In the EPA’s May 2025 letter announcing the grant termination, it said Thomasville’s project promoted “initiatives that conflict with the Agency’s policy of prioritizing merit, fairness, and excellence.” The grant was “inconsistent with, and no longer effectuates, Agency priorities,” the letter said.

Environmental justice projects are rooted in science, not DEI, said Jillian Blanchard, the senior vice president of climate change and environmental justice at , a national nonprofit that provides pro bono legal assistance in focus areas such as health equity, immigration, and environmental health.

“Where is the water dirty? Where is the air unclean?” she said. “That is where the money should go.”

In June of last year, nearly two dozen communities and organizations around the country filed a to get the Community Change Grants reinstated. The lawsuit argued that the projects — such as efforts to create energy-efficient housing in Kalamazoo, Michigan, and empower Houston residents in the pollution permitting process — were vital.

The case was dismissed by a federal district judge in 2025 but is being appealed.

Thomasville was not named in that lawsuit. But the city did appeal the EPA’s decision on its project with the support of Blanchard’s group. The city and the EPA continue to dispute the issue.

This March, the EPA’s deputy inspector general, which serves as an independent watchdog for the agency, concluding that the process for determining the awardees was fair.

Such federal funding is needed because large-scale change is difficult for small municipalities to achieve without getting stuck with high-interest loans, Blanchard said.

“It’s next to impossible,” she said. “That’s one of the reasons the things haven’t been done.”

‘It’s Not Over’

The city of Thomasville has found other ways to make some improvements in the meantime. With the help of a nearly $3 million federal Community Development Block Grant from the Department of Housing and Urban Development, it made repairs to portions of Dewey City’s sewer, water, and drainage systems.

The Thomasville Community Development Corp. has begun building affordable housing in Dewey City and intends to convert a portion of the closed Douglass school into apartments for seniors.

The corporation has also applied for $764,000 in through the office of Sen. Jon Ossoff (D-Ga.) that it hopes to use to construct a community health clinic in Dewey City. Decisions on these funding requests will be made this fall.

“It’s not over,” said Williams, whose legacy in Thomasville runs deep. At the center of what locals call The Bottom — a two-block stretch of downtown where independent Black and other minority-owned businesses once thrived — is a plaque honoring his father, Earl Williams Jr., the city’s first Black mayor.

As he peered at his father’s memorial on a muggy afternoon, he reaffirmed his intentions.

“There’s more work to be done, and I’m able,” he said. “I like pouring into the community.”

But he has little hope the initial grant will be restored under the current administration.

“That was our shot. We didn’t do anything to miss it,” he said. “We just did it during the wrong period of time.”

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In February, ±á²¹·É²¹¾±â€˜i’s parole board granted the now-52-year-old compassionate release, which allows prisoners to receive early probation to seek .

But without a long-term care facility willing to accept him, Alameda has not been able to leave.

As of June, at least three other prisoners granted release to tend to their medical needs were living indefinitely in the infirmary after long-term care facilities were unwilling to accept them, primarily because of their criminal backgrounds, the state parole authority said.

“This is a challenge across the country,” said Molly Crane, an attorney for FAMM, which advocates for .

Every state allows for prisoners, though HawaiÊ»i is the only one without a specific law, relying instead on an internal policy. The prisoners who typically qualify for compassionate release can’t care for themselves or have terminal illnesses and may need an assisted living center, a nursing home, or hospice.

But many long-term care facilities nationwide decline to take such prisoners, leaving them incarcerated for months — or years — after they were granted release.

In , a study found that rejections from nursing homes soared after they were told that a patient was coming from prison. , prisoners with extensive medical needs stayed an average of 200 days after being granted parole, because of denials from long-term care centers. And in , prisoners granted parole sued the state when they couldn’t get placed in nursing homes.

President Donald Trump’s signature One Big Beautiful Bill Act further strains long-term care providers’ ability to take people from incarceration. Prisoners don’t qualify for Medicaid, so parolees after they’re granted the release. The law, enacted last summer, reduces the window in which facilities can get reimbursed from three months to before they apply. That means facilities risk not getting paid for new Medicaid patients whose applications are not submitted within the reduced timeframe.

The Centers for Medicare & Medicaid Services “encourages providers and beneficiaries to prioritize timely application submission to maximize coverage,” CMS spokesperson Timothy Foster said.

‘Risk Is Just Too High’

Most nursing homes nationwide already have a waiting list for new residents, according to a by the American Health Care Association and the National Center for Assisted Living. Those waitlists are another hurdle to getting prisoners placed, said Bob Merce, a former attorney who advocates for prisoners’ compassionate release.

“We tell the nursing homes that most of the people who we are talking about cannot hurt somebody,” Merce said.

Some of the prisoners staying at the Halawa infirmary in June couldn’t walk or dress themselves. One man couldn’t recall what his illness was. Another with brain cancer couldn’t coherently respond to questions.

Sean Sanada, the OÊ»ahu Region CEO with the HawaiÊ»i Health Systems Corp., oversees the region’s two state-funded long-term care facilities, Leahi Hospital and Maluhia. Sanada said that the health system has reviewed dozens of compassionate release referrals but has never accepted any of them.

Sanada said the facilities don’t discriminate based on where the resident comes from. His main concerns, he said, were his staff’s safety and the lack of resources to adequately care for the patient.

“The risk is just too high in most of those instances,” Sanada said.

Violent incidents in long-term care facilities have been well documented. A observing 14 assisted living facilities found that in just one month, 15% of residents experienced resident-to-resident aggression.

When long-term care facilities refuse to accept prisoners who have been granted compassionate release, it leaves state taxpayers footing a larger bill. The annual cost to incarcerate an individual in ±á²¹·É²¹¾±â€˜i with complex needs is up to eight times the $112,505 average of housing one person in prison, according to FAMM. In comparison, the average Medicaid reimbursement for a long-term care patient at a HawaiÊ»i Health Systems Corp. facility is about .

Four states — Connecticut, Georgia, Massachusetts, and Vermont — contract with nursing facilities to take prisoners who are granted compassionate release, according to FAMM.

The iCare Health Network’s MissionCare Health, which operates nursing homes for people coming out of prison, secured contracts in three of those states. David Skoczulek, iCare’s vice president of business development and communication, estimated that its rates are $100 to $350 a day more per patient than the average nursing home rates in the states where they operate.

In Hawaiʻi, the correctional department determines recommendations to send to the parole board, which decides whether to grant the release. Prisoners who are granted the early probation can be released to family members who commit to caring for them or to a long-term care facility.

Corey Reincke, head of the HawaiÊ»i Paroling Authority, said that in his 24-year career he couldn’t recall getting anyone placed into a long-term care facility without family intervening, for instance by contacting facilities themselves.

“Parole has to find a facility that can meet their medical needs and is also willing to take them,” Reincke said. “That’s where we’re hitting the roadblocks.”

For one parolee, Reincke called more than 100 care homes, he said, but they all declined to accept the patient, over safety concerns. According to a 2024 state report, while HawaiÊ»i’s long-term care facilities use about workforce strains make it difficult to maintain even those levels.

HawaiÊ»i Prisoners’ Refuge: Family

Last year, 69-year-old Paul Kupihea died at a hospital five days after the state granted him compassionate release to his family. He died before he could get on a flight to his home island.

In July 2025, Lahela Kruse, the mother of Kupihea’s child, received a call from a Honolulu hospital informing her that his condition had become severe. By then he had been diagnosed with an incurable form of cancer and had been in and out of the hospital while still in custody.

Kruse and their daughter flew to Oʻahu to see him and were shocked when they saw how sick he was. Their daughter agreed to take him into her home in Hilo, on Hawaiʻi Island, despite not having a relationship with him for most of her life.

“She knew he was sick,” Kruse said. “I told her that, but she didn’t know the severity of it. I didn’t truly know.”

Her daughter’s willingness to take him prompted his compassionate release. But Kruse said the notification about Kupihea’s illness came too late.

FAMM’s Crane has been working on expanding compassionate release laws in states to allow for more prisoners to qualify and strengthen transparency in the process. HawaiÊ»i lawmakers have tried for years to pass bills on compassionate release, but none has succeeded.

Crane said without a law that outlines a formal process and who qualifies, even family support isn’t enough. Prisoners can still face life-threatening delays, she said.

“The absence of a compassionate release statute means that people who need compassionate release languish and even die in prison,” Crane said.

In Alameda’s cell, two beds stood about 3 feet apart, with a seatless metal toilet in the corner and a window looking out on a concrete wall. The smell of bleach permeated the room. Alameda said he hoped to see his daughter soon. She recently turned 5.

“I made some mistakes in my life,” said Alameda, who has been incarcerated since 2024 for drug possession, driving a stolen vehicle, and jumping bail. “I tried when my daughter was born, but I know I’ll change, because she needs me out of here.”

Merce, the former attorney, is still trying to find a place for Alameda, who committed no violent crimes. Merce became aware of prisoners’ struggles through his work as a trial lawyer. He said he has helped about 15 prisoners leave HawaiÊ»i correctional facilities for medical treatment.

He said he’s seen cases in which people have waited years to get out.

“The ones that stick with me, though,” Merce said, “are the ones that I never found placements for.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .