• Click here to hear Boden on “Central Valley Daily”
• Read Boden’s “House Cats With Bird Flu Could Pose a Risk to Public Health”

KFF Health News South Carolina correspondent Lauren Sausser juxtaposed the increasing trendiness of rural health care and the lack of Medicaid expansion in the South on America’s Heroes Group on Feb. 12.

• Click here to watch Sausser on America’s Heroes Group
• Read Sausser’s “Across the South, Rural Health Care Has Become ‘Trendy.’ Medicaid Expansion Has Not.”

KFF Health News contributor Rebecca Grapevine, of Healthbeat, discussed the barriers to lifesaving HIV drugs in Georgia on America’s Heroes Group on Feb. 12.

• Click here to watch Grapevine on America’s Heroes Group
• Read “Biden Rule Cleared Hurdles to Lifesaving HIV Drug, but in Georgia Barriers Remain”

KFF Health News Southern correspondent Sam Whitehead discussed childhood vaccination rates on WUGA’s “The Georgia Health Report” on Feb. 7.

• Click here to hear Whitehead on “The Georgia Health Report”
• Read Whitehead’s “Childhood Vaccination Rates, a Rare Health Bright Spot in Struggling States, Are Slipping,” co-reported with Daniel Chang

KFF Health News public health local editor and correspondent Amy Maxmen discussed the U.S.’ pulling out of the World Health Organization on America’s Heroes Group on Feb. 5.

• Click here to watch Maxmen on America’s Heroes Group
• Read Maxmen’s “What a US Exit From the WHO Means for Global Health”

KFF 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 KFF.

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The day after Trump’s inauguration, South Carolina GOP Gov. Henry McMaster asked federal officials to approve a work requirement plan. Ohio Republican Gov. Mike DeWine plans to soon follow suit. Republicans in Congress are eyeing Medicaid work requirements as they seek to slash billions from the federal budget.

But, just as a second Trump administration reignites interest in work requirements, Georgia is proposing to scale back key parts of the nation’s only active program. And Arkansas announced an effort to revive — with fundamental changes — a program that ended after a legal judgment in 2019.

The Georgia and Arkansas proposals, from the only two states to have implemented Medicaid work requirements, reveal the disconnect between rhetoric behind such programs and the realities of running them, said consumer advocates and health policy researchers.

“They recognize that what they did the first time didn’t work,” said Ben Sommers, a Harvard professor and a former health official in the Biden and Obama administrations. “It should be a signal to federal policymakers: Don’t point to Georgia and Arkansas and say, ‘Let’s do that.’”

More than a dozen states had Medicaid work requirement programs approved during Trump’s first administration.

After an expensive and bumpy rollout, Georgia in January posted a draft renewal plan for its Georgia Pathways to Coverage program. The plan removes the requirement to document work every month and to pay premiums. Those key elements — which supporters have argued promote employment and personal responsibility — were never implemented, the state said.

Enrollees would still have to meet the work requirement when they first apply and when they renew each year. The draft plan also expands the group of people who can opt out of work reporting to include parents of children under age 6. A public comment period on the plan is open through Feb. 20.

Arkansas’ latest request to federal officials doesn’t require enrollees to report their work hours. Instead, it proposes checking whether people are working, caregiving, or fulfilling other qualifying activities by using data, which could include income, job history, educational status, whether a child lives at home, and other criteria, said Gavin Lesnick, a spokesperson for the state’s Medicaid agency.

People deemed “not on track towards meeting their personal health and economic goals” won’t be disenrolled but can participate in a “success coaching” program to maintain coverage, according to the state’s proposal. A public comment period on Arkansas’ program runs through March 3.

‘Fundamentally Flawed’

More than 90% of U.S. adults eligible for Medicaid expansion are already working or could be exempt from requirements, according to KFF. Still, several states are quickly moving to restart Medicaid work requirements.

Besides the three states of Arkansas, Ohio, and South Carolina, Iowa and South Dakota are considering similar proposals. Lawmakers in Montana are weighing them as they debate renewing the state’s Medicaid expansion.

This week, House Republicans floated a budget proposal to cut $880 billion from the Energy and Commerce Committee, which oversees Medicaid, the state-federal health insurance program for people with low incomes or disabilities. Before the release of that plan, Speaker Mike Johnson said Republicans were discussing changes to Medicaid that include imposing work requirements.

Supporters of such requirements say Medicaid should be reserved for people who are working.

Right now, it “disincentivizes many low-income families from earning additional income” because they would lose health coverage if they make too much money, said South Carolina Gov. McMaster in his January letter to federal officials. He has argued that a work-reporting requirement is “fiscally responsible” and “will incentivize employment.”

There is no evidence showing such programs improve economic outcomes for people; the requirements don’t help people find jobs, but not having health insurance can keep them from working, health policy researchers say.

The goal of Ohio’s plan is to focus “resources and efforts on those who are engaged with their health choices and independence,” said the state. The plan doesn’t require most individuals to regularly “report activities, fill out forms, or take any action” beyond what is generally required for Medicaid enrollment. Ohio estimates that more than 61,000 people, or 8% of enrollees subject to its measure, would lose Medicaid eligibility in the first year.

Consumer advocates, health policy analysts, and researchers said the scaling back seen in recent work requirement proposals speaks to the challenges of mandating them for public benefits — and could serve as a cautionary tale for Republicans in Washington, D.C., and across the country. The programs can eliminate people from the Medicaid rolls or suppress enrollment, while adding costly layers of bureaucracy, they said.

“As a matter of health policy, work-reporting requirements in Medicaid are fundamentally flawed,” said Leo Cuello, a researcher at the Georgetown Center for Children and Families.

Lessons Learned?

Arkansas got its initial program off the ground in 2018 before a federal judge said it was illegal. Unlike Georgia, the state had already expanded Medicaid. That work-reporting requirement led to more than 18,000 people losing coverage, in part because enrollees were unaware or confused about how to report they were working.

In his ruling that ended the program, Judge James Boasberg said its approval was “arbitrary and capricious” because it failed to address a core goal of Medicaid: “the provision of medical coverage to the needy.”

Arkansas’ latest proposal tries to address a potential legal challenge by suspending, rather than terminating, health coverage through the end of the calendar year for people who don’t meet requirements.

“We have worked to design this amendment taking into account lessons learned from previous work requirements,” said Arkansas Medicaid Director Janet Mann at a press conference in late January announcing the new proposal.

But the requirements are “subjective,” and the difference between suspension and termination isn’t meaningful, said Camille Richoux, health policy director of Arkansas Advocates for Children and Families.

“The impact is the same: You can’t go to the doctor,” she said. “You can’t get your prescriptions filled.”

In Georgia, the Pathways program, launched in 2023, has offered coverage to a small portion of those who would qualify for Medicaid if the state had fully expanded it to all low-income adults, as 40 others have done. With the proposed changes, the state estimates enrollment in Pathways would grow to as many as 30,000 people in the final year of the pilot. The state currently estimates at least 246,000 would become eligible for Medicaid under a full expansion.

About 6,500 people were enrolled in Pathways as of late January, said Grant Thomas, the state’s deputy Medicaid commissioner, in a legislative hearing. According to state officials, the program has cost more than $57 million in state and federal funds through December, with most of that money going toward program administration, not benefits.

“Pathways is doing what it is designed to do: increase access to affordable health care coverage while lowering the uninsured rate across Georgia,” said Russel Carlson, who oversees the state’s Medicaid program as commissioner of the Department of Community Health. The changes to Pathways are an attempt to “improve the member experience” while finding ways “to make government more efficient and accessible,” he added.

Pathways requires that enrollees regularly submit documentation to prove they are working, but the program doesn’t include meaningful measures to help people find work, critics said. People who could be eligible for Pathways have said the whole process is time-consuming due to lengthy questionnaires, a glitchy system for uploading documents, and confusing technical language on the website, according to those working with potential enrollees.

“There’s stuff that sounds good on paper, but when you go to implement it in real life, it’s costly and burdensome,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.

So far, Pathways has cost state and federal taxpayers nearly $9,000 per enrollee, largely back-end costs to run the program. States that have expanded Medicaid spent about $6,500 per enrollee in that group in 2021, according to KFF researchers.

Georgia GOP Gov. Brian Kemp has said he’s committed to his signature health program, but some Republican state lawmakers have shown an openness to consider full expansion.

A group of Democratic senators cited KFF Health News’ reporting last year when they asked the federal government’s top watchdog to investigate Pathways spending.

Even with the proposed changes, some people, including those who work in the informal or gig economy, may not have official records and may be locked out of health coverage, said Laura Colbert, executive director of Georgians for a Healthy Future, a nonprofit consumer health advocacy organization. People caring for older children or aging relatives, older adults who struggle to find work, and those with medical conditions that prevent them from working still wouldn’t qualify for health coverage, she said.

“The Pathways program just doesn’t reflect the reality of how people are working,” Colbert said. “Pathways is a program that has clearly been developed by people who have had salaried jobs with predictable incomes.”

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In South Dakota, too, official records show zero abortions that year.

And in Idaho, home to abortion battles that have recently made their way to the U.S. Supreme Court, the official number of recorded abortions was just five.

In nearly a dozen states with total or near-total abortion bans, government officials claimed that zero or very few abortions occurred in 2023, the first full year after the Supreme Court eliminated federal abortion rights.

Those statistics, the most recent available and published in government records, have been celebrated by anti-abortion activists. Medical professionals say such accounts are not only untrue but fundamentally dishonest.

“To say there are no abortions going on in South Dakota is ludicrous,” said Amy Kelley, an OB-GYN in Sioux Falls, South Dakota, citing female patients who have come to her hospital after taking abortion pills or to have medical procedures meant to prevent death or end nonviable pregnancies. “I can think of five off the top of my head that I dealt with,” she said, “and I have 15 partners.”

For some data scientists, these statistics also suggest a troubling trend: the potential politicization of vital statistics.

“It’s so clinically dishonest,” said Ushma Upadhyay, a public health scientist at the University of California-San Francisco, who co-chairs WeCount, an academic research effort that has kept a tally of the number of abortions nationwide since April 2022.

The zeroing out is statistically unlikely, Upadhyay said, and also runs counter to the reality that pregnancy “comes with many risks and in many cases emergency abortion care will be needed.”

“We know they are sometimes necessary to save the pregnant person’s life,” she said, “so I do hope there are abortions occurring in South Dakota.”

State officials reported a sharp decline in the official number of abortions after the Supreme Court overturned Roe v. Wade in June 2022.

• Arkansas reported zero abortions in 2023, compared with 1,621 in 2022.
• Texas reported 60 in 2023, after reporting 50,783 abortions in the state in 2021.
• Idaho reported five in 2023 compared with 1,553 in 2021.
• South Dakota, which had severely restricted abortions years ahead of the Dobbs ruling, reported zero in 2023 compared with 192 abortions in 2021.

Anti-abortion politicians and activists have cited these statistics to bolster their claims that their decades-long crusade to end abortion is a success.

“Undoubtedly, many Arkansas pregnant mothers were spared from the lifelong regrets and physical complications abortion can cause and babies are alive today in Arkansas,” Rose Mimms, executive director of Arkansas Right to Life, said in a press statement. “That’s a win-win for them and our state.”

A spokesperson for the Arkansas Department of Health, Ashley Whitlow, said in an email that the department “is not able to track abortions that take place out of the state or outside of a healthcare facility.” State officials, she said, collect data from “in-state providers and facilities for the Induced Abortion data reports as required by Arkansas law.”

WeCount’s tallies of observed telehealth abortions do not appear in the official state numbers. For instance, from April to June 2024 it counted an average of 240 telehealth abortions a month in Arkansas.

Groups that oppose abortion rights acknowledge that state surveillance reports do not tell the full story of abortion care occurring in their states. Mimms, of Arkansas Right to Life, said she would not expect abortions to be reported in the state, since the procedure is illegal except to prevent a patient’s death.

“Women are still seeking out abortions in Arkansas, whether it’s illegally or going out of state for illegal abortion,” Mimms told KFF Health News. “We’re not naive.”

The South Dakota Department of Health “compiles information it receives from health care organizations around the state and reports it accordingly,” Tia Kafka, its marketing and outreach director, said in an email responding to questions about the statistics. Kafka declined to comment on specific questions about abortions being performed in the state or characterizations that South Dakota’s report is flawed.

Kim Floren, who serves as director of the Justice Empowerment Network, which provides funds and practical support to help South Dakota patients receive abortion care, expressed disbelief in the state’s official figures.

“In 2023, we served over 500 patients,” she said. “Most of them were from South Dakota.”

“For better or worse, government data is the official record,” said Ishan Mehta, director for media and democracy at Common Cause, the nonpartisan public interest group. “You are not just reporting data. You are feeding into an ecosystem that is going to have much larger ramifications.”

When there is a mismatch in the data reported by state governments and credible researchers, including WeCount and the Guttmacher Institute, a reproductive health research group that supports abortion rights, state researchers need to dig deeper, Mehta said.

“This is going to create a historical record for archivists and researchers and people who are going to look at the decades-long trend and try to understand how big public policy changes affected maternal health care,” Mehta said. And now, the recordkeepers “don’t seem to be fully thinking through the ramifications of their actions.”

A Culture of Fear

Abortion rights supporters agree that there has been a steep drop in the number of abortions in every state that enacted laws criminalizing abortion. In states with total bans, 63 clinics have stopped providing abortions. And doctors and medical providers face criminal charges for providing or assisting in abortion care in at least a dozen states.

Practitioners find themselves working in a culture of confusion and fear, which could contribute to a hesitancy to report abortions — despite some state efforts to make clear when abortion is allowed.

For instance, South Dakota Department of Health Secretary Melissa Magstadt released a video to clarify when an abortion is legal under the state’s strict ban.

The procedure is legal in South Dakota only when a pregnant woman is facing death. Magstadt said doctors should use “reasonable medical judgment” and “document their thought process.”

Any doctor convicted of performing an unlawful abortion faces up to two years in prison.

In the place of reliable statistics, academic researchers at WeCount use symbols like dashes to indicate they can’t accurately capture the reality on the ground.

“We try to make an effort to make clear that it’s not zero. That’s the approach these departments of health should take,” said WeCount’s Upadhyay, adding that health departments “should acknowledge that abortions are happening in their states but they can’t count them because they have created a culture of fear, a fear of lawsuits, having licenses revoked.”

“Maybe that’s what they should say,” she said, “instead of putting a zero in their reports.”

Mixed Mandates for Abortion Data

For decades, dozens of states have required abortion providers to collect detailed demographic information on the women who have abortions, including race, age, city, and county — and, in some cases, marital status and the reason for ending the pregnancy.

Researchers who compile data on abortion say there can be sound public health reasons for monitoring the statistics surrounding medical care, namely to evaluate the impact of policy changes. That has become particularly important in the wake of the Supreme Court’s 2022 Dobbs decision, which ended the federal right to an abortion and opened the door to laws in Republican-led states restricting and sometimes outlawing abortion care.

Isaac Maddow-Zimet, a Guttmacher data scientist, said data collection has been used by abortion opponents to overburden clinics with paperwork and force patients to answer intrusive questions. “It’s part of a pretty long history of those tools being used to stigmatize abortion,” he said.

In South Dakota, clinic staff members were required to report the weight of the contents of the uterus, including the woman’s blood, a requirement that had no medical purpose and had the effect of exaggerating the weight of pregnancy tissue, said Floren, who worked at a clinic that provided abortion care before the state’s ban.

“If it was a procedural abortion, you had to weigh everything that came out and write that down on the report,” Floren said.

The Centers for Disease Control and Prevention does not mandate abortion reporting, and some Democratic-led states, including California, do not require clinics or health care providers to collect data. Each year, the CDC requests abortion data from the central health agencies for every state, the District of Columbia, and New York City, and these states and jurisdictions voluntarily report aggregated data for inclusion in the CDC’s annual “Abortion Surveillance” report.

In states that mandate public abortion tracking, hospitals, clinics, and physicians report the number of abortions to state health departments in what are typically called “induced termination of pregnancy” reports, or ITOPs.

Before Dobbs, such reports recorded procedural and medication abortions. But following the elimination of federal abortion rights, clinics shuttered in states with criminal abortion bans. More patients began accessing abortion medication through online organizations, including Aid Access, that do not fall under mandatory state reporting laws.

At least six states have enacted what are called “shield laws” to protect providers who send pills to patients in states with abortion bans. That includes New York, where Linda Prine, a family physician employed by Aid Access, prescribes and sends abortion pills to patients across the country.

Asked about states reporting zero or very few abortions in 2023, Prine said she was certain those statistics were wrong. Texas, for example, reported 50,783 abortions in the state in 2021. Now the state reports on average five a month. WeCount reported an average of 2,800 telehealth abortions a month in Texas from April to June 2024.

“In 2023, Aid Access absolutely mailed pills to all three states in question — South Dakota, Arkansas, and Texas,” Prine said.

Texas Attorney General Ken Paxton filed a lawsuit in January against a New York-based physician, Maggie Carpenter, co-founder of the Abortion Coalition for Telemedicine, for prescribing abortion pills to a Texas patient in violation of Texas’ near-total abortion ban. It’s the first legal challenge to New York’s shield law and threatens to derail access to medication abortion.

Still, some state officials in states with abortion bans have sought to choke off the supply of medication that induces abortion. In May, Arkansas Attorney General Tim Griffin wrote cease and desist letters to Aid Access in the Netherlands and Choices Women’s Medical Center in New York City, stating that “abortion pills may not legally be shipped to Arkansas” and accusing the medical organizations of potentially “false, deceptive, and unconscionable trade practices” that carry up to $10,000 per violation.

Good-government groups like Common Cause say that the dangers of officials relying on misleading statistics are myriad, including a disintegration of public trust as well as ill-informed legislation.

These concerns have been heightened by misinformation surrounding health care, including an entrenched and vocal anti-vaccine movement and the objections of some conservative politicians to mandates related to covid-19, including masks, physical distancing, and school and business closures.

“If the state is not going to put in a little more than the bare minimum to just find out if their data is accurate or not,” Mehta said, “we are in a very dangerous place.”

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But that ended in December when Mark Newberry retired. To attract a new doctor, Havana leaders took out want ads in local newspapers, posted notices on social media, and sweetened the pot with a rent-free medical office equipped with an X-ray, an ultrasound machine, and a bone density scanner — all owned by the town.

Local leaders hope the recruitment campaign will help attract candidates amid a nationwide shortage of doctors.

“This is important for our community,” said Kendrah Wilkerson, Havana’s town manager, “in the same way that parks are important and good future planning is important.”

According to a Florida Department of Health report, doctor shortages affect all or part of nearly every county, but less populous counties, such as Gadsden, where Havana is located, have the fewest physicians per 10,000 residents.

Florida’s doctor shortage is expected to grow in the next decade, with one study projecting a statewide need of 18,000 physicians — including 6,000 primary care doctors — by 2035.

“This is a huge, huge issue,” said Matthew Smeltzer, a managing partner of Capstone Recruiting Advisors, a company that helps hospitals, physician practices, and other employers find and hire doctors. “It probably hits small towns the hardest, just because most people would prefer to live in a midsize or large community.”

In this challenging environment, Havana leaders are hoping that want ads and rent-free perks will make their small town stand out and persuade a doctor to practice here.

Wilkerson describes the community, just south of the Georgia border, as an ideal place to raise a family. Its country roads are lined with farms, pastures, and churches. Main Street downtown features antique stores, gift shops, a general store, and restaurants.

“Everything you would imagine a Hallmark movie to be is kind of where we live,” Wilkerson said. “It’s people who still care and look out for each other, and neighbors are actually friends.”

Offering generous incentives was how town leaders got Newberry to practice in Havana in 1993. The town gave Newberry an initial deal similar to the one it’s offering now, and later began providing him about $15,000 a year in financial support.

Newberry, who served about 2,000 patients, declined to be interviewed. “I’m just retiring!” he said in an email, adding that “the town has chosen unconventional ways” of recruiting a doctor.

By subsidizing office space and the use of medical equipment to attract a doctor, Havana is looking out for the needs of its residents, Wilkerson said.

Without a town doctor, some of Newberry’s former patients now have to travel to Tallahassee, about a 30-minute drive southeast of Havana. Others are seeing doctors in Quincy, about a 20-minute drive west.

“Our hope is that they’ll come back when we find us a new doctor,” Havana Mayor Eddie Bass said.

Susan Freiden, a former town manager who retired in 2006, said having a local doctor is also important to meet the needs of the town’s low-income residents, many of whom are older adults. “Not everybody can get to Tallahassee to get a doctor,” she said. “Not everybody has transportation.”

But it remains to be seen whether rent-free office space and equipment are enough to attract a doctor to Havana. The town’s recruitment campaign has drawn a lot of interest from nurse practitioners, but few primary care physicians have applied for the position.

Town leaders say they’re holding out hope of finding a family physician, who can practice and prescribe medications independently.

“We would really, you know, prefer to have a true doctor that can handle it all for us,” Bass said.

Smeltzer, the physician headhunter, said primary care physicians are in especially low supply. And though in his experience Florida, North Carolina, Tennessee, and Texas are among the places doctors want to live and work, it often takes something extra to persuade them to work in a small town, he said.

“If someone wants to practice in a small town, they’re more likely to go to where they have ties, whether it’s themselves or their spouse or significant other,” he said.

The challenge for a community of Havana’s size, Smeltzer said, is that “there may literally be nobody from that town that went to med school. Or, if there is, maybe it’s one. But were they a primary care physician?”

Still, there is a silver lining. Smeltzer said young physicians are placing a high value on work-life balance and meaningful relationships with their patients — qualities that may give an edge to a small-town, independent practice.

“We hear quality of life and work-life balance far more in the last three to five years than we ever heard before,” he said, “and that’s almost in lockstep with compensation in terms of what they’re focusing on.”

Freiden, the former Havana town manager, said those are the same values Newberry had when he started to practice here. She even became one of his patients.

“He was just perfect,” she said, “because he wasn’t all about the money, if you can imagine that. He was kind of a different kind of physician.”

Fortunately for Havana, the town recently received interest from a family medicine doctor who grew up here, went to medical school, and expects to finish a three-year residency at Tallahassee Memorial HealthCare in June.

Camron Browning, a 2003 graduate of Northside Havana High School, told the seven-member Town Council in a December interview that he was focusing on family medicine and that, during his residency, he has seen thousands of patients, delivered babies, and gained experience as a hospitalist.

“My goal,” he said, “was to be able to come home and serve my hometown.”

Smeltzer said Havana’s incentives could be attractive to new doctors, such as Browning, who would face daunting startup costs to establish an independent practice.

After the December interview, the Council voted unanimously to begin contract negotiations with Browning, who said he would plan to be ready to see patients as soon as possible after completing his residency.

“I’m here to stay,” Browning told the Council. “This was always my dream.”

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“Tell them she’s on Eliquis!” said Martin, a nurse who lived an hour’s drive away in Winston-Salem. She knew the blood thinner could lead to life-threatening blood loss.

When the ambulance arrived, the medics evaluated Martin’s aunt and then did something few emergency medical services crews do: They gave her a blood transfusion to replace what she’d lost, stabilizing her sinking blood pressure.

The ambulance took her to the local high school, and from there a medical helicopter flew her to the nearest trauma center, in Winston-Salem. She needed more units of blood in the helicopter and at the hospital but eventually recovered fully.

“The whole situation would have been different if they hadn’t given her blood right away,” Martin said. “She very well might have died.”

More than 60,000 people in the U.S. bleed to death every year from traumatic events like car crashes or gunshot wounds, or other emergencies, including those related to pregnancy or gastrointestinal hemorrhaging. It’s a leading cause of preventable death after a traumatic event.

But many of those people likely wouldn’t have died if they had received a blood transfusion promptly, trauma specialists say. At a news conference last fall, members of the American College of Surgeons estimated that 10,000 lives could be saved annually if more patients received blood before they arrived at the hospital.

“I don’t think that people understand that ambulances don’t carry blood,” said Jeffrey Kerby, who is chair of the ACS Committee on Trauma and directs trauma and acute care surgery at the University of Alabama-Birmingham Heersink School of Medicine. “They just assume they have it.”

Of the more than 11,000 EMS agencies in the U.S. that provide ground transport to acute care hospitals, only about 1% carry blood, according to a 2024 study.

The term “blood deserts” generally refers to a problem in rural areas where the nearest trauma center is dozens of miles away. But heavy traffic and other factors in suburban and urban areas can turn those areas into blood deserts, too. In recent years, several EMS agencies throughout the country have established “pre-hospital blood programs” aimed at getting blood to injured people who might not survive the ambulance ride to the trauma center.

With blood loss, every minute counts. Blood helps move oxygen and nutrients to cells and keeps organs working. If the volume gets too low, it can no longer perform those essential functions.

If someone is catastrophically injured, sometimes nothing can save them. But in many serious bleeding situations, if emergency personnel can provide blood within 30 minutes, “it’s the best chance of survival for those patients,” said Leo Reardon, the Field Transfusion Paramedic Program director for the Canton, Massachusetts, fire department. “They’re in the early stages of shock where the blood will make the most difference.”

There are several roadblocks that prevent EMS agencies from providing blood. Several states don’t allow emergency services personnel to administer blood before they arrive at the hospital, said John Holcomb, a professor in the division of trauma and acute care surgery at UAB’s Heersink School.

“It’s mostly tradition,” Holcomb said. “They say: ‘It’s dangerous. You’re not qualified.’ But both of those things are not true.”

On the battlefields in the Middle East, operators of military medical facilities would maintain that only nurses and doctors could do blood transfusions, said Randall Schaefer, a U.S. Army trauma nurse who was deployed there and now consults with states on implementing pre-hospital blood programs.

But in combat situations, “we didn’t have that luxury,” Schaefer said. Medical staff sometimes relied on medics who carried units of blood in their backpacks. “Medics can absolutely make the right decisions about doing blood transfusions,” she said.

A quick response made a difference: Soldiers who received blood within minutes of being injured were four times as likely to survive, according to military research.

Civilian emergency services are now incorporating lessons learned by the military into their own operations.

But they face another significant hurdle: compensation. Ambulance service payments are based on how far vehicles travel and the level of services they provide, with some adjustments. But the fee schedule doesn’t cover blood products. If EMS responders carry blood on calls, it’s usually low-titer O whole blood, which is generally safe for anyone to receive, or blood components — liquid plasma and packed red blood cells. These products can cost from $80 to $600 on average, according to Schaefer’s study. And payments don’t cover the blood coolers, fluid warming equipment, and other gear needed to provide blood at the scene.

On Jan. 1, the Centers for Medicare & Medicaid Services began counting any administration of blood during ambulance pre-hospital transport as an “advanced life support, level 2” (ALS2) service, which will boost payment in some cases.

The higher reimbursement is welcome, but it’s not enough to cover the cost of providing blood to a patient, which can run to more than $1,000, Schaefer said. Agencies that run these programs are paying for them out of their own operating budgets or using grants or other sources.

Blood deserts exist in rural and urban areas. Last August, Herby Joseph was walking down the stairs at his cousin’s house in Brockton, Massachusetts, when he slipped and fell. The glass plate he was carrying shattered and sliced through the blood vessels in his right hand.

“I saw a flood of blood and called my cousin to call 911,” Joseph, 37, remembered.

The ambulance team arrived in just a few minutes, evaluated him, and called in the Canton-based Field Transfusion Paramedic Program team, which began administering a blood transfusion shortly thereafter. The program serves 30 towns in the Boston area. Since the transfusion program began last March, the team has responded to more than 40 calls, many of them related to car accidents along the ring of interstate highways surrounding the area, Reardon said.

Brockton has a Level 3 trauma center, but Joseph’s injuries required more intensive care. Boston Medical Center, the Level 1 trauma center where the EMS team was taking Joseph, is about 23 miles from Brockton, and depending on traffic it can take more than a half hour to get there.

Joseph was given more blood at the medical center, where he remained for nearly a week. He eventually underwent three surgeries to repair his hand and has now returned to his warehouse job.

Although Boston has several Level 1 trauma centers, the region south of the city is pretty much a trauma desert, said Crisanto Torres, one of the trauma surgeons who cared for Joseph.

Boston Medical Center partners with the Canton Fire Department to operate the field transfusion program. It’s an important service, Torres said.

“You can’t just put up a new Level 1 trauma center,” he said. “This is one way to blunt the inequity in access to care. It buys patients time.”

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Three years later, he landed in an inpatient hospital after expressing suicidal thoughts.

After more than a decade cycling through juvenile detention, foster care placements, and state prisons, Valdez realizes now that treatment for his mental health conditions would have made life on his own much easier.

“It’s not until you’re put in, like, everyday situations and you respond adversely and maladaptive,” he said, “you kind of realize that what you went through had an effect on you.”

“I was struggling with a lot of mental stuff,” said Valdez, now 27.

For years, people like Valdez have often been left to fend for themselves when seeking health care services after their release from jail, prison, or other carceral facilities. Despite this population’s high rate of mental health problems and substance use disorders, they often return to their communities with no coverage, which increases their chances of dying or suffering a lapse that sends them back behind bars.

A new federal law aims to better connect incarcerated children and young adults who are eligible for Medicaid or the Children’s Health Insurance Program to services before their release. The goal is to help prevent them from developing a health crisis or reoffending as they work to reestablish themselves.

“This could change the trajectory of their lives,” said Alycia Castillo, associate director of policy for the Texas Civil Rights Project. Without that treatment, she said, many young people leaving custody struggle to reintegrate into schools or jobs, become dysregulated, and end up cycling in and out of detention facilities.

Medicaid has historically been prohibited from paying for health services for incarcerated people. So jails, prisons, and detention centers across the country have their own systems for providing health care, often funded by state and local budgets and not integrated with a public or private health system.

The new law is the first change to that prohibition since the Medicare and Medicaid Act’s inception in 1965, and it came in a spending bill signed by President Joe Biden in 2022. It took effect Jan. 1 this year, and requires all states to provide medical and dental screenings to Medicaid- and CHIP-eligible youths 30 days before or immediately after they leave a correctional facility. Youths must continue to receive case management services for 30 days after their release.

More than 60% of young people who are incarcerated are eligible for Medicaid or CHIP, according to a September 2024 report from the Center for Health Care Strategies. The new law applies to children and young adults up to age 21, or 26 for those who, like Valdez, were in foster care.

Putting the law into practice, however, will require significant changes to how the country’s thousands of correctional facilities provide health care to people returning to communities, and it could take months or even years for the facilities to be fully in compliance.

“It’s not going to be flipping a switch,” said Vikki Wachino, founder and executive director of the Health and Reentry Project, which has been helping states implement the law. “These connection points have never been made before,” said Wachino, a former deputy administrator of the Centers for Medicare & Medicaid Services.

The federal CMS under the Biden administration did not respond to a question about how the agency planned to enforce the law.

It’s also unclear whether the Trump administration will force states to comply. In 2018, President Donald Trump signed legislation requiring states to enroll eligible youths in Medicaid when they leave incarceration, so they don’t experience a gap in health coverage. The law Biden signed built on that change by requiring facilities to provide health screenings and services to those youths, as well as ones eligible for CHIP.

Even though the number of juveniles incarcerated in the U.S. has dropped significantly over the past two decades, more than 64,000 children and young adults 20 and younger are incarcerated in state prisons, local and tribal jails, and juvenile facilities, according to estimates provided to KFF Health News by the Prison Policy Initiative, a nonprofit research organization that studies the harm of mass incarceration.

A ‘Neglected Part of the Health System’

The federal Bureau of Justice Statistics estimates that about a fifth of the country’s prison population spent time in foster care. Black youths are nearly five times as likely as white youths to be placed in juvenile facilities, according to the Sentencing Project, a nonprofit that advocates for reducing prison and jail populations.

Studies show that children who receive treatment for their health needs after release are less likely to reenter the juvenile justice system.

“Oftentimes what pulls kids and families into these systems is unmet needs,” said Joseph Ribsam, director of child welfare and juvenile justice policy at the Annie E. Casey Foundation and a former state youth services official. “It makes more sense for kids to have their health care tied to a health care system, not a carceral system.”

Yet many state and local facilities and state health agencies nationwide will have to make a lot of changes before incarcerated people can receive the services required in the law. The facilities and agencies must first create systems to identify eligible youths, find health care providers who accept Medicaid, bill the federal government, and share records and data, according to state Medicaid and corrections officials, as well as researchers following the changes.

In January, the federal government began handing out around $100 million in grants to help states implement the law, including to update technology.

Some state officials are flagging potential complications.

In Georgia, for example, the state juvenile justice system doesn’t have a way to bill Medicaid, said Michelle Staples-Horne, medical director for the Georgia Department of Juvenile Justice.

In South Dakota, suspending someone’s Medicaid or CHIP coverage while they are incarcerated instead of just ending it is a challenge, Kellie Wasko, the state’s secretary of corrections, said in a November webinar on the new law. That’s a technical change that’s difficult to operationalize, she said.

State Medicaid officials also acknowledged that they can’t force local officials to comply.

“We can build a ball field, but we can’t make people come and play ball,” said Patrick Beatty, deputy director and chief policy officer for the Ohio Department of Medicaid.

States should see the law as a way to address a “neglected part of the health system,” said Wachino, the former CMS official. By improving care for people transitioning out of incarceration, states may spend less money on emergency care and on corrections, she said.

“Any state that is dragging its feet is missing an opportunity here,” she said.

‘Our System Is Making People Worse’

The Texas Department of Family Services took custody of Valdez when he was 8 because his mother’s history of seizures made her unable to care for him, according to records. Valdez said he ran away from foster care placements because of abuse or neglect.

A few years later, he entered the Texas juvenile justice system for the first time. Officials there would not comment on his case. But Valdez said that while he was shuffled between facilities, his antidepressant and antipsychotic medications would be abruptly stopped and his records rarely transferred. He never received therapy or other support to cope with his childhood experiences, which included sexual abuse, according to his medical records.

Valdez said his mental health deteriorated while he was in custody, from being put in isolation for long periods of time, the rough treatment of officials, fears of violence from other children, and the lack of adequate health care.

“I felt like an animal,” Valdez said.

In August, the U.S. Department of Justice released a report that claims the state exposes children in custody to excessive force and prolonged isolation, fails to protect them from sexual abuse, and fails to provide adequate mental health services. The Texas Juvenile Justice Department has said it is taking steps to improve safety at its facilities.

In 2024, 100% of children in Texas Juvenile Justice Department facilities needed specialized treatment, including for problems with mental health, substance use, or violent behavior, according to the department.

Too often, “our system is making people worse and failing to provide them with the continuity of care they need,” said Elizabeth Henneke, founder and CEO of the Lone Star Justice Alliance, a nonprofit law firm in Texas.

Valdez said trauma from state custody shadowed his life after release. He was quick to anger and violence and often felt hopeless. He was incarcerated again before he had a breakdown that led to his hospitalization in 2022. He was diagnosed with post-traumatic stress disorder and put on medication, according to his medical records.

“It helped me understand that I wasn’t going crazy and that there was a reason,” he said. “Ever since then, I’m not going to say it’s been easy, but it’s definitely been a bit more manageable.”

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But the CEO of Herbruck’s Poultry Ranch wasn’t sure how the family egg producer (one of the largest in the U.S., in business for over three generations) was going to get through it, financially or emotionally. One staffer broke down in Herbruck’s office in tears.

“The mental toll on our team of dealing with that many dead chickens is just, I mean, you can’t imagine it,” Herbruck said. “I didn’t sleep. Our team didn’t sleep.”

The stress of watching tens of thousands of sick birds die of avian flu each day, while millions of others waited to be euthanized, kept everyone awake.

In April 2024, as his first hens tested positive for the highly pathogenic avian influenza H5N1 virus, Herbruck turned to the tried-and-true U.S. Department of Agriculture playbook, the “stamping-out” strategy that helped end the 2014-15 bird flu outbreak, which was the largest in the U.S. until now.

Within 24 to 48 hours of the first detection of the virus, state and federal animal health officials work with farms to cull infected flocks to reduce the risk of transmission. That’s followed by extensive disinfection and months of surveillance and testing to make sure the virus isn’t still lurking somewhere on-site.

Since then, egg farms have had to invest millions of dollars into biosecurity. For instance, employees shower in and shower out, before they start working and after their shifts end, to prevent spreading any virus. But their efforts have not been enough to contain the outbreak that started three years ago.

This time, the risk to human health is only growing, experts say. Sixty-six of the 67 total human cases in the United States have been just since March, including the nation’s first human death, reported last month.

“The last six months have accelerated my concern, which was already high,” said Nahid Bhadelia, an infectious diseases physician and the founding director of Boston University’s Center on Emerging Infectious Diseases.

Controlling this virus has become more challenging, precisely because it’s so entrenched in the global environment, spilling into mammals such as dairy cows, and affecting roughly 150 million birds in commercial and backyard flocks in the U.S.

Because laying hens are so susceptible to the H5N1 virus, which can wipe out entire flocks within days of the first infection, egg producers have been on the front lines in the fight against various bird flu strains for years. But this moment feels different. Egg producers and the American Egg Board, an industry group, are begging for a new prevention strategy.

Many infectious disease experts agree that the risks to human health of continuing current protocols are unsustainable, because of the strain of bird flu driving this outbreak.

“The one we’re battling today is unique,” said David Swayne, former director of the Southeast Poultry Research Laboratory at the USDA’s Agricultural Research Service and a leading national expert in avian influenza.

“It’s not saying for sure there’s gonna be a pandemic” of H5N1, Swayne said, “but it’s saying the more human infections, the spreading into multiple mammal species is concerning.”

For Herbruck, it feels like war. Ten months after Herbruck’s Poultry Ranch was hit, the company is still rebuilding its flocks and rehired most of the 400 workers it laid off.

Still, he and his counterparts in the industry live in fear, watching other farms get hit two, even three times in the past few years.

“I call this virus a terrorist,” he said. “And we are in a battle and losing, at the moment.”

When Biosecurity Isn’t Working … or Just Isn’t Happening

So far, none of the 23 people who contracted the disease from commercial poultry have experienced severe cases, but the risks are still very real. The first human death was a Louisiana patient who had contact with both wild birds and backyard poultry. The person was over age 65 and reportedly had underlying medical conditions.

And the official message to both backyard farm enthusiasts and mega-farms has been broadly the same: Biosecurity is your best weapon against the spread of disease.

But there’s a range of opinions among backyard flock owners about how seriously to take bird flu, said Katie Ockert, a Michigan State University Extension educator who specializes in biosecurity communications.

Skeptics think that “we’re making a mountain out of a molehill,” Ockert said, or that “the media is maybe blowing it out of proportion.” This means there are two types of backyard poultry enthusiasts, Ockert said: those doing great biosecurity, and those who aren’t even trying.

“I see both,” she said. “I don’t feel like there’s really any middle ground there for people.”

And the challenges of biosecurity are completely different for backyard coops than massive commercial barns: How are hobbyists with limited time and budgets supposed to create impenetrable fortresses for their flocks, when any standing water or trees on the property could draw wild birds carrying the virus?

Rosemary Reams, an 82-year-old retired educator in Ionia, Michigan, grew up farming and has been helping the local 4-H poultry program for years, teaching kids how to raise poultry. Now, with the bird flu outbreak, “I just don’t let people go out to my barn,” she said.

Reams even swapped real birds with fake ones for kids to use while being assessed by judges at recent 4-H competitions, she said.

“We made changes to the fair last year, which I got questioned about a lot. And I said, ‘No, I gotta think about the safety of the kids.’”

Reams was shocked by the news of the death of the Louisiana backyard flock owner. She even has questioned whether she should continue to keep her own flock of 20 to 30 chickens and a pair of turkeys.

“But I love ’em. At my age, I need to be doing it. I need to be outside,” Reams said. “That’s what life is about.” She said she’ll do her best to protect herself and her 4-H kids from bird flu.

Even “the best biosecurity in the world” hasn’t been enough to save large commercial farms from infection, said Emily Metz, president and CEO of the American Egg Board.

The egg industry thought it learned how to outsmart this virus after the 2014-15 outbreak. Back then, “we were spreading it amongst ourselves between egg farms, with people, with trucks,” Metz said. So egg producers went into lockdown, she said, developing intensive biosecurity measures to try to block the routes of transmission from wild birds or other farms.

Metz said the measures egg producers are taking now are extensive.

“They have invested hundreds of millions of dollars in improvements, everything from truck washing stations — which is washing every truck from the FedEx man to the feed truck — and everything in between: busing in workers so that there’s less foot traffic, laser light systems to prevent waterfowl from landing.”

Lateral spread, when the virus is transmitted from farm to farm, has dropped dramatically, down from 70% of cases in the last outbreak to just 15% as of April 2023, according to the USDA.

And yet, Metz said, “all the measures we’re doing are still getting beat by this virus.”

The Fight Over Vaccinating Birds

Perhaps the most contentious debate about bird flu in the poultry industry right now is whether to vaccinate flocks.

Given the mounting death toll for animals and the increasing risk to humans, there’s a growing push to vaccinate certain poultry against avian influenza, which countries like China, Egypt, and France are already doing.

In 2023, the World Organization for Animal Health urged nations to consider vaccination “as part of a broader disease prevention and control strategy.”

Swayne, the avian influenza expert and poultry veterinarian, works with WOAH and said most of his colleagues in the animal and public health world “see vaccination of poultry as a positive tool in controlling this panzootic in animals,” but also as a tool that reduces chances for human infection, and chances for additional mutations of the virus to become more human-adapted.

But vaccination could put poultry meat exporters (whose birds are genetically less susceptible to H5N1 than laying hens) at risk of losing billions of dollars in international trade deals. That’s because of concerns that vaccination, which lowers the severity of disease in poultry, could mask infections and bring the virus across borders, according to John Clifford, a former chief veterinary officer of the USDA. Clifford is currently an adviser to the USA Poultry and Egg Export Council.

“If we vaccinate, we not only lose $6 billion potentially in exports a year,” Clifford said. “If they shut us off, that product comes back on the U.S. market. Our economists looked at this and said we would lose $18 billion domestically.”

Clifford added that would also mean the loss of “over 200,000 agricultural jobs.”

Even if those trade rules changed to allow meat and eggs to be harvested from vaccinated birds, logistical hurdles remain.

“Vaccination possibly could be on the horizon in the future, but it’s not going to be tomorrow or the next day, next year, or whatever,” Clifford said.

Considering just one obstacle: No current HPAI vaccine is a perfect match for the current strain, according to the USDA. But if the virus evolves to be able to transmit efficiently from human to human, he said, “that would be a game changer for everybody, which would probably force vaccination.”

Last month, the USDA announced it would “pursue a stockpile that matches current outbreak strains” in poultry.

“While deploying a vaccine for poultry would be difficult in practice and may have trade implications, in addition to uncertainty about its effectiveness, USDA has continued to support research and development in avian vaccines,” the agency said.

At this point, Metz argued, the industry can’t afford not to try vaccination, which has helped eradicate diseases in poultry before.

“We’re desperate, and we need every possible tool,” she said. “And right now, we’re fighting this virus with at least one, if not two, arms tied behind our back. And the vaccine can be a huge hammer in our toolbox.”

But unless the federal government acts, that tool won’t be used.

Industry concerns aside, infectious diseases physician Bhadelia said there’s an urgent need to focus on reducing the risk to humans of getting infected in the first place. And that means reducing “chances of infections in animals that are around humans, which include cows and chickens. Which is why I think vaccination to me sounds like a great plan.”

The lesson “that we keep learning every single time is that if we’d acted earlier, it would have been a smaller problem,” she said.

This article is from a partnership that includes Michigan Public, NPR, and KFF Health News.

KFF 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 KFF.

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In late January, two school-age children from Gaines County were hospitalized with measles. Since an estimated 1 in 5 people with the disease end up in the hospital, the two cases suggested a larger outbreak.

As of Feb. 12, there were 24 cases, mainly among children, with at least 14 hospitalizations, said Zach Holbrooks, executive director of the South Plains Public Health District, which includes Gaines. A few cases are in surrounding counties. The department is investigating many other potential cases in hopes of treating people quickly and curbing the spread of the virus. “There may be active cases out there and the individual has chosen not to seek medical attention,” Holbrooks said.

Public health practitioners warn such outbreaks will become more common because of scores of laws around the U.S. — pending and passed — that ultimately lower vaccine rates. Many of the measures allow parents to more easily exempt their children from school vaccine requirements, and a swell of vaccine misinformation has led to record rates of exemptions.

As Robert F. Kennedy Jr., one of the most influential purveyors of dangerous vaccine misinformation, prepares to take the helm of the Department of Health and Human Services, researchers say such bills have a higher chance of passing and that more parents will refuse vaccines because of false information spread at the highest levels of government.

“Mr. Kennedy has been an opponent of many health-protecting and life-saving vaccines, such as those that prevent measles and polio,” scores of Nobel Prize laureates wrote in a letter to the Senate. Having him head HHS, they wrote, “would put the public’s health in jeopardy.”

Most people who aren’t protected by vaccination will get measles if exposed. Gaines County has one of the lowest rates of childhood vaccination in Texas. At a local public school district in the community of Loop, only 46% of kindergarten students have gotten vaccines against measles, mumps, and rubella. Vaccination rates may be even lower at private schools and within homeschool groups, which don’t always report the information.

Holbrooks’ team is scrambling to track transmission, ensure that kids and babies seek prompt care, and offer measles vaccines to anyone who hasn’t yet gotten them.

“We are going to see more kids infected. We will see more families taking time off from work. More kids in the hospital,” said Rekha Lakshmanan, chief strategy officer for The Immunization Partnership in Houston, a nonprofit that advocates for vaccine access. “This is the tip of the iceberg.”

As a rule, at least 95% of people need to be vaccinated against measles for a community to be well protected. That threshold is high enough to protect infants too young for the vaccine, people who can’t take the vaccine for medical reasons, and anyone who doesn’t mount a strong, lasting immune response to it.

Measles is extremely contagious, so health workers preemptively treated infants too young to be vaccinated who had shared the emergency room with children later diagnosed with the virus, said Katherine Wells, public health director in Lubbock, Texas. Some children from Gaines were hospitalized in that county. The disease can cause severe complications, and about one of every thousand children with measles die.

An outbreak among a largely unvaccinated population in Samoa in 2019 and 2020 caused 83 deaths, mainly among children, and more than 5,700 cases. Kennedy, who peddles misinformation about measles vaccines, had visited the island earlier on a trip arranged by a Samoan anti-vaccine influencer, according to a 2021 blog post by Kennedy.

Without evidence, Kennedy cast doubt on the fact that measles caused the tragedy in Samoa. “We don’t know what was killing them,” he said at his first confirmation hearing. Samoa’s top health official denounced this evasion as “a complete lie,” in an interview with The Associated Press.

Last school year, the number of kindergartners exempted from a vaccine requirement — 3.3% — was higher than ever reported before, according to the Centers for Disease Control and Prevention. Numbers were far higher than that in Gaines County, where nearly 1 in 5 children in kindergarten had a vaccine exemption for philosophical or religious reasons in 2023-24.

Over the past couple of years, several states have allowed more parents to obtain exemptions. Already, about 25 bills have been filed in the 2025 Texas legislative session that could limit vaccination in various ways.

“We’re seeing a level of momentum this legislative session that we’ve never seen in the past,” Lakshaman said. Changes are afoot at the local level, too. For example, a school board in the Houston area voted to remove references to vaccines in its curriculum. “There is a top-down and bottom-up assault on these protections,” Lakshaman said.

About 80% of the public believes that the benefits of the measles, mumps, and rubella vaccines outweigh the risks, according to a 2025 KFF poll.

“Lawmakers who put forth dangerous policies need to know the people they hear from don’t represent the majority,” Lakshaman said. Her group offers resources on its website to help people influence decisions on vaccination policies.

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Years ago, Wilkins was dating a man newly diagnosed with HIV and went to get tested, she said, but was not offered PrEP.

Since then, Wilkins said, doctors either have told her she doesn’t need the drug or were reluctant to prescribe it. Her insurance through work would not cover a long-acting injectable form that tends to have better results than the original pill form. Getting to appointments across Atlanta for the pills was a challenge. She is now enrolled in a drug trial for a promising PrEP injection but worries about future access and cost.

Preexposure prophylaxis, known as PrEP, reduces the risk of new HIV infections through sex by 99% and among injectable drug users by at least 74%, according to the Centers for Disease Control and Prevention.

Among states, Georgia has the highest rate of new HIV infections, but residents — especially women and Black patients like Wilkins — are often not getting PrEP, data shows.

A rule enacted by the Biden administration that took effect for many Affordable Care Act plans on Jan. 1 should make it easier for people like Wilkins to get long-acting PrEP injectable drugs.

A new Trump administration adds an X factor to this and other federal health programs. On Jan. 27, the White House announced a federal funding freeze, which sent shudders through health agencies and nonprofits. By Jan. 29, it had reversed the order.

Federal initiatives like the Ryan White HIV/AIDS Program and HIV prevention funding seemed to be affected — and “blocking access to PrEP would have deadly consequences,” said Wayne Turner, a senior attorney at the National Health Law Program.

Georgia has big racial and gender discrepancies in PrEP uptake, said Patrick Sullivan, who is an epidemiology professor at Emory University and leads AIDSVu and PrEPVu, which track HIV data and access to the drug — work that is backed by Gilead Sciences, a PrEP drug manufacturer.

Public health experts use what’s called a “PrEP-to-need ratio” to measure how many people at risk of HIV are getting the drug. A higher number is better. In Georgia for 2023, the statewide ratio was 6, while it was nearly 167 in Vermont, according to PrEPVu.

While the ratio for white people in Georgia was roughly 22, it was about 3 for Black people and just over 3 for Hispanic people. And while it was 7 for men, it was just over 2 for women.

“Black people generally are underserved by PrEP, and women are underserved by PrEP relative to men,” Sullivan said.

Increasing PrEP uptake would help the state cut its new HIV diagnoses, said Dylan Baker, associate medical director at Grady Health’s HIV Prevention Program.

Georgia’s rate of new HIV diagnoses was 27 per 100,000 in 2022, according to the most recent available data. That’s second only to Washington, D.C., and more than double the national rate of 13 per 100,000. That amounts to about 2,500 new cases diagnosed in Georgia in a year.

Globally about 3.5 million people used PrEP in 2023, up from 200,000 in 2017 but short of the United Nations’ 2025 target of 21.2 million people, according to a 2024 report by the United Nations Program on HIV/AIDS.

PrEP users in Atlanta report many challenges in getting the drug, including cost, medical providers who don’t prescribe it, stigma, a lack of inclusive marketing, and transportation. Wilkins said she has run up against all of those.

“Here I am telling you that I’m here to get tested because I have come into contact with someone who was living with HIV, and we had a sexual relationship, and you’re not even mentioning PrEP to me,” Wilkins said. “That was a disservice.”

Insurers Now Required To Cover PrEP

Cost has long been a barrier. The Biden administration last fall issued guidance requiring most insurers to cover the full cost of all forms of PrEP, without prior authorization, along with certain lab work and other services. This includes pills as well as Apretude, an injection given every two months.

That means insured PrEP users should not face out-of-pocket costs, said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, which lobbied for the rule.

It applies to those on the federal marketplace plans and most large private health plans. A similar rule exists for Medicare and Medicare Advantage plans.

Schmid said he does not think the Trump administration will repeal the rule, but he is concerned the U.S. Supreme Court could end coverage for preventive services, including PrEP, when it issues a decision in Braidwood Management v. Becerra, anticipated this summer.

The rule will not help the uninsured. In Georgia, which did not expand Medicaid under the ACA, about 1 million adults under age 65 are uninsured.

“The cost is also a struggle, especially given different people are part of the gig economy, a lot of folks don’t always have access to health insurance,” said Maximillian Boykin, an Atlanta PrEP user.

Expanding Medicaid would help. States that have done so, Sullivan said, “have higher levels of PrEP uptake.”

Winning the PrEP Lottery

Since getting on PrEP in 2019, Wilkins has encountered two doctors who did not want to prescribe it.

One female OB-GYN told her “‘Girl, at our age, we should know better.’” Wilkins said she “fired” that doctor, telling her that such comments are stigmatizing.

When Wilkins moved, she looked for a nearby primary care provider so she would not have to pay for transportation to get PrEP.

But the doctor she found, Wilkins said, told her to find an infectious disease specialist for PrEP.

“‘You’re not treating an infectious disease,’ I say. ‘This is preventive care,’” Wilkins recalled.

Wilkins’ fortunes turned when she was selected to join a study for a twice-yearly injectable form of PrEP.

Lenacapavir, already approved for HIV treatment, showed promising results for HIV prevention in two earlier Gilead trials. Wilkins is part of a trial in Atlanta including about 250 cisgender women nationally who have sex with men.

It’s much better than a daily pill or even a shot once every two months, Wilkins said.

She hopes to stay on the drug, but the U.S. list price for lenacapavir as an HIV treatment averages about $40,000 a year.

Gilead last year announced it signed royalty-free licensing agreements with six manufacturers to make generic lenacapavir for 120 primarily low- and lower-middle-income countries.

It’s not clear where it falls with the Biden rule. “We believe it should be covered,” Schmid said, “but want the federal government to state that clearly.”

For many patients, challenges remain. Most people are willing to travel about 30 minutes for routine health care, Sullivan said, but in cities like Atlanta, those relying on public transportation may face longer commutes to PrEP providers. Some who need PrEP have unstable housing without firm mailing addresses.

Privacy is another concern. “Everybody should be able to find a place that's comfortable,” Sullivan said. “More of that can go on in primary health care.”

Others agree that public health messaging around PrEP services should target more diverse audiences. Dázon Dixon Diallo is the founder of SisterLove, an HIV, sexual, and reproductive health organization focused on Black women in the Southeast.

“You’re not going to get to us by giving us a 3-second cameo in a commercial about PrEP,” she said. “There’s no story in there for me, right?”

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SUITLAND, Md. — At a SuperSuds Laundromat just south of Washington, D.C., a steady stream of customers loaded clothes into washers and dryers on a recent Sunday morning, passing the time on their phones or watching television.

Amid the low hum of spinning clothes, Adrienne Jones made the rounds in a bright yellow sweatshirt, asking customers about their health needs. “Do you have health coverage?” Jones, an outreach manager for Fabric Health, asked Brendan Glover, 25, who was doing laundry with his toddler in tow.

Glover works in law enforcement, but he lost his coverage in 2024 when a job ended. “I am young, so I don’t think about it, but I know I will need it,” he said.

Jones collected his contact information, gave him a gift card for a future laundromat visit, and promised to help him find affordable coverage.

State Medicaid and Affordable Care Act coverage programs have long struggled to connect with lower-income Americans to help them access health care. They send letters and emails, place phone calls, and post on social media platforms such as Facebook and X.

Some of these state programs are trying an alternative approach: meeting people at the laundromat — where they regularly go and usually have time to chat.

Fabric Health, a Washington, D.C.-based startup, sends outreach workers into laundromats in Maryland, Pennsylvania, New Jersey, and — as of January — the District of Columbia, to help people get and use health coverage, including by helping schedule checkups or maternity care. The workers, many of whom are bilingual, visit the laundromats also to establish relationships, build trust, and connect people with government assistance.

Medicaid health plans including those run by CareFirst BlueCross BlueShield in Maryland, UPMC in Pittsburgh, and Jefferson Health in Philadelphia pay Fabric Health to connect with their enrollees. The company was paid by the Maryland Managed Care Organization Association, the state’s Medicaid health plan trade group, to help people recertify their Medicaid eligibility after covid pandemic-era coverage protections expired.

Since 2023, the company has connected with more than 20,000 people in Maryland and Pennsylvania alone, collecting contact information and data on their health and social needs, said Allister Chang, a co-founder and the chief operating officer. Chang also serves on the D.C. State Board of Education as Ward 2’s elected representative.

Fabric Health would not disclose its fees to KFF Health News. The company is structured as a public benefit corporation, meaning it is a for-profit business created to provide a social benefit and is not required to prioritize seeking profits for shareholders.

Pennie, Pennsylvania’s ACA marketplace, which opened in 2020, pays Fabric Health to talk to people in the Philadelphia and Pittsburgh areas about coverage options and enroll them.

A survey last year found that two-thirds of uninsured people in the state have never heard of Pennie, said Devon Trolley, Pennie’s executive director.

“Fabric’s approach is very novel and creative,” she said. “They go to where people are sitting with time on their hands and develop grassroots relationships and get the word out about Pennie.”

For enrollees, the laundromat chats can be easier and quicker than connecting with their health plans’ customer service. For the health plans, they can increase state performance payments, which are tied to enrollee satisfaction and effectiveness at getting them services such as cancer screenings.

“Our pitch is: People spend two hours a week waiting around in laundromats and that idle time can be incredibly productive,” said Courtney Bragg, a co-founder and the CEO of Fabric Health.

CareFirst began working with the company last year to help people in Maryland renew coverage, schedule checkups, and sign up for other benefits including energy assistance and food stamps.

Sheila Yahyazadeh, chief external operations officer for the CareFirst plan, said the initiative shows the importance of human interaction. “There is a misconception that technology will solve all, but a human face is absolutely fundamental to make this program successful because at the end of the day people want to talk to someone and feel seen and cared for,” she said.

On a previous visit to SuperSuds, Jones, the Fabric Health outreach worker, met Patti Hayes, 59, of Hyattsville, Maryland, who is enrolled in the Medicaid health plan operated by CareFirst but had not seen a primary care physician in over a year. She said she preferred to see a Black physician.

After they met at the laundromat, Jones helped her find a new doctor and schedule an appointment. She also helped her find a therapist in her plan’s network.

“This is helpful because it’s more of a personal touch,” Hayes said.

Fabric Health also texts people to stay in touch and tell them when the outreach workers will be back at their laundromat so they can meet again in person.

Paola Flores, 38, of Clinton, Maryland, told a Fabric Health worker she needed help switching Medicaid plans so she could get better care for her autistic child. Communicating with her in Spanish, the worker said she would help her, including by making an appointment with a pediatrician.

“Good help is hard to find,” Flores said.

Ryan Moran, Maryland’s Medicaid director, said Fabric Health helped keep people enrolled during the Medicaid “unwinding,” when everyone on the program had to get renewed after the expiration of pandemic-era coverage protections that lasted three years.

Outreach workers there focused on laundromats in towns that had high rates of people being disenrolled for paperwork reasons.

“There is no question about the value of human-to-human interaction and the ability to be on the ground where people are, that removes barriers and gets people to engage with us,” Moran said.

KFF 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 KFF.

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