The amounts represent what Medicaid spent covering the residents’ care when they lived at the Glenwood Resource Center, a state-run facility that closed last summer.

The bills are extraordinary examples of a practice called Medicaid estate recovery. Federal law requires states to try to collect money after some types of Medicaid recipients die. The point is to encourage people to use their own resources before relying on the public program. But some states, including Iowa, are particularly aggressive about the collections, national reports show.

Joy Higgins was stunned by a letter she received a few weeks after her 41-year-old daughter, Kristin, died last May. The letter was written on Iowa Department of Health and Human Services stationery. At the top, in bold letters, it said, “Re: Kristin Higgins.”

“Dear Joy Higgins,” the letter read. “Our sincere condolences to you, as we understand the above person is deceased.”

The letter explained that any money Kristin Higgins left behind would have to be remitted to the state to help repay Medicaid $4,263,148.67. Her family had 30 days to respond.

Joy Higgins, who lives in Council Bluffs, wonders why state debt collectors would send a massive bill to the family of someone like her daughter, who had little income because of a severe developmental disability stemming from a premature birth.

“What are they gaining? That’s my question. Except for kicking someone in the face right after they lost a loved one?” Higgins said.

Kristin Higgins’ only income was a Social Security disability benefit of $1,105 monthly. Most of that went directly to the state institution, where she lived for more than 30 years. Just $50 was set aside monthly as an allowance for personal expenses, according to a state ledger obtained by her family. “They knew exactly how much she had,” her mother said.

When she died, Kristin’s personal account had a balance of $2,239.84. The family put that money toward her funeral, an allowed expense. Nothing was left for the state to take. Higgins said receiving the letter was traumatic even though the family didn’t have to pay the Medicaid bill.

The Higginses have heard about similar attempts to collect from other families, including that of Eric Tomlyn, who died in 2020 at age 29 after spending most of his life at the Glenwood Resource Center.

Shortly after his death, the Tomlyn family received a Medicaid bill of more than $4.2 million. His mother, Susan Tomlyn, was shocked by the letter. “I was like, ‘What? What? Oh my God,’” she recalled.

She filled out a form explaining that the small balance in her son’s personal account had gone toward his funeral. “That’s the last I heard of it,” Tomlyn said.

Supporters of estate recovery efforts say the rules encourage people to pay for their own care before applying for Medicaid, which is mainly intended to help those with little money.

Critics of estate recovery programs say they often target families with little to give. Wealthier families tend to have lawyers who can structure estates in ways that avoid Medicaid repayment demands, the critics note.

Like Higgins, Tomlyn thought her Medicaid recovery bill came from state officials because it was printed on letterhead from the Iowa Department of Health and Human Services. The people who signed the letters identified themselves as being from the “Estate Recovery Program.” But the people who produce such letters work for private contractors hired to collect Medicaid debts, according to Alex Murphy, a spokesperson for the state agency. Their contract requires them to use state stationery.

Murphy said in an email to KFF Health News that such letters are sent after every death of an Iowa Medicaid recipient who was at least 55 years old or who lived in a long-term care facility. He said the letters “request information from family members regarding the deceased person’s assets and expenses,” and the letters note that repayments are expected only from the person’s estate.

Iowa’s Medicaid collections are handled by Sumo Group, a Des Moines company. Its director, Ben Chatman, declined to answer questions, including why the company sent bills to families of people with disabilities who lived most of their lives in state institutions. “I don’t do media relations,” Chatman said.

Sumo Group is a subcontractor of a national company, Gainwell Technologies, which has handled Medicaid collections for several states. In Iowa, the company is paid 11% of whatever it can collect from the estates of Medicaid participants. A spokesperson for Gainwell declined to comment.

Iowa’s Medicaid estate recovery program brought in $40.2 million in the fiscal year that ended last June, up nearly 14% from two years earlier, state records show. That total represents a sliver of the state’s total Medicaid budget, which is expected to hit $9 billion this year.

Nearly two-thirds of Iowa estate recovery cases wound up being closed with no collection of money last fiscal year, according to the state. In cases in which money was recouped, the average amount paid was about $10,000.

Thirty-five Iowa families were granted hardship waivers, which the state allows if an heir’s health or life would be endangered because payment of the Medicaid bill would deprive them of food, clothing, shelter, or medical care. Officials denied an additional 20 requests for hardship waivers.

A 2021 report to Congress estimated states collected more than $700 million annually from Medicaid participants’ estates. That money is shared with the federal government, which helps finance Medicaid. Some states claw back much less than others. Hawaii, for example, collected just $31,000 in 2019, the latest year analyzed in the federal report. Iowa, with about twice as many residents as Hawaii, raked back more than $26 million that year.

Americans aren’t subject to such clawbacks for using any other federal health program, including Medicare, which covers older people of all income levels.

The national group Justice in Aging has helped lead opposition to Medicaid estate recovery programs. Eric Carlson, a California attorney for the group, said the issue usually comes into play after the death of a person who had nursing home care covered by Medicaid. Recovery demands often force survivors to sell homes that are their families’ main form of wealth, he said.

Carlson said he hadn’t previously heard of Medicaid estate recovery bills topping $4 million, like the ones sent to survivors of the two Iowans with disabilities.

He wondered why debt collectors would pursue such cases, which are unlikely to yield any money but could cause anxiety for families. “Of course, if you open up a piece of mail that says you owe millions of dollars, you’re going to think the worst,” he said.

Carlson said he would advise anyone who receives such a letter to respond to it with documentation showing that their loved one’s estate can’t repay a Medicaid debt. “It’s never a good idea to ignore it,” he said. Failure to respond to the bill could lead to continued collection efforts, which could threaten a family member’s finances or property, he said.

Some states have reined in their Medicaid clawback efforts. For example, Massachusetts legislators last year voted to drastically limit their program. This was the second time Massachusetts reduced its Medicaid estate recovery effort, which once was one of the most aggressive in the U.S.

Critics in Congress have also tried to limit the practice.

Rep. Jan Schakowsky (D-Ill.) has twice introduced bills to eliminate the federal requirement that states claw back Medicaid spending from recipients’ estates. Last year’s bill gained 47 Democratic co-sponsors, but it received no support from the Republicans controlling the chamber, and there was no similar bill in the Senate. She plans to try again this year, even though her party remains in the minority.

Schakowsky said in an interview that she’d never heard of Medicaid estate recovery demands reaching millions of dollars, as the Iowa families faced. But demands for hundreds of thousands of dollars are common. For many families, “that’s still impossible” to meet, she said.

Schakowsky hopes that members of Congress from both parties will agree to curtail the program once they realize how much angst it causes their constituents and how relatively little money it returns to the government. “The whole program is ridiculous,” she said.

Her quest could become even tougher if the Trump administration moves ahead with proposals to trim Medicaid spending.

The office of Sen. Chuck Grassley, who is the senior member of Iowa’s all-Republican congressional delegation and has taken leading roles in many health policy debates, declined to comment on the issue.

The Iowa Department of Health and Human Services said it notifies families about the estate recovery process when they apply for Medicaid. Joy Higgins said she doesn’t recall seeing such a notice.

The institution where Kristin Higgins spent most of her life was closed last year after federal officials investigated complaints of poor medical care. But Joy Higgins said her daughter was treated well there overall. “If I had millions in the bank, I’d give it to the state,” she said. “I would. It was worth it.”

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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.

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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.

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

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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.

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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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Now, a small but growing number of house cats have gotten sick from H5N1, the bird flu strain driving the current U.S. outbreak, after eating raw food or drinking unpasteurized milk. Some of those cats died.

The strain of bird flu currently circulating has not adapted to efficiently spread among people. And there have been no known cases of cat-to-human transmission during the current outbreak of H5N1.

Still, there’s always been the risk that cats, which are arguably only semi-domesticated, could bring home a disease from a midnight prowl.

“Companion animals, and especially cats, are 100% a public health risk in terms of the risk of zoonotic transmission to people,” said virologist Angela Rasmussen, who studies disease progression in emerging viruses at the University of Saskatchewan’s Vaccine and Infectious Disease Organization.

This is because we snuggle with and sleep in bed with our cats. When we’re not looking, cats drink from our water glasses and walk on kitchen counters. So, cat owners should be aware of the ongoing spread of bird flu. “By reducing the risk to your cats, you reduce the risk to yourself,” Rasmussen said.

Rasmussen doesn’t think pet owners should be afraid their cats will give them bird flu but said taking precautions is good for pets, and for public health.

Signs of bird flu in cats include runny nose and discharge around the eyes, explained Michael Q. Bailey, president-elect of the American Veterinary Medical Association.

H5N1 also causes neurological problems like dizziness and seizures, which are symptoms of rabies, too. Rabies is almost always fatal, and it poses a threat to human health, so any animal suspected of having the viral disease must be euthanized. Bailey encourages people to ensure pets are up-to-date on their vaccinations.

Veterinarian Jane Sykes, who specializes in infectious diseases in cats and dogs at the University of California-Davis School of Veterinary Medicine, said people should not assume it’s bird flu if their cat is sick — even if their animal spends time outdoors or eats a raw diet. Upper-respiratory illnesses are common in cats, while H5N1 is “still pretty rare.”

Sykes gives her indoor cat, Freckles, regular kibble exclusively. She told NPR and KFF Health News she has no concerns about Freckles getting H5N1 because the heating process of making dry or canned pet food kills viruses.

More Cases in Cats, More Risk to Humans

Some people feed their pets raw meat or unpasteurized milk because they think it’s a more nutritious or natural diet. The American Veterinary Medical Association’s website discourages this due to foodborne pathogens like salmonella and listeria, and now the highly pathogenic H5N1.

By keeping pets healthy, veterinarians play an essential role in protecting humans from zoonotic diseases. The American Veterinary Medical Association says the risk of H5N1 spilling over from a pet to a person is “considered extremely low, but not zero.”

State and local public health agencies, including those in Los Angeles County and Washington state, have issued similar warnings against raw food diets for pets.

Concerns for human health are partly why the FDA announced last month it is now requiring cat and dog food companies to update their safety plans to protect against bird flu.

This came after the Oregon Department of Agriculture discovered a cat that was “strictly an indoor cat” had contracted H5N1 and died after consuming a frozen turkey product made by the raw pet food brand Northwest Naturals. It stated that “tests confirmed a genetic match between the virus in the raw and frozen pet food and the infected cat.”

Northwest Naturals voluntarily recalled that batch of its frozen turkey-based product. The company told KFF Health News and NPR that the recall involved “a small product run” and that it has concerns about the accuracy of the Oregon Agriculture Department’s testing.

Los Angeles County’s public health department said five cats from two households tested positive for bird flu after drinking unpasteurized raw milk from the Raw Farm dairy in California’s Central Valley.

Raw Farm voluntarily recalled its milk and cream after retail products tested positive for H5N1, but it denies any food safety issues, calling the concern “a political issue.”

Veterinarians also warn pet owners not to allow cats unsupervised time outside as there’s the risk of them getting H5N1 by interacting with other animals that might carry the disease.

“This is a very scary virus, given that it can infect so many different host species,” said Bruce Kornreich, director of Cornell University’s Feline Health Center.

At least one instance of a cat infecting a person with bird flu occurred in 2016. As NPR reported, a veterinarian in New York City caught the virus after having close contact with infected cats. The vet experienced mild symptoms and quickly recovered.

In that case, the strain of bird flu was H7N2, not the H5N1 that is now circulating in the U.S.

H7N2 is a very different type of virus, Sykes explained. But she said it shows that cat-to-human transmission of avian influenza is theoretically possible.

There isn’t a lot of research on transmission of bird flu from companion animals like cats or dogs to humans, though Rasmussen agreed it’s definitely a concern: The more infections you have in animals, “the more your luck is potentially going to run out.”

Most people who have caught H5N1 are agricultural workers who had direct contact with infected poultry or cattle. Of at least 67 confirmed human cases of H5N1 in the U.S., there’s been one fatality in an immunocompromised person who had contact with birds.

In general, zoonotic disease researchers want more H5N1 surveillance in companion animals of all types. Even if the human death toll of H5N1 remains relatively low, it remains a public health risk.

Chances for Mutation

Part of the concern with this H5N1 outbreak is that bird flu viruses change. Just a few mutations could make this strain adept at spreading between people. And the more people who catch H5N1, the more likely it would adapt to be more efficient, said Suresh Kuchipudi, a virologist at the University of Pittsburgh School of Public Health, where he researches zoonotic diseases. Kuchipudi has studied H5N1 in cats.

Another concern is something called reassortment. If an animal or person is infected with two viruses at once, the viruses can trade genetic material, creating something new. This is common in influenza, so virologists are on the lookout for a case in which the bird flu reassorts to make a virus that’s far more contagious, and potentially more virulent.

Virologist Rasmussen is way more worried about this happening in pigs. Human respiratory physiology is more like that of swines than felines. So far, the current outbreak of H5N1 has not reached commercial hog operations. Rasmussen hopes it stays that way.

Kuchipudi said that reassortments are relatively rare events, but the outcome is completely unpredictable. Sometimes the results are benign, though it was likely a reassortment that involved an avian virus that led to the 1918 flu pandemic, which killed an estimated 50 million people. In the century since, virologists have established a global surveillance network to monitor influenza viruses. Scientists say continued investment in this network is key to preparing for and hopefully preventing another pandemic.

Winter is “reassortment season” because of all the influenza viruses circulating, Rasmussen said. A reassortment in cats could technically be possible since these pets occasionally get seasonal flu, but it’s highly unlikely. Rather, Rasmussen said, it’s more likely that a cat would pass H5N1 to a human who already has seasonal flu, and then a reassortment happens in the sick person. While the risk isn’t zero, Rasmussen doubts this will happen. It would depend on how ill the human was, and how much virus they’re exposed to from their cat.

“Unless the cat is really shedding a ton of virus, and you’re kind of making out with the cat, I think it would be hard,” she said.

Rasmussen and Kuchipudi caution there isn’t enough research to know for sure how much virus cats shed, or even how they shed the virus.

The Centers for Disease Control and Prevention was poised to release a new study about H5N1 in cats, but that was delayed when the Trump administration paused the Morbidity and Mortality Weekly Report. That investigation, revealed through emails obtained by KFF Health News in a public records request, found that house cats likely got bird flu from dairy workers.

Scientists and public health agencies should question previously held assumptions about bird flu, Kuchipudi urged. He noted that 20 years ago nobody would have predicted that bird flu would infect dairy cattle the way it is now.

Dogs Seem To Fare Better

The FDA says other domesticated animals, including dogs, can get bird flu infections. There are no confirmed cases of H5N1 among dogs in the U.S., though in other countries they have died from the virus.

There’s some disagreement and an overall lack of research on whether cat biology makes them more susceptible to H5N1 than other mammals, including humans, pigs, or dogs.

But cat behaviors, such as their love of dairy and predation of wild birds, put them at higher risk, Kuchipudi said. Also, living in groups might play a role as there are more feral cat colonies in the U.S. than packs of stray dogs.

There’s very little people can do about the H5N1 circulating in wild birds. As Rasmussen explained, “It’s flying around in the skies. It’s migrating north and south with the seasons.”

But she said there’s a lot people can do to keep the virus out of their homes.

That includes limiting a pet’s exposure to H5N1 by not feeding them raw food or unpasteurized milk, and trying to keep them from interacting with animals like rodents and wild birds that could be infected with the virus.

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

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Ahora, un pequeño pero creciente número de gatos domésticos se han enfermado con H5N1, la cepa de gripe aviar protagonista del brote actual en el país, después de comer alimentos crudos o beber leche sin pasteurizar. Algunos de ellos murieron.

La cepa de gripe aviar que circula actualmente no se ha adaptado para propagarse de manera eficiente entre las personas. Y no se han conocido casos de transmisión de gato a humano durante el brote actual de H5N1.

Aun así, siempre ha existido el riesgo de que los gatos, que posiblemente solo estén semi domesticados, puedan traer a casa una enfermedad al acecho nocturno.

“Los animales de compañía, y especialmente los gatos, son un riesgo para la salud pública en un 100% en términos de riesgo de transmisión zoonótica a las personas”, dijo la viróloga Angela Rasmussen, que estudia la progresión de la enfermedad en virus emergentes en la Vaccines and Infectious Disease Organization de la Universidad de Saskatchewan.

Las personas duermen con sus gatos. Los gatos beben de los vasos de agua humanos y caminan sobre la mesada de la cocina. Por eso, los dueños de gatos deben ser conscientes de la propagación continua de la gripe aviar. “Al reducir el riesgo para sus gatos, se reduce el riesgo para tí mismo”, dijo Rasmussen.

Rasmussen no cree que los dueños de mascotas deban tener miedo de que sus gatos les transmitan la gripe aviar, pero dijo que tomar precauciones es bueno para las mascotas y para la salud pública.

Los síntomas de la gripe aviar en los gatos incluyen secreción nasal y alrededor de los ojos, explicó Michael Q. Bailey, presidente electo de la American Veterinary Medical Association.

El H5N1 también causa problemas neurológicos como mareos y convulsiones, que comparte con los síntomas de la rabia. La rabia es casi siempre mortal y supone una amenaza para la salud humana, por lo que cualquier animal sospechoso de tener esta enfermedad viral debe ser sacrificado. Bailey anima a las personas a asegurarse de que sus mascotas estén al día con sus vacunas.

La veterinaria Jane Sykes, que se especializa en enfermedades infecciosas en gatos y perros en la Facultad de Medicina Veterinaria de la Universidad de California-Davis, dijo que las personas no deben asumir que se trata de gripe aviar si su gato está enfermo, incluso si su animal pasa tiempo al aire libre o come una dieta cruda. Las enfermedades de las vías respiratorias superiores son comunes en los gatos, mientras que el H5N1 es “todavía bastante raro”.

Sykes le da a su gato, Freckles, alimento para mascotas. Dijo a NPR y KFF Health News que no le preocupa que Freckles contraiga el H5N1 porque el proceso de calentamiento para hacer alimentos secos o enlatados para mascotas mata los virus.

Más casos en gatos, más riesgo para los humanos

Algunas personas alimentan a sus mascotas con carne cruda o leche no pasteurizada porque creen que es una dieta más nutritiva o natural. El sitio web de la American Veterinary Medical Association desaconseja esta práctica debido a los patógenos transmitidos por los alimentos, como la salmonella y la listeria, y ahora el altamente patógeno H5N1.

Al mantener sanas a las mascotas, los veterinarios desempeñan un papel esencial en la protección de los humanos contra las enfermedades zoonóticas. La asociación afirma que el riesgo que el H5N1 se transmita de una mascota a una persona se considera “extremadamente bajo, pero no cero”.

Las agencias de salud pública estatales y locales, incluidas las del condado de Los Ángeles y del estado de Washington, han emitido advertencias similares sobre alimentar a las mascotas con alimentos crudos.

Las preocupaciones por la salud humana son en parte la razón por la que la Administración de Drogas y Alimentos (FDA) anunció el mes pasado que ahora exige a las empresas de alimentos para perros y gatos que actualicen sus planes de seguridad para protegerse contra la gripe aviar.

Esto se produjo después que el Departamento de Agricultura de Oregon descubriera que un gato que era “estrictamente de interior” había contraído H5N1 y había muerto después de consumir un producto de pavo congelado elaborado por la marca de comida cruda para mascotas Northwest Naturals. Afirmó que “las pruebas confirmaron una coincidencia genética entre el virus en la comida cruda y congelada para mascotas y el gato infectado”.

Northwest Naturals retiró voluntariamente ese lote de su producto a base de pavo congelado. La empresa dijo a KFF Health News y NPR que el retiro del mercado involucraba “una pequeña producción de producto” y que tenía inquietudes sobre la precisión de las pruebas del Departamento de Agricultura de Oregón.

El departamento de salud pública del condado de Los Ángeles dijo que cinco gatos de dos hogares dieron positivo en la prueba de gripe aviar después de beber leche cruda no pasteurizada de la lechería Raw Farm en el Valle Central de California.

Raw Farm retiró voluntariamente su leche y crema después que los productos minoristas dieran positivo en la prueba de H5N1, pero niega cualquier problema de seguridad alimentaria, calificando la preocupación como “un problema político”.

Los veterinarios también advierten a los dueños de mascotas que no permitan que los gatos pasen tiempo sin supervisión al aire libre, ya que existe el riesgo de que contraigan el H5N1 al interactuar con otros animales que podrían transmitir la enfermedad.

“Este es un virus muy aterrador, dado que puede infectar a muchas especies diferentes de huéspedes”, dijo Bruce Kornreich, director del Centro de Salud Felina de la Universidad Cornell.

Al menos un caso de un gato que infectó a una persona con gripe aviar ocurrió en 2016. Como informó NPR, un veterinario de la ciudad de Nueva York contrajo el virus después de tener contacto cercano con gatos infectados. El veterinario experimentó síntomas leves y se recuperó rápidamente.

En ese caso, la cepa de gripe aviar era H7N2, no el H5N1 que ahora circula en el país.

La mayoría de las personas que han contraído el H5N1 son trabajadores agrícolas que tuvieron contacto directo con aves de corral o ganado infectados. De al menos 67 casos humanos confirmados de H5N1, ha habido una muerte en una persona inmunodeprimida que tuvo contacto con aves.

En general, los investigadores de enfermedades zoonóticas quieren una mayor vigilancia del H5N1 en animales de compañía de todo tipo. Incluso si el número de muertes humanas por H5N1 todavía es relativamente bajo, sigue siendo un riesgo para la salud pública.

Posibles mutaciones

Parte de la preocupación con este brote de H5N1 es que los virus de la gripe aviar cambian. Sólo unas pocas mutaciones podrían hacer que esta cepa sea capaz de propagarse entre personas. Y cuantas más personas se contagien del H5N1, más probable es que se adapte y se vuelva más eficiente, dijo Suresh Kuchipudi, virólogo de la Facultad de Salud Pública de la Universidad de Pittsburgh, donde investiga enfermedades zoonóticas. Kuchipudi ha estudiado el H5N1 en gatos.

Otro motivo de preocupación es algo llamado recombinación. Si un animal o una persona se infecta con dos virus a la vez, los virus pueden intercambiar material genético y crear algo nuevo. Esto es común en la gripe, por lo que los virólogos están atentos a un caso en el que la gripe aviar se recombine para crear un virus mucho más contagioso y potencialmente más virulento.

El virólogo Rasmussen está mucho más preocupado por que esto suceda en los cerdos. La fisiología respiratoria humana se parece más a la de los cerdos que a la de los felinos. Hasta ahora, el brote actual de H5N1 no ha llegado a las explotaciones porcinas comerciales. Rasmussen espera que siga así.

Kuchipudi dijo que las recombinaciones son eventos relativamente raros, pero el resultado es completamente impredecible. A veces los resultados son benignos. Aunque es probable que haya sido una recombinación que involucrara un virus aviar lo que condujera a la pandemia de gripe de 1918, que mató a unos 50 millones de personas. En el siglo transcurrido desde entonces, los virólogos han establecido una red de vigilancia mundial para controlar los virus de la gripe. Los científicos dicen que la inversión continua en esta red es clave para prepararse y, con suerte, prevenir otra pandemia.

El invierno es la “temporada de redistribución” debido a todos los virus de la gripe que circulan, dijo Rasmussen. Una redistribución en gatos podría ser técnicamente posible ya que estas mascotas ocasionalmente contraen gripe estacional, pero es muy poco probable. En cambio, dijo Rasmussen, es más probable que un gato transmita el H5N1 a un humano que ya tiene gripe estacional, y luego se produzca una redistribución en la persona enferma. Si bien el riesgo no es cero, Rasmussen duda que esto suceda. Dependería de qué tan enfermo esté el humano y a qué cantidad de virus esté expuesto a través de su gato.

“A menos que el gato esté realmente eliminando una tonelada de virus y la persona se esté besando con el gato, creo que sería difícil”, dijo.

Rasmussen y Kuchipudi advierten que no hay suficiente investigación para saber con certeza cuánto virus eliminan los gatos, o incluso cómo lo eliminan.

Los Centros para el Control y la Prevención de Enfermedades (CDC) estaban a punto de publicar un nuevo estudio sobre el H5N1 en gatos, pero eso se retrasó cuando la administración Trump detuvo el Informe Semanal de Morbilidad y Mortalidad.

Esa investigación, revelada a través de correos electrónicos obtenidos por KFF Health News en una solicitud de registros públicos, encontró que los gatos domésticos probablemente contrajeron la gripe aviar de los trabajadores de las lecherías.

Los científicos y las agencias de salud pública deberían cuestionar las suposiciones previas sobre la gripe aviar, instó Kuchipudi. Señaló que hace 20 años nadie habría predicho que la gripe aviar infectaría al ganado lechero de la forma en que lo hace ahora.

Los perros parecen tener mejor suerte

La FDA dice que otros animales domésticos, incluidos los perros, pueden contraer infecciones de gripe aviar. No hay casos confirmados de H5N1 entre perros en los EE. UU., aunque en otros países han muerto a causa del virus.

Hay cierto desacuerdo y una falta general de investigación sobre si la biología de los gatos los vuelve más susceptibles al H5N1 que otros mamíferos, incluidos los humanos, los cerdos o los perros.

Pero los comportamientos de los gatos, como su amor por los productos lácteos y la depredación de aves silvestres, los ponen en mayor riesgo, dijo Kuchipudi. Además, vivir en grupos podría desempeñar un papel, ya que hay más colonias de gatos salvajes en los que grupos de perros callejeros.

Hay muy poco que la gente pueda hacer sobre el H5N1 que circula en las aves silvestres. Como explicó Rasmussen, “Está volando por los cielos. “Está migrando de norte a sur con las estaciones”.

Pero dijo que hay muchas cosas que la gente puede hacer para mantener el virus fuera de sus hogares.

Eso incluye limitar la exposición de una mascota al H5N1 no alimentándola con alimentos crudos o leche no pasteurizada, y tratar de evitar que interactúe con animales como roedores y aves silvestres que podrían estar infectados con el virus.

Este artículo es parte de una asociación que incluye a NPR y 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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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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The effort, billed as a way to reduce red tape in government, would leave district court as the only option outside of the state health department for people to fight officials’ rejections of their applications for Medicaid, temporary financial assistance, food aid, and other programs.

Montana lawmakers are considering a bill requested by the state Department of Public Health and Human Services to eliminate its Board of Public Assistance. The health department backed a similar bill in 2023 as part of the Republican governor’s “Red Tape Relief” initiative, but the measure died in committee.

On Feb. 4, the state Senate passed the bill, sponsored by state Sen. Jeremy Trebas (R-Great Falls), on a 45-5 vote. It must also pass scrutiny of the state House of Representatives and Gianforte before it becomes law.

The three-person board, whose members are appointed by the governor, also decides appeals of administrative rulings that someone received more aid than they qualified for and therefore owes the state money.

During a Jan. 29 committee hearing, state officials who proposed the cut said they’re trying to eliminate unnecessary bureaucracy in government. Opponents of the plan worry the change would limit people’s chance of having their voices heard in hard-to-use and often overstretched systems.

“We know we’ve made a difference,” said Carolyn Pease-Lopez, a Democratic former state lawmaker who said she has been on the board since 2017.

Pease-Lopez said she was unaware until contacted by KFF Health News that the health department was trying again to get rid of the board.

Starting in 2023 and into last year, the state’s public assistance workforce was overstretched because of a massive effort to check who qualifies for Medicaid, the state and federal health insurance program for low-income people. People trying to tap into public assistance in Montana and elsewhere have said they face long waits for help managing their benefits.

In Montana, about 2,300 public assistance appeals a year go first to the health department’s Office of Administrative Hearings. Last year, roughly 15 of those cases went on to the Board of Public Assistance, the last forum for people to argue their case before going to district court.

The board is an unnecessary intermediate step, health department officials said.

The board upheld the health department’s decisions in all but one of the roughly 15 cases that came before it last year, said Rutherford Hayes, administrator of the Office of Administrative Hearings.

The health department, he said during the Jan. 29 hearing, “ultimately has far more legal expertise than a volunteer lay board does.” One of the board’s six annual meetings was canceled, he said, because there weren’t any cases to discuss.

Pease-Lopez said not every case that lands before the board is cut-and-dried, and that the panel sometimes plays the role of an intermediary. She recalled an instance in which a small medical company was on the hook to repay thousands of dollars to the state due to coding errors the health department hadn’t caught for years.

Pease-Lopez said in that case the board acted as a mediator between the company and state attorney to find a compromise.

“They wanted thousands and thousands of dollars that would have upended their business,” Pease-Lopez said. She said the board “gives the state a chance to not just have tunnel vision and be driven by the rules alone, but to kind of look at the whole picture.”

State officials have said that even though the board typically sides with the agency’s initial decision, keeping it running takes staff time. That includes preparing records for board meetings and assigning an attorney to represent the agency.

The agency has said eliminating the board would help appellants take their case to district court more quickly.

In 2023, lawmakers who opposed the plan worried it would cut the public’s access to an independent body. They also noted that appealing to the board is free, and people who are fighting to access public assistance programs may not have the money for court fees or a lawyer.

Still, no one spoke in opposition to the board’s elimination Jan. 29.

Sharon Bonogofsky, who served on the board for roughly two years starting in 2021, said she understands the argument for its elimination. She said the work sometimes felt redundant since the board usually upheld the state’s decisions.

She said with or without the board, more resources need to go toward helping people understand their benefits, avoid paperwork mistakes that might result in their owing the state money, and transition smoothly off of state assistance programs.

“Some of these people just had all they could handle keeping their lives together, and that bit of support they were receiving was a real lifeline,” Bonogofsky 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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For Taylor Farms, a major global purveyor of packaged salads and cut vegetables, that’s made it a logical place to pioneer a novel type of health care for its workforce, one that could have broad utility in the smartphone era: cross-border medical consultations through an app.

The company is among the first customers of a startup called MiSalud, which connects Spanish-speaking Taylor Farms employees to physicians and mental health therapists in Mexico. Providers aren’t licensed in the U.S. and can’t prescribe medications but instead serve as health coaches who can dispense advice and work with a U.S.-based doctor if needed.

Amy Taylor, who has led the company’s wellness initiative since 2014 and is the daughter-in-law of company founder Bruce Taylor, said about 5,600 of Taylor Farms’ 6,400 employees who work where MiSalud is currently available have signed up for the app, and 2,300 have used the app at least once. The service is free for employees and up to three family members.

Amy Taylor said the company hopes the app, which is part of a broader wellness program, can help employees stay healthier while keeping health care and other labor costs in check. She plans a full evaluation once the program has been in place for two years.

The health of farmworkers is a major concern for the state’s agricultural economy. A 2022 study led by researchers from the University of California-Merced evaluated the health of more than 1,200 farmworkers and found that 37% of men and 47% of women reported having at least one chronic condition, including common conditions such as diabetes, high blood pressure, and anxiety.

Taylor said her company’s employees, ranging from fieldworkers and drivers to retail packaging and office staff, mirror the study’s findings. She said predominant health concerns among workers include obesity, high blood pressure, diabetes, and mental health.

“These are the people who are feeding America healthy food,” Taylor said of the company’s employees. “They should also be healthy.”

MiSalud — or “My Health” — was the inspiration of Bismarck Lepe, a serial entrepreneur and Stanford graduate, who hails from a migrant farmworker family. Until age 6, when his family settled in Oxnard, California, they would travel between Mexico, California, and Washington state to harvest fruit. He saw that family and friends often delayed health care until they could return to Mexico because the U.S. system was too difficult to navigate, and insurance coverage too expensive or hard to find.

“My mother still prefers to get her health care in Mexico,” Lepe said. “It’s easier for her.”

Lepe and co-founders Wendy Johansson and Cindy Blanco Ochoa launched MiSalud Health in 2021 with $5 million from a venture capital fund backed by Melinda French Gates’ Pivotal Ventures, which focuses on social-impact investing. It has since added Samsung Next and Ulu Ventures as investors.

MiSalud started out by offering consultations with Mexican physicians for individuals who downloaded the app, Johansson said. But people keen enough to find the app, download it, and sign up for the program themselves weren’t ultimately those who needed it most, and in 2023 the company pivoted to offering its service to companies as an employee benefit. (Individuals can still use it too.)

Besides Taylor Farms, the company counts the California city of Lynwood among about a dozen other clients, according to Johansson. MiSalud touted that nearly 40% of employees served by its platform say that without the app they would either have ignored their health concerns or waited until they could travel to Mexico to see a doctor.

Paul Brown, a UC-Merced professor of health economics who contributed to the university’s farmworker health study, warned that telehealth consultations aren’t adequate substitutes for in-person care by a primary care physician or a specialist. However, “to the extent that these types of programs can kind of link people into more standard care, that’s good,” he added.

Brown said MiSalud’s approach could be more effective if policies changed to allow Mexican doctors to more easily treat patients in the U.S. A California program begun in 2002 allows Mexican doctors to travel to the Salinas Valley and other heavily Latino communities and treat patients, but cross-border telemedicine, even between states, remains limited.

Even so, Taylor Farms employees say the app has been helpful. Rosa “Rosita” Flores, a line supervisor with the company’s retail operations, said she decided to give MiSalud a try after co-workers raved about it.

A recent company wellness fair, partly sponsored by MiSalud, had alerted her to the importance of monitoring her blood sugar and blood pressure levels, so she booked an appointment on the app to discuss it. “The app is very easy to use,” she said in Spanish. When she had to cancel a video chat after her daughter got sick, the health coaches followed up by text.

Proponents of cross-border medicine say the approach helps bridge linguistic and cultural barriers in health care. Almost half of all U.S. immigrants — about two-thirds of whom are native Spanish speakers — have limited proficiency in English, and research has repeatedly shown that language barriers often discourage people from seeking care.

For example, Alfredo Alvarez, a MiSalud health coach who is a licensed physician in Mexico, pointed to belief in el mal de ojo, or the “evil eye” — the idea that a jealous or envious glance by someone can cause harm, especially to children. An American doctor might be dismissive of the notion, but he understands.

“This isn’t uncommon here,” he said of Mexico. “It’s a belief in traditional medicine.”

It’s not that Alvarez encourages his socios, or members, to pass an egg over the child or make the child wear a special bracelet — traditional ways of diagnosing and treating el mal de ojo. Rather, he acknowledges their traditions and steers them to evidence-based medicine.

MiSalud’s coaches can try to break stereotypes as well. For example, Alvarez said, a Mexican reverence for machismo can translate to the idea that “men don’t do doctor visits.” Meanwhile, he said, women may overlook their health in prioritizing other family members’ needs.

Coaches also try to remove the stigma around seeking mental health treatment. “A lot of our socios have been extremely uncomfortable with or wary of mental health professionals,” said Rubén Benavides Crespo, a MiSalud mental health coach who is a licensed psychologist in Mexico.

The app tries to break through by making it easy to book counseling appointments and asking questions such as whether someone has trouble sleeping, rather than invoking more worrisome or potentially stigmatizing terms like anxiety or depression.

MiSalud representatives say the app saw a 50% increase in requests for mental health support following the November presidential election. A more common request, however, is grief counseling, often following the loss of a loved one.

“Loss requires adaptation,” Benavides said.

For Sam Chaidez, director of operations for a Taylor Farms location in Gonzales, MiSalud is a welcome addition for weight management. The son of fieldworkers, Chaidez graduated from UC-Davis and returned to the Salinas Valley to work for the company in 2007.

In 2019, Chaidez, a new parent at the time, began to understand his risk for diabetes and other health problems because of Taylor Farms’ wellness program. Through diet and exercise and, more recently, coaching by MiSalud, Chaidez has shed 150 pounds.

Chaidez encourages co-workers to walk with him at lunch, and he credits MiSalud coaches for helping him keep the weight off and stay healthy. “It’s been a great help,” he said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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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“Patients who speak Spanish really prefer a Spanish-speaking provider,” Deem said. “I’ve gotten to know this community pretty well.”

Clemson doesn’t operate an academic medical center, nor does it run a medical school. Arguably, the public university is best known for its football program. Yet, with millions of dollars earmarked from the state legislature, it has expanded into delivering health care, with clinics in Walhalla and beyond. School leaders are attempting to address gaps in rural and underserved parts of a state where health outcomes routinely rank among the worst in the country.

“Some of these communities have such high need,” said Ron Gimbel, director of Clemson Rural Health, which operates four clinics and a fleet of mobile health units as part of the university’s College of Behavioral, Social and Health Sciences. “They have so many barriers that impact their ability to be healthy.”

Clemson Rural Health is one of several programs attempting to meet this need in the state.

“Rural health is trendy,” said Graham Adams, CEO of the South Carolina Office of Rural Health.

State lawmakers nationwide are spending millions of dollars to address a rural health care crisis long in the making. For more than a decade, though, Republican-controlled legislatures in most Southern states have refused billions in federal funds that would provide public health insurance coverage to more low-income adults. These are the same states where racial health disparities and health outcomes are often worse than in other regions.

Nearly every state has extended Medicaid coverage for women in the months after they give birth. But 10 states haven’t fully expanded Medicaid coverage with federal money made available under the 2010 Affordable Care Act. Seven of these states — Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee, and Texas — are in the South. With few exceptions, adults without children in these states don’t qualify for Medicaid coverage, regardless of their income level.

Georgia Gov. Brian Kemp and South Carolina Gov. Henry McMaster, both Republicans, recently announced plans to expand Medicaid in limited ways to include some parents. The South Carolina plan would impose work requirements on some of these newly eligible Medicaid beneficiaries, while the Georgia plan would allow some parents of young children to skirt the state’s existing Medicaid work rules. Both plans require federal approval.

Jonathan Oberlander, a professor and health policy scholar at the University of North Carolina, said he doesn’t expect to see any of the remaining states rushing to fully expand Medicaid. Before Donald Trump took office on Jan. 20, Republicans in Washington had already expressed their intention to dramatically cut spending for Medicaid, which covers 72 million people at a cost of nearly $900 billion.

“There’s a large gray cloud hanging over Medicaid expansion right now, and that’s because there’s so much uncertainty about what the Trump administration and congressional Republicans are going to do,” Oberlander said.

Even so, in South Carolina this year the advocacy group CoverSC plans to lobby the General Assembly to pass a bill to adopt Medicaid expansion, said Beth Johnson, regional government relations director for the American Cancer Society Cancer Action Network and a CoverSC board member. The state’s legislative session began Jan. 14.

If such a measure were approved, the federal government would cover 90% of the state’s Medicaid expansion costs and South Carolina would be expected to pay 10%, or an estimated $270 million during the first year, according to a 2024 report by the Milken Institute School of Public Health at George Washington University.

Across all 10 non-expansion states — which, outside the South, also include Kansas, Wisconsin, and Wyoming — about 1.5 million people fall into a coverage gap, according to 2024 estimates from KFF, the health information nonprofit that includes KFF Health News. That means they do not qualify for Medicaid coverage or financial assistance to buy insurance through the federal marketplace.

Many of the people who would qualify for Medicaid if these states were to expand eligibility are gig workers, Johnson said. They play music, drive for Uber, or deliver pizza, and they typically don’t qualify for health insurance through their jobs.

“They are providing services that we all appreciate,” she said. “And they simply can’t afford health insurance.”

In some South Carolina communities, Clemson Rural Health attempts to fill this gap by providing primary care, cancer screenings, nutrition education, and diabetes management for uninsured patients free of charge or at reduced rates. Only about half of the patients seen by Clemson Rural Health have health insurance, Gimbel said, compared with 92% of the U.S. population.

During the current state fiscal year, Clemson Rural Health has been underwritten by a $2.5 million contract, its largest source of funding, from the state Department of Health and Human Services, which administers Medicaid in South Carolina and operates with a budget approved by state lawmakers.

That’s a relatively small amount of money compared with the $47.5 million the state legislature has given to the Medical University of South Carolina in recent years to move into rural communities. MUSC has served Charleston for most of its 200-year history, but since 2019 it has expanded across the state by purchasing, building, or partnering with seven rural hospitals — some on the brink of closure — and one freestanding emergency department. MUSC is set to open an additional rural hospital this year.

Other states have made similar investments. The University of Georgia, for example, has established a new medical school, partly to send more physicians into underserved and rural areas. The Georgia General Assembly kicked in half the cost of a new $100 million building for medical education and research in Athens.

Meanwhile, the Tennessee General Assembly passed a budget last year that included $81 million for a variety of rural health initiatives.

Outside the South, state legislatures in Colorado, Nevada, West Virginia, and elsewhere have made recent investments in rural health, in addition to expanding Medicaid eligibility.

Some of this spending has been prompted by a wave of rural hospital closures — more than 100 since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

It’s not yet clear what long-term impact some of these initiatives will have — for instance, whether the Clemson program will “reduce premature mortality, decrease preventable hospitalizations, and improve overall quality of life,” as it aims to do, according to its website. Some public health experts point out that bolstering the number of rural clinics, hospitals, and doctors in the South won’t matter much if patients can’t afford to make an appointment.

“Lack of ability to pay is one of the greatest barriers,” said Adams, the Office of Rural Health chief.

Oberlander said conservative lawmakers often consider projects such as building new rural clinics more politically palatable than expanding Medicaid coverage.

“The further away you get from the ACA, the less polarized the politics of health care,” he said.

South Carolina Senate President Thomas Alexander, a Republican who lives in Walhalla, said the General Assembly is willing to invest in some rural health initiatives to improve health care access.

“Just because you expand Medicaid doesn’t mean you’ve expanded access to the services,” Alexander said. “I want to focus on expanding access to the services.”

Gimbel would not comment on Medicaid expansion in South Carolina, and he said it’s too soon to know how federal Medicaid changes under the Trump administration might affect funding for Clemson Rural Health, which currently receives money from the state’s Medicaid agency. But making the Clemson program financially solvent might take several more years, he said.“If rural health was profitable,” he said, “we wouldn’t have a rural health problem.”

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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This story can be republished for free (details).