As the Michigan state health director, he had spent the past year, and some $30 million in state tax dollars, trying to avoid that very thing.

Gordon was a Democrat, a veteran of the Obama administration, and he did not want people to lose the Medicaid coverage they had recently gained through the Affordable Care Act.

But Gordon and his boss, Democratic Gov. Gretchen Whitmer, had reluctantly inherited a law passed two years earlier, when Republicans led the state. And that law mandated that Michigan institute a work requirement for Medicaid on Jan. 1, 2020.

Gordon and his team determined that most enrollees were already meeting the law’s requirements, either because they were already working or had an exemption. Thousands more reported their status through the newly built phone and online systems.

But even so, estimates suggested 80,000 to 100,000 Michiganders were going to be booted off the rolls within the year.

“That’s the population of the city of Flint who were on track to lose their insurance,” said Gordon, who led the state health department until 2021. “We’re implementing this about as well as this thing can be implemented, and it is still going to be pretty catastrophic.”

The new tax-and-spending law signed by President Donald Trump in July mandates a vast expansion of Medicaid work requirements to most states.

These systems will lead to 5.3 million more people being uninsured in 2034, according to an estimate from the Congressional Budget Office.

The law applies to 40 states and Washington, D.C., because they expanded Medicaid in recent years to cover more working-age adults.

About 18 million people will be affected once the work mandate is fully implemented nationally, according to the CBO. Unless their state gets an exemption till 2028, by 2027, these enrollees will need to prove they’re working, volunteering, getting job training, or doing other qualifying activities at least 80 hours a month to keep their coverage.

Republicans say this is a commonsense way to weed out “freeloaders.” Democrats argue that’s just political cover for slashing a program that saved some 27,000 lives starting in 2010, when the Affordable Care Act was signed, through 2022.

The number of people who lose coverage, either temporarily or permanently, could vary widely by state, depending on how each state implements and maintains its reporting system.

Michigan’s experience illustrates how challenging it can be to stop large numbers of people from inadvertently losing coverage, even when leaders try their best to prevent that.

“We were very committed to implementing a law that we didn’t agree with, in a way that reduced the number of people who lost insurance just because the government screwed something up,” Gordon said.

A Year of High-Stakes Work

In 2013, then-Gov. Rick Snyder, a Republican, waged a fierce battle within his own party to expand Michigan’s Medicaid program.

To Snyder, it was an opportunity to simultaneously save money and expand access: By slashing the rate of uninsured Michiganders by almost half, the state could reduce the burden of uncompensated care on the health system and boost the economy by improving the physical health of the workforce.

But opponents saw it as an expansion of “Obamacare” that would shift massive new costs onto state and federal taxpayers. A work requirement became a point of compromise and a way for Snyder to mollify some of that opposition.

From a coverage perspective, Michigan’s expansion of Medicaid was a success. Low-income adults signed up, ballooning new enrollment beyond what even supporters had initially estimated.

By 2019, there were nearly 700,000 new Medicaid recipients in Michigan, and the state was responsible for an increasing share of their health care costs. (Medicaid is paid for jointly by states and the federal government.)

Fiscal hawks were worried. “It’s now become the largest budget problem in Michigan,” said Jarrett Skorup of the Mackinac Center for Public Policy, a free-market think tank

Snyder signed the bill creating the 80-hour-a-month work requirement in 2018, but it wouldn’t go into effect until 2020, after he left office.

That left newly elected Democratic governor Whitmer’s administration holding the bag. She tapped Gordon, who’d held senior roles in the federal Office of Management and Budget and Department of Education during the Obama administration, to lead the sprawling state health department.

Gordon was terrified that Michigan would become another Arkansas, which was the first state to implement a work requirement, in 2018. The change led more than 18,000 Arkansas residents to lose their coverage.

People in Arkansas were disenrolled “because computers went down, because forms weren’t clear, because they just never heard about it,” Gordon said. “Maybe they got sicker, maybe they died because of this decision.”

If Michiganders lost coverage at the same rate as Arkansans, as many as 160,000 people would have lost their health insurance within a year, according to one estimate.

Trying To Make Medicaid Work Requirements … Work

In some ways, Michigan was better positioned than other states to implement a work requirement, Gordon said: The unemployment rate was the lowest it had been in two decades and the state was already pretty good at collecting and tracking employment and wage data.

“If the state can figure out on its own, without having to ask you if you’re working, that’s great, because then you don’t have to do anything,” Gordon said. “You’re just exempted.”

Michigan eventually changed its law to allow people more time to report their work activities and to automatically determine their compliance or exemption by cross-checking data from other assistance programs, like food benefits.

To see if recipients were students or had health-related exemptions, Gordon and his team also tried to capture data from community college enrollment and medical insurance claims.

Dozens of staffers reprogrammed the state’s outdated benefits enrollment portal, created full-time call centers, set up audit and appeals processes, hired compliance review teams, and trained hundreds of local organizers to provide tech and enrollment assistance.

Forms and letters alerting hundreds of thousands of enrollees to the new policy were redesigned to be attention-grabbing and easier to understand.

The sheer amount of effort and time required meant other public health efforts had to take a back seat, Gordon said. “Your first job is going to suffer, and that is a consequence of work requirements.”

In Michigan, Black infant mortality rates were some of the highest in the nation. Thousands of people were still dying from overdoses.

Yet at the state health department, “all of the oxygen in the room was dedicated — almost all, I should say — to the work requirement implementation,” said Renuka Tipirneni, an internal medicine physician at the University of Michigan who studies Michigan’s Medicaid expansion.

Even after all that work, Gordon and his team had no illusions the system they’d spent $30 million creating was flawless.

“There was a real sense that everyone was doing everything they could,” he said. But they still worried that “huge numbers of people were going to fall through the cracks. Because that’s just what happens with systems like this.”

A “Waste” of $30 Million

By the time the work requirement went into effect on Jan. 1, 2020, the state had been able to determine that the vast majority of the nearly 700,000 Medicaid expansion recipients already met the work requirement or were exempt.

That left about 100,000 people whose status was unknown and who therefore still had to go through the reporting process. By March, around 80,000 of those had failed to report and were on track to lose coverage.

On the one hand, it was a lower rate of coverage loss than Arkansas had. But it was still “an enormous number of people” set to lose coverage, Gordon said.

Before that could happen, a federal judge issued a ruling on March 4, 2020, blocking Michigan’s policies from going forward. That same day, Gordon was scheduled to testify before a Republican-led subcommittee about how the rollout was going.

Instead, he found himself explaining to legislators that the state’s work requirement was essentially dead in the water, and that “we had, on the demand of the people holding the hearing, spent tens of millions of dollars for no purpose.”

Given how brief Michigan’s experiment with a Medicaid work requirement was — only about two months of the policy’s being in effect, with no one losing coverage in the end — the Mackinac Center’s Skorup doesn’t see a lot of takeaways about the real-life impacts of work requirements.

“If you have an administration that is not sold on these being necessary at all, then I think they’re more likely to drag their feet on implementing this, which is what I think they did,” Skorup said, referring to the Whitmer administration.

Skorup is concerned because Medicaid costs keep rising, with 2.6 million Michiganders (1 in 4 residents) now covered by the program or the related Children’s Health Insurance Program. Skorup believes Medicaid spending is “crowding out” teacher pay, pensions, and roads in the state budget.

Supporters of Medicaid expansion say the program’s growth has benefited Michigan, pointing to research that Medicaid expansion helped boost employment and school enrollment and was a net positive for the state financially.

Court Ruling Comes Days Before Covid Hits

Only days after the court ruling stopped the work requirement in Michigan, officials announced the state’s first cases of covid-19. The 80,000 Michiganders who might have lost Medicaid were spared, so their health coverage continued as the pandemic unfolded. Gordon continued as health director until 2021, when he resigned over “differences of opinion” with Whitmer about some pandemic restrictions.

These days, Gordon is experiencing a sense of déjà vu, with new predictions showing as many as 500,000 Michiganders could lose coverage within the first year of federally mandated work requirements, according to state estimates.

“We would have a more honest and more efficient policy if Republicans just kick people off Medicaid,” he said.

That would be “incredibly harmful,” he said. “But this thing they’re doing isn’t any less harmful. It’s just more wasteful administratively, and more confusing to everyone.”

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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One of the most recent actions by the Department of Health and Human Services, launched in mid-June, targets the University of Michigan Health system over a former employee’s claims that she was fired for requesting a religious exemption from providing gender-affirming care.

An administration release announcing the probe says the Michigan case is the third investigation in “a larger effort to strengthen enforcement of laws protecting conscience and religious exercise” for medical providers, citing federal laws known as the Church Amendments.

The probes are the first time HHS has explicitly claimed the amendments “allow providers to refuse gender-affirming care or to misgender patients,” said Elizabeth Sepper, a professor at the University of Texas who studies conscience laws. Those laws, Sepper said, primarily allow objections to performing abortions or sterilizations but “don’t apply to gender-affirming care, by their very own text.”

But religious freedom groups that supported the health worker in the Michigan case, Valerie Kloosterman, say the investigation is a welcome recognition of existing protections for medical professionals to refuse to provide some types of care that conflict with their beliefs.

“We are pleased to learn that the Department of Health and Human Services is taking its responsibility seriously to enforce the federal statutes protecting religious health care providers,” said Kloosterman’s attorney Kayla Toney, of the First Liberty Institute, which advocates for religious liberty plaintiffs.

The two other cases HHS announced in recent months involve ultrasound technicians who didn’t want to be involved in “abortion procedures contrary to their religious beliefs or moral convictions,” and a nurse who asked for a religious exemption to “avoid administering puberty blockers and cross-sex hormones to children,” according to HHS. The department did not disclose the locations for those investigations.

Sepper said opening investigations into gender-affirming care cases is a new tactic for HHS after federal courts blocked a 2019 effort by the previous Trump administration to broaden conscience rules.

And it sends a message that this administration will “investigate or otherwise harass providers of gender-affirming care, even when that provision is legal in the states where they operate,” said Sam Bagenstos, a general counsel at HHS during the Biden administration and a professor at the University of Michigan.

HHS spokesperson Andrew Nixon declined to comment, citing the ongoing investigation.

HHS launched its investigation years after Kloosterman filed a lawsuit against her former employer. She started working for Metropolitan Hospital in Caledonia, Michigan, as a physician assistant in 2004. When the hospital merged to become part of University of Michigan Health-West in 2021, Kloosterman took part in a “mandatory diversity training,” according to a federal lawsuit filed in 2022.

In that training and follow-up discussions, the health system “attempted to compel Ms. Kloosterman to pledge, against her sincerely held religious convictions and her medical conscience, that she would speak biology-obscuring pronouns and make referrals for ‘gender transition’ drugs and procedures,” according to the lawsuit by Kloosterman’s attorneys.

These were, at this point, purely hypotheticals: “No patient ever asked her for a referral for such drugs or procedures, and she never used pronouns contrary to a patient’s wishes,” the suit claimed.

But when Kloosterman requested a religious accommodation, she was “summoned” to a meeting with administrators, who “called her ‘evil’ and a ‘liar,’ mockingly told her that she could not take the Bible or her religious beliefs to work with her, and blamed her for gender dysphoria-related suicides,” according to the lawsuit, which alleges she was fired in August 2021, shortly after the meeting.

The health system denied all allegations, and in April 2024, U.S. District Judge Jane Beckering dismissed Kloosterman’s case to proceed into arbitration. Kloosterman’s lawyers filed an appeal with the U.S. Court of Appeals for the 6th Circuit. Appellate judges heard oral arguments in the case in February but have not issued a decision.

HHS initiated its investigation under the Church Amendments because it’s “committed to enforcing Federal conscience laws in health care,” said Paula M. Stannard, director of the department’s Office for Civil Rights, in a statement announcing the investigation. “Health care workers should be able to practice both their professions and their faith.”

But the investigation “represents a real expansion beyond what the Trump administration did in the first term, and also in terms of the text of the law,” Sepper said.

The Church Amendments date to the 1970s and allow health care institutions and providers to refuse to participate in abortion or sterilization procedures.

“Some of these also apply to end-of-life care and to physician aid in dying. So they have relatively narrow scope,” Sepper said. “They focus on a set of procedures. They don’t allow health care providers or institutions to refuse to provide all kinds of care based on their religious or moral objections.”

There is one broader provision in these laws that “is about the conscience-based decision to perform, or not to perform, a lawful medical procedure,” said Bagenstos, the former HHS general counsel during the Biden administration. But that applies only to recipients of a “grant or contract for biomedical or behavioral research,” he said. So this case is “an extreme stretch of the conscience protections, and probably more than a stretch.”

But Ismail Royer, director of Islam and religious freedom at the Religious Freedom Institute, which filed an amicus brief supporting Kloosterman’s lawsuit, said the Church Amendments are just a few of the laws HHS enforces, along with broad civil rights protections and laws that prohibit discrimination on the basis of religion.

“This is not a case where someone is refusing to treat someone who is LGBT,” Royer said. “This is a case of someone who does not believe that they should be forced to use pronouns that would constitute a lie.”

Other providers are available if a patient’s “feelings are hurt,” he said. “But hurt feelings do not constitute the basis for the government violating our constitutional rights.”

The stakes for a health system are very different in an HHS investigation than in civil suits, Sepper said. The government agency, which oversees the vast majority of health care spending, could decide to strip Medicare and Medicaid funding from the health system. HHS has previously been hesitant to remove funding, Sepper said.

But it would be highly unusual — and possibly illegal — for HHS to actually withhold funding from the health system over a case like this, Bagenstos said.

By taking up these investigations so publicly, Sepper said, HHS is putting health systems “in a very difficult situation.” Antidiscrimination laws require them to treat transgender patients equally, she said. But now the administration is prioritizing “employees that might want to make it more difficult for transgender patients to receive care.”

These investigations are “meant to offer red meat to the anti-LGBT rights movement, to tell them that HHS is squarely on their side,” Sepper said.

This article is from a partnership with Michigan Public and NPR.

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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“Oh my god,” physician assistant Anna Rink gasped, as she and three other Planned Parenthood employees finally walked outside. The crowd whooped and cheered. Then Rink addressed the gathering.

“Thank you for trusting us with your care,” Rink called out, her voice quavering. “And I’m not stopping here. I’m only going to make it better. I promise. I’m going to find a way.”

“We’re not done!” someone called out. “We’re not giving up!”

But Planned Parenthood of Michigan is giving up on four of its health centers in the state, citing financial challenges. That includes Marquette, the only clinic that provided abortion in the vast, sparsely populated Upper Peninsula. For the roughly 1,100 patients who visit the clinic each year for anything from cancer screenings to contraceptive implants, the next-closest Planned Parenthood will now be a nearly five-hour drive south.

It’s part of a growing trend: At least 17 clinics closed last year in states where abortion remains legal, and another 17 have closed in just the first five months of this year, according to data gathered by ineedana.com. That includes states that have become abortion destinations, like Illinois, and those where voters have enshrined broad reproductive rights into the state constitution, like Michigan.

Experts say the closures indicate that financial and operational challenges, rather than future legal bans, may be the biggest threats to abortion access in states whose laws still protect it.

“These states that we have touted as being really the best kind of versions of our vision for reproductive justice, they too struggle with problems,” said Erin Grant, a co-executive director of the Abortion Care Network, a national membership organization for independent clinics.

“It’s gotten more expensive to provide care, it’s gotten more dangerous to provide care, and it’s just gotten, frankly, harder to provide care, when you’re expected to be in the clinic and then on the statehouse steps, and also speaking to your representatives and trying to find somebody who will fix your roof or paint your walls who’s not going to insert their opinion about health care rights.”

But some abortion rights supporters question whether leaders are prioritizing patient care for the most vulnerable populations. Planned Parenthood of Michigan isn’t cutting executive pay, even as it reduces staff by 10% and shuts down brick-and-mortar clinics in areas already facing health care shortages.

“I wish I had been in the room so I could have fought for us, and I could have fought for our community,” said Viktoria Koskenoja, an emergency medicine physician in the Upper Peninsula, who previously worked for Planned Parenthood in Marquette. “I just have to hope that they did the math of trying to hurt as few people as possible, and that’s how they made their decision. And we just weren’t part of the group that was going to be saved.”

Why Now?

If a clinic could survive the fall of Roe v. Wade, “you would think that resilience could carry you forward,” said Brittany Fonteno, president and CEO of the National Abortion Federation.

But clinic operators say they face new financial strain, including rising costs, limited reimbursement rates, and growing demand for telehealth services. They’re also bracing for the Trump administration to again exclude them from Title X, the federal funding for low- and no-cost family planning services, as the previous Trump administration did in 2019.

PPMI says the cuts are painful but necessary for the organization’s long-term sustainability. The clinics being closed are “our smallest health centers,” said Sarah Wallett, PPMI’s chief medical operating officer. And while the thousands of patients those clinics served each year are important, she said, the clinics’ small size made them “the most difficult to operate.” The clinics being closed offered medication abortion, which is available in Michigan up until 11 weeks of pregnancy, but not procedural abortion.

Planned Parenthood of Illinois (a state that’s become a post-Roe v. Wade abortion destination) shuttered four clinics in March, pointing to a “financial shortfall.” Planned Parenthood of Greater New York is now selling its only Manhattan clinic, after closing four clinics last summer due to “compounding financial and political challenges.” And Planned Parenthood Association of Utah, where courts have blocked a near-total abortion ban and abortion is currently legal until 18 weeks of pregnancy, announced it closed two centers as of May 2.

Earlier this spring, the Trump administration began temporarily freezing funds to many clinics, including all Title X providers in California, Hawaii, Maine, Mississippi, Missouri, Montana, and Utah, according to a KFF analysis.

While the current Title X freeze doesn’t yet include Planned Parenthood of Michigan, PPMI’s chief advocacy officer, Ashlea Phenicie, said it would amount to a loss of about $5.4 million annually, or 16% of its budget.

But Planned Parenthood of Michigan didn’t close clinics the last time the Trump administration froze its Title X funding. Its leader said that’s because the funding was stopped for only about two years, from 2019 until 2021, when the Biden administration restored it. “Now we’re faced with a longer period of time that we will be forced out of Title X, as opposed to the first administration,” said PPMI president and CEO Paula Thornton Greear.

And at the same time, the rise of telehealth abortion has put “new pressures in the older-school brick-and-mortar facilities,” said Caitlin Myers, a Middlebury College economics professor who maps brick-and-mortar clinics across the U.S. that provide abortion.

Until a few years ago, doctors could prescribe abortion pills only in person. Those restrictions were lifted during the covid-19 pandemic, but it was the Dobbs decision in 2022 that really “accelerated expansions in telehealth,” Myers said, “because it drew all this attention to models of providing abortion services.”

Suddenly, new online providers entered the field, advertising virtual consultations and pills shipped directly to your home. And plenty of patients who still have access to a brick-and-mortar clinic prefer that option. “Put more simply, it’s gotta change their business model,” she said.

Balancing Cost and Care

Historically, about 28% of PPMI’s patients receive Medicaid benefits, according to Phenicie. And, like many states, Michigan’s Medicaid program doesn’t cover abortion, leaving those patients to either pay out-of-pocket or rely on help from abortion funds, several of which have also been struggling financially.

“When patients can’t afford care, that means that they might not be showing up to clinics,” said Fonteno of the National Abortion Federation, which had to cut its monthly budget nearly in half last year, from covering up to 50% of an eligible patient’s costs to 30%. “So seeing a sort of decline in patient volume, and then associated revenue, is definitely something that we’ve seen.”

Meanwhile, more clinics and abortion funds say patients have delayed care because of those rising costs. According to a small November-December 2024 survey of providers and funds conducted by ineedana.com, “85% of clinics reported seeing an increase of clients delaying care due to lack of funding.” One abortion fund said the number of patients who had to delay care until their second trimester had “grown by over 60%.”

Even when non-abortion services like birth control and cervical cancer screenings are covered by insurance, clinics aren’t always reimbursed for the full cost, Thornton Greear said.

“The reality is that insurance reimbursement rates across the board are low,” she said. “It’s been that way for a while. When you start looking at the costs to run a health care organization, from supply costs, etc., when you layer on these funding impacts, it creates a chasm that’s impossible to fill.”

Yet, unlike some independent clinics that have had to close, Planned Parenthood’s national federation brings in hundreds of millions of dollars a year, the majority of which is spent on policy and legal efforts rather than state-level medical services. The organization and some of its state affiliates have also battled allegations of mismanagement, as well as complaints about staffing and patient care problems. Planned Parenthood of Michigan staffers in five clinics unionized last year, with some citing management problems and workplace and patient care conditions.

Asked whether Planned Parenthood’s national funding structure needs to change, PPMI CEO Thornton Greear said: “I think that it needs to be looked at, and what they’re able to do. And I know that that is actively happening.”

The Gaps That Telehealth Can’t Fill

When the Marquette clinic’s closure was announced, dozens of patients voiced their concerns in Google reviews, with several saying the clinic had “saved my life,” and describing how they’d been helped after an assault, or been able to get low-cost care when they couldn’t afford other options.

Planned Parenthood of Michigan responded to most comments with the same statement and pointed patients to telehealth in the clinic’s absence:

“Please know that closing health centers wasn’t a choice that was made lightly, but one forced upon us by the escalating attacks against sexual and reproductive health providers like Planned Parenthood. We are doing everything we can to protect as much access to care as possible. We know you’re sad and angry — we are, too.

“We know that telehealth cannot bridge every gap; however, the majority of the services PPMI provides will remain available via the Virtual Health Center and PP Direct, including medication abortion, birth control, HIV services, UTI treatment, emergency contraception, gender-affirming care, and yeast infection treatment. Learn more at ppmi.org/telehealth.”

PPMI’s virtual health center is already its most popular clinic, according to the organization, serving more than 10,000 patients a year. And PPMI plans to expand virtual appointments by 40%, including weekend and evening hours.

“For some rural communities, having access to telehealth has made significant changes in their health,” said Wallett, PPMI’s chief medical operating officer. “In telehealth, I can have an appointment in my car during lunch. I don’t have to take extra time off. I don’t have to drive there. I don’t have to find child care.”

Yet even as the number of clinics has dropped nationally, about 80% of clinician-provided abortions are still done by brick-and-mortar clinics, according to the most recent #WeCount report, which looked at 2024 data from April to June.

And Hannah Harriman, a Marquette County Health Department nurse who previously spent 12 years working for Planned Parenthood of Marquette, is skeptical of any suggestion that telehealth can replace a rural brick-and-mortar clinic. “I say that those people have never spent any time in the U.P.,” she said, referring to the Upper Peninsula.

Some areas are “dark zones” for cell coverage, she said. And some residents “have to drive to McDonald’s to use their Wi-Fi. There are places here that don’t even have internet coverage. I mean, you can’t get it.”

Telehealth has its advantages, said Koskenoja, the emergency medicine physician who previously worked for Planned Parenthood in Marquette, “but for a lot of health problems, it’s just not a safe or realistic way to take care of people.”

She recently had a patient in the emergency room who was having a complication from a gynecological surgery. “She needed to see a gynecologist, and I called the local OB office,” Koskenoja said. “They told me they have 30 or 40 new referrals a month,” and simply don’t have enough clinicians to see all those patients. “So adding in the burden of all the patients that were being seen at Planned Parenthood is going to be impossible.”

Koskenoja, Harriman, and other local health care providers have been strategizing privately to figure out what to do next to help people access everything from Pap smears to IUDs. The local health department can provide Title X family planning services 1½ days a week, but that won’t be enough, Harriman said. And there are a few private “providers in town that offer medication abortion to their patients only — very, very quietly,” she said. But that won’t help patients who don’t have good insurance or are stuck on waitlists.

“It’s going to be a patchwork of trying to fill in those gaps,” Koskenoja said. “But we lost a very functional system for delivering this care to patients. And now, we’re just having to make it up as we go.”

This article is from a partnership with Michigan Public and NPR.

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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Pero el CEO de Herbruck’s Poultry Ranch, una de las granjas avícolas más grandes de Estados Unidos, en el negocio desde hace más de tres generaciones, no sabía cómo iba a sobrellevarlo, tanto financiera como emocionalmente.

Un empleado rompió a llorar en la oficina de Herbruck.

“Uno no se puede imaginar el desgaste mental de nuestro equipo al tener que enfrentarse a la muerte de tal cantidad de pollos”, dijo Herbruck. “Yo no dormía. Nuestro equipo no dormía”.

El estrés de ver morir de gripe aviar a decenas de miles de aves enfermas cada día, mientras millones de otras esperaban a ser sacrificadas, los mantenía a todos despiertos.

En abril de 2024, cuando sus primeras gallinas dieron positivo para el virus H5N1 de la gripe aviar, altamente patógena, Herbruck recurrió al plan, de eficacia probada, “estrategia de erradicación” del Departamento de Agricultura de Estados Unidos (USDA) que ayudó a poner fin al brote de gripe aviar de 2014-15, el mayor del país hasta ahora.

En un plazo de 24 a 48 horas desde la primera detección del virus, funcionarios estatales y federales de salud animal trabajan con las granjas para sacrificar los gallineros infectados y reducir el riesgo de transmisión. A esto le sigue una desinfección exhaustiva y meses de vigilancia y pruebas para asegurarse que el virus no sigue acechando en algún lugar de la granja.

Desde entonces, las granjas avícolas han tenido que invertir millones de dólares en bioseguridad. Por ejemplo, los empleados se duchan al entrar y al salir, antes de empezar a trabajar y al terminar su turno, para evitar la propagación del virus. Pero sus esfuerzos no han sido suficientes para contener el brote que comenzó hace tres años.

Expertos dicen que, esta vez, el riesgo para la salud humana no hace más que aumentar. De los 67 casos humanos registrados, 66  han ocurrido desde marzo de 2024, incluida la primera muerte humana del país, notificada en enero.

“Los últimos seis meses ha aumentado mi preocupación, que ya era alta”, señaló Nahid Bhadelia, médica especialista en enfermedades infecciosas y directora fundadora del Centro de Enfermedades Infecciosas Emergentes de la Universidad de Boston.

Controlar este virus se ha vuelto más difícil, precisamente porque está tan arraigado en el entorno global, contagiando a mamíferos como vacas lecheras y afectando a unos 150 millones de aves en gallineros comerciales y domésticos en Estados Unidos.

Debido a que las gallinas ponedoras son tan susceptibles al virus H5N1, que puede acabar con bandadas enteras a los pocos días de la primera infección, los productores de huevos han estado en la primera línea de batalla contra diversas cepas de gripe aviar durante años.

Pero este momento se siente diferente. Los productores y la American Egg Board, un grupo de la industria, piden una nueva estrategia de prevención.

Muchos expertos en enfermedades infecciosas coinciden en que los riesgos para la salud humana de continuar con los protocolos actuales son insostenibles, debido a la cepa de gripe aviar que está provocando este brote.

“La que combatimos hoy es única”, aseguró David Swayne, ex director del Laboratorio de Investigación Avícola del Sureste en el USDA y uno de los principales expertos nacionales en gripe aviar.

“No se puede decir con certeza que vaya a haber una pandemia” de H5N1, agregó Swayne, “pero sí que cuantas más infecciones humanas haya, más preocupante será la propagación a múltiples especies de mamíferos”.

Para Herbruck, parece una guerra. Diez meses después que su granja avícola se viera afectada, la empresa sigue reconstruyendo sus gallineros y ha vuelto a contratar a la mayoría de los 400 trabajadores que despidió.

Aun así, él y sus pares en la industria viven con miedo, viendo cómo otras granjas se ven afectadas dos veces, incluso tres en los últimos años.

“A este virus yo llamo terrorista”, dijo. “Estamos en medio de una batalla, y por ahora la estamos perdiendo”.

Cuando la bioseguridad no funciona… o no existe

Hasta ahora, ninguna de las 23 personas que contrajeron la enfermedad a través de aves de corral comerciales ha experimentado casos graves, pero los riesgos siguen siendo muy reales.

La primera muerte humana fue la de un paciente de Louisiana que había estado en contacto tanto con aves silvestres como con aves de corral. Esta persona tenía más de 65 años y, según se informó, padecía enfermedades subyacentes.

Y el mensaje oficial tanto para los entusiastas de los gallineros domésticos como para las mega granjas ha sido en general el mismo: la bioseguridad es su mejor arma contra la propagación de enfermedades.

Pero hay opiniones encontradas entre los criadores de aves de corral domésticos sobre la seriedad con la que se debe tomar la gripe aviar, dijo Katie Ockert, educadora de la Universidad Estatal de Michigan que se especializa en comunicaciones de bioseguridad.

Los escépticos piensan que “estamos haciendo una montaña de un grano de arena”, afirmó Ockert, o que “los medios de comunicación quizá están exagerando”. Esto significa que hay dos tipos de aficionados a las aves de corral, según Ockert: los que implementan una gran bioseguridad y los que ni siquiera lo intentan.

“Veo a ambos”, dijo. “No creo que haya un término medio”.

Y los desafíos de bioseguridad son completamente diferentes para los gallineros domésticos que para los enormes gallineros comerciales: ¿Cómo se supone que unos aficionados con tiempo y presupuesto limitados van a crear fortalezas impenetrables para sus gallinas, cuando cualquier charco o árbol en la propiedad podría atraer a aves silvestres portadoras del virus?

Rosemary Reams, educadora jubilada de 82 años de Ionia, Michigan, creció en una granja y lleva años ayudando al programa local de aves de corral 4-H, enseñando a los niños a criar aves de corral. Ahora, con el brote de gripe aviar, “simplemente no dejo que la gente se acerque a mi gallinero”, dijo.

Reams contó que incluso cambió aves reales por falsas para que los niños las usaran mientras eran evaluados por los jueces en las recientes competiciones de 4-H.

“El año pasado hicimos cambios en la feria sobre los que me preguntaron mucho. Y dije: ‘Así, no tengo que pensar en la seguridad de los niños’”.

Reams se sorprendió por la noticia de la muerte del dueño de un gallinero doméstico en Louisiana. Incluso se ha preguntado si debería seguir manteniendo su propia bandada de 20 a 30 pollos y un par de pavos.

“Pero los quiero. A mi edad, necesito hacerlo. Necesito estar al aire libre”, dijo Reams. “De eso se trata la vida”. Dijo que hará todo lo posible para proteger a los niños del programa 4-H, y a ella misma, de la gripe aviar.

Ni siquiera “la mejor bioseguridad del mundo” ha sido suficiente para salvar a las grandes granjas comerciales de la infección, explicó Emily Metz, presidenta y CEO de la American Egg Board.

La industria del huevo pensó que había aprendido a burlar a este virus después del brote de 2014-15. En aquel entonces, “lo estábamos propagando entre nosotros, entre granjas de huevos, con personas, con camiones”, aseguró Metz. Así que los productores de huevos se cerraron al exterior, contó, y desarrollaron medidas intensivas de bioseguridad para tratar de bloquear las rutas de transmisión de aves silvestres o de otras granjas.

Según Metz, los productores de huevos han tomado medidas exhaustivas.

“Han invertido cientos de millones de dólares en mejoras, desde estaciones de lavado de camiones (que lavan todos los camiones, desde el de FedEx hasta el que transporta alimentos) y todo lo demás: transporte de trabajadores para que haya menos tráfico peatonal, sistemas de luz láser para evitar que las aves acuáticas se posen”.

La propagación lateral, cuando el virus se transmite de una granja a otra, ha disminuido dramáticamente, pasando del 70% de los casos en el último brote a sólo el 15% en abril de 2023, según el USDA.

Y, sin embargo, para Metz “este virus sigue superando a todas las medidas que hemos tomado”.

Otra lucha: vacunar a las aves

Quizás el debate más polémico sobre la gripe aviar en la industria avícola en este momento es si se deben vacunar a las aves.

Dado el creciente número de muertes de animales y el aumento del riesgo para los seres humanos, existe una presión cada vez mayor para vacunar a ciertas aves de corral contra la gripe aviar, algo que países como China, Egipto y Francia ya están haciendo.

En 2023, la Organización Mundial de Sanidad Animal (WOAH) instó a las naciones a considerar la vacunación “como parte de una estrategia más amplia de prevención y control de enfermedades”.

Swayne, experto en gripe aviar y veterinario avícola, trabaja con la WOAH y afirmó que la mayoría de sus colegas en el mundo de la salud animal y pública “consideran la vacunación de las aves de corral como una herramienta positiva para controlar este virus en los animales”, pero también como una herramienta que reduce las posibilidades de infección humana y de que mutaciones adicionales del virus se adapten más a los humanos.

Pero la vacunación podría poner a los exportadores de carne de aves de corral (cuyas aves son genéticamente menos susceptibles al H5N1 que las gallinas ponedoras) en riesgo de perder miles de millones de dólares en acuerdos comerciales internacionales.

Esto se debe a la preocupación de que la vacunación, que reduce la gravedad de la enfermedad en las aves de corral, pueda “ocultar” las infecciones y llevar el virus a través de las fronteras, según John Clifford, ex director veterinario del USDA. Clifford es actualmente asesor del Consejo de Exportación de Aves de Corral y Huevos de Estados Unidos.

“Si vacunamos, no sólo perdemos $6.000 millones potencialmente en exportaciones al año”, indicó Clifford. “Si nos cierran, ese producto vuelve al mercado estadounidense. Nuestros economistas lo estudiaron y dijeron que perderíamos $18.000 millones a nivel nacional”.

Clifford añadió que eso también significaría la pérdida de “más de 200.000 puestos de trabajo agrícolas”.

Incluso si esas normas comerciales cambiaran para permitir la obtención de carne y huevos de aves vacunadas, seguirían existiendo obstáculos logísticos.

“La vacunación podría estar en el horizonte en el futuro, pero no será mañana o pasado mañana, ni el año que viene, ni nada parecido”, dijo Clifford.

Hay que considerar sólo un obstáculo: ninguna vacuna actual contra la gripe aviar altamente patógena es una combinación perfecta para la cepa actual, según el USDA. Pero si el virus evoluciona para poder transmitirse eficientemente de humano a humano, Clifford aseguró que “eso cambiaría las reglas del juego para todos, lo que probablemente forzaría la vacunación”.

En enero, el USDA anunció que “mantendría una reserva que coincida con las cepas del brote actual” en aves de corral.

“Aunque el despliegue de una vacuna para aves de corral sería difícil en la práctica y podría tener implicaciones comerciales, además de la incertidumbre sobre su eficacia, el USDA ha seguido apoyando la investigación y el desarrollo de vacunas aviares”, comunicó la agencia.

En este momento, argumentó Metz, la industria no puede permitirse no intentar la vacunación, que ya ha ayudado a erradicar enfermedades en aves de corral anteriormente.

“Estamos desesperados y necesitamos todas las herramientas posibles”, dijo. “Y ahora mismo, estamos luchando contra este virus con al menos un brazo atado a la espalda, si no dos. Y la vacuna puede ser un gran martillo en nuestra caja de herramientas”.

Pero a menos que el gobierno federal actúe, esa herramienta no se utilizará.

Dejando de lado las preocupaciones de la industria, la doctora en enfermedades infecciosas Bhadelia señaló que, en primer lugar, hay una necesidad urgente por centrarse en reducir el riesgo de infección en los seres humanos. Y eso significa reducir las “posibilidades de infección en los animales que están cerca de los humanos, como las vacas y los pollos. Por eso creo que la vacunación es un gran plan”.

La lección “que aprendemos cada vez que esto ocurre es que si hubiéramos actuado antes, el problema habría sido menor”, concluyó.

Este artículo es producto de una alianza que incluye a Michigan Public, 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.

USE OUR CONTENT

This story can be republished for free (details).

“Hi! I’m Dr. Mona!” she said warmly. “Any chance you guys live in Flint?” She learned the family is from neighboring Grand Blanc.

“That’s so sad!” Hanna said. “You should move to Flint! And have another baby! And you could be part of the Rx Kids program!” The parents chuckled politely. But the doctor was not kidding.

Billed as the first-ever citywide cash aid program for pregnant moms and babies, Rx Kids gives Flint residents $1,500 mid-pregnancy, and $500 each month for the baby’s first year. There are no strings attached. No income limits. And it’s universal; nearly every baby born since the program launched in January is enrolled.

Parents who bring their babies in for checkups at this clinic rattle off the ways the money has helped, from the cribs, diapers, clothes, and wipes they’ve bought to how it’s “kept them afloat” during maternity leave or provided crucial income when a spouse died.

But the true goal of Rx Kids goes far beyond Flint, as Hanna acknowledged, scooping up one of the Rx Kids babies in an exam room. “Do you think we should do this for babies everywhere? What do you think?” she asked, cooing. The baby gurgled happily, smiling. “That was an affirmative yes.”

Cash Payments as a Tool To Reduce Child Poverty

Many other countries, including Austria, Belgium, Canada, France, Germany, Ireland, Norway, Sweden, and the United Kingdom, already offer a child cash benefit. The U.S. essentially did, too, during the coronavirus pandemic: The 2021 expanded child tax credit gave low- and middle-income families (including those previously excluded because of insufficient income) hundreds of dollars per kid in direct, monthly payments for six months.

The child poverty rate fell to a historic low. But the expanded program expired at the end of 2021 and Congress did not renew it. The child poverty rate went back up.

For Luke Shaefer, director of the Poverty Solutions initiative at the University of Michigan’s Ford School of Public Policy and a longtime advocate of child cash benefits, it was “the most brutal day” of his career.

Soon after, he got an email from Hanna asking if he wanted to collaborate on the program that would become Rx Kids. The program’s goals go beyond cash aid for Michigan families: It is also aimed at getting donors, lawmakers, and voters excited about how child cash benefits could help their communities.

The list of the recently converted includes Republican state Sen. John Damoose, who has become an outspoken advocate for expanding Rx Kids. Referring to himself as “a pro-life person,” Damoose said, “I sure as heck better be concerned about making it easier for mothers to make the decision to have their children.” He said the Republican Party needs to get serious about supporting programs like Rx Kids. “We’ve been accused for years about being pro-birth, not pro-life. And I think that’s not without merit. We need to put our money where our mouth is and support these children and support their mothers.”

Already, what once seemed like a moon shot is gaining traction: Shaefer and Hanna say their communications with Vice President Kamala Harris’ presidential campaign helped shape Harris’ “baby bonus” proposal. President-elect Donald Trump’s campaign also supported expanding the child tax credit.

Meanwhile, Michigan has budgeted some $20 million in state Temporary Assistance for Needy Families cash to partially fund an expansion of Rx Kids to a short list of communities, if those areas can raise local matching funds. Those areas include rural communities like Michigan’s remote eastern Upper Peninsula, part of which is in Damoose’s district. “We want to make the tent as big as possible,” Hanna said.

But some Upper Peninsula health officials were initially wary. Each new Rx Kids community will need to raise millions of dollars in private donations to start and sustain the program in their community. “It could be a good thing,” Leann Espinoza, maternal-infant health program manager for the eastern Upper Peninsula, said in August. “But I’m not getting my hopes up. I know that sounds terrible.”

Upper Peninsula Families ‘Fall Through the Cracks’

In the wood-paneled rec room of the Clark Township Community Center, Espinoza broke the news to her team this summer: Rx Kids is not a program the eastern Upper Peninsula will be able to fund on its own.

It’s about “$3 million that we would need to raise,” she said, looking at three other LMAS District Health Department staff members.

Tonya Winberg, the public health nurse for Mackinac County, looked stunned. “It’s just, where does that $3 million come from?” Winberg asked. Other potential Rx Kids expansion sites, like Kalamazoo, have wealthy private foundations that can fund the program. The eastern Upper Peninsula does not.

“And how do we sustain it?” Espinoza added. “We hate to start programs, and then the funding is gone and we have to tell people, ‘It’s not here anymore; we can’t do it anymore.’”

The ruggedly beautiful and densely forested Upper Peninsula is used to feeling forgotten. There’s a running joke about how often it’s mislabeled as Canada or Wisconsin on maps. It has about a third of Michigan’s land mass, but just 3% of its residents. The sheer scale and sparse population mean options for food, housing, and child care are limited. Poverty rates are higher than the state average in much of Espinoza’s territory, and the region has some of the highest rates of newborns suffering from prebirth drug exposure in the state, according to the state health department.

At the community center, Espinoza and her colleagues start listing all the ways Rx Kids would be a lifesaver for families in the Upper Peninsula, many of whom have some income and some resources but “don’t make enough to make it,” Espinoza said. “The fall-through-the-cracks families. And those are the ones that I really, really, really think this program would benefit, especially up here.”

Espinoza’s next meeting was with one of those families. Jessica Kline and her 18-month-old daughter, Aurora, live in Munising, a tourist town on Lake Superior. “She’s got a big personality, and her hair is red, so she came with a warning label,” Kline said of her daughter, laughing.

Aurora is a tiny force, speeding around the family’s apartment, unfazed by the nasal tube that connects her to an oxygen machine. She was born early, at just 24 weeks gestation, weighing less than 2 pounds. No hospital in the Upper Peninsula was equipped to care for a preemie that young. So Aurora and her parents spent seven months at a hospital in Ann Arbor, five hours south of their home. “We didn’t have a reliable vehicle,” Kline said. “We didn’t have a source of income.” Hospital social services provided $19 a day for food, which Kline would save up to buy supplies for Aurora.

When they finally got Aurora home to the Upper Peninsula, their house had been vandalized, the copper pipes stripped out. Espinoza’s team helped them find housing, and drove them to get groceries. Every day is a series of small battles, from finding the medical supplies Aurora needs to figuring out how to get to a revolving door of specialists hundreds of miles away. Still, Aurora’s dad has a job in town. They’ve got family nearby. They’re making it work, Kline said.

But having a program like Rx Kids could have made a huge difference in her daughter’s first year. “Five hundred dollars a month would have been enough to actually be able to get ourselves on our feet,” she said.

After Espinoza left Kline’s apartment, she drove south to her office in Manistique. It was late. Everyone else had gone home. Espinoza sat at her desk, trying to be pragmatic. She knows Rx Kids would not magically solve the lack of child care and housing and all the other things you need to break the cycle of poverty. But it would fix Kline’s car. It would help.

There will undoubtedly be critics, Espinoza said — people who believe parents will just use this money to buy drugs. “‘What did they do to earn it?’” she imagined them saying. “‘You’re just giving them free money, and they didn’t do anything to get it?’ Because they don’t understand. They don’t understand the barriers. They don’t understand that sometimes the choice isn’t always yours. Like, I’ve talked to moms who desperately want to go to work, and they want to support their family, but there’s no child care. And so they have no other choice.”

Espinoza recently got an update from Rx Kids’ Hanna: Largely because of private foundations outside the Upper Peninsula, the program has raised enough money to fund a “perinatal” version of Rx Kids for five counties in the eastern Upper Peninsula. The perinatal program would provide the $1,500 payment mid-pregnancy, plus $500 a month for a baby’s first three months, rather than the full year. “But the goal really is the full program, so we are still raising money,” Hanna said via email.

“I think it’s fantastic if we even just get the perinatal version to start,” Espinoza said. “That’s more than we had before.”

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.

USE OUR CONTENT

This story can be republished for free (details).

It was an incredible moment, but also a terrifying one. A court had just denied the Myers’ parental rights to the twins, who were born via surrogate using embryos made from Jordan’s sperm and Tammy’s eggs. (Tammy’s eggs had been frozen before she underwent treatment for breast cancer.)

“In the early hours of their lives, we had no lifesaving medical decision-making power for their care,” Tammy Myers told lawmakers at a Michigan Senate committee hearing in March.

Instead, the state’s surrogacy restrictions required the Myers to legally adopt their biological twins, Eames and Ellison.

“Despite finally being granted legal parenthood of our twins almost two years after they were born, our wounds from this situation remain raw, casting a long shadow over the cherished memories that we missed,” Myers told lawmakers, her voice catching.

Until this spring, Michigan was the only state that had a broad criminal ban on surrogacy. Many families say that ban left them in legal limbo: They were compelled to leave the state to have children; find strangers on Facebook who would carry their child; or, like the Myers, be forced to legally adopt their own biological children.

Gov. Gretchen Whitmer of Michigan signed legislation in April repealing the 1988 criminal ban, legalizing surrogacy contracts and compensated surrogacy after more than three decades. But the legalization is raising fears among conservatives and religious groups, who echo Pope Francis’ concerns that surrogacy exploits women and makes children “the basis of a commercial contract.”

As reproductive technology advanced in recent decades, most states passed laws permitting and regulating surrogacy. But Michigan did not, said Courtney Joslin, a professor at the University of California-Davis School of Law who specializes in family law. Still, those restrictions didn’t prevent Michiganders from having children via surrogacy.

“Criminal bans, or even civil bans, don’t end the practice,” Joslin said. “People are still engaged in surrogacy, and it’s becoming more clear that the effect of a ban is just to leave the parties without any protection. And that includes the person acting as a surrogate.”

In 2009, a couple in western Michigan had to surrender custody of twins after their surrogate decided to keep the babies. The surrogate claimed that she hadn’t been aware of an arrest and a mental health issue in the intended mother’s past. In 2013, a surrogate from Connecticut fled to Michigan to give birth, knowing state law would give her parental rights. She and the intended parents had disagreed over whether to terminate the pregnancy following the discovery of major fetal abnormalities.

The Myers family, however, thought they would be able to avoid any protracted legal fights. They had the full support of their surrogate, Lauren Vermilye, a stranger who’d volunteered to be their surrogate after seeing Tammy’s posts on Facebook. Yet even with Vermilye and her husband, Jonathan, saying that the twins belonged to the Myers, Michigan judges denied the Myers’ request for a prebirth order giving them parental rights.

“As a devoted family already raising our kind, inclusive and gentle-hearted 8-year-old daughter, Corryn, we were forced to prove our worthiness through invasive psychological testing, home visits, and endless meetings to discuss our parenting plan to prove that we were fit to raise our twins, Eames and Ellison,” Tammy Myers told lawmakers in March.

Opponents of Michigan’s repeal of its surrogacy ban distinguish altruistic surrogacy — in which the surrogate mother does not receive any compensation, including for her medical and legal expenses — from a contract for a child.

Legislators in Michigan’s House of Representatives passed bills late last year to allow courts to recognize and enforce surrogacy contracts. These bills allowed parents to compensate surrogates, including for medical and legal expenses. But as the legislation moved forward early this year, religious and conservative groups, and some Republican lawmakers, continued voicing their opposition.

Michigan’s surrogacy laws were not preventing altruistic surrogacy in the state, argued Genevieve Marnon, the legislative director of Right to Life of Michigan, at a state Senate committee hearing in March.

“However, current law does require a legal adoption of a child who is born of one woman and then given to another person,” Marnon said. “That practice is child-protective, to prevent the buying and selling of children, and to ensure children are going to a safe home.”

Michigan’s ban on surrogacy is “in keeping with much of the rest of the world,” Marnon said in March. Several European countries ban or restrict surrogacy, including Italy, which is cracking down on international surrogacy, an arrangement involving a surrogate mother who lives in a different country than the biological parents.

“India, Thailand, and Cambodia had laws similar to those contemplated in these bills, but due to exploitation of their women caused by surrogacy tourism, they changed their laws to stop that,” Marnon told the senators in March.

In January, Pope Francis called for a universal ban on surrogacy, “which represents a grave violation of the dignity of the woman and the child, based on the exploitation of situations of the mother’s material needs,” he said.

Rebecca Mastee, a policy advocate with the Michigan Catholic Conference, told lawmakers that while she acknowledged the suffering of people with infertility, surrogacy can exploit women and treat babies like commodities.

“At the core of such agreements is a contract for a human being,” she said.

“That made my blood boil, hearing that,” said Eric Portenga. He and his husband, Kevin O’Neill, had traveled from their home in Ann Arbor to the Capitol in Lansing to attend the hearings in March.

If you’ve been through the surrogacy process “you know there’s no commodification at all,” Portenga said. “You want a family because you have love to give. And you want to build the love that you have, with your family.”

When Portenga and O’Neill were trying to become fathers, they reached out to surrogacy agencies in other states but were told the process would cost $200,000. “We would have had to have sold the house,” O’Neill said.

Like the Myers, the couple turned to Facebook and social media, “just putting our story out there that we wanted to become dads,” O’Neill said. A friend of a friend, Maureen Farris, reached out to the couple: She’d been wanting to help a family through surrogacy for years, she said. And Farris lived just a few hours south in Ohio, where surrogacy contracts and compensation are legal.

Farris’ contract with Portenga and O’Neill was fairly standard. Both sides had to undergo psychological background checks and have legal representation. The contract also set compensation for Farris, which covered medical and legal fees. The contract stipulated Farris couldn’t travel to Michigan beyond a certain point in her pregnancy because if she’d gone into labor and given birth in the state, she would be considered the legal parent of the child.

That contract, Portenga and O’Neill said, gave Farris more protection and agency than she would have had in Michigan at the time. “They’re carrying a human life inside of them,” O’Neill said of surrogates. “They’re not able to work. Their bodies will be changed forever. They’re getting compensated for the amazing gift they’re giving people.”

After the embryo transfer was successful, Portenga and O’Neill learned Farris was pregnant — with identical triplet girls.

“They came out and just unraveled this huge string of ultrasound photographs and, and that’s when we knew our life had changed,” Portenga said, sitting at home in the family’s kitchen. The girls were born in Ohio — where the dads could be legally named their parents — and then the family of five returned to Michigan.

Today, Sylvie, Parker, and Robin O’Neill are 2 years old, and very busy. Parker is the “leader of the pack,” while Robin is the “brains of the operation” — she can count to 10 but likes to skip the number five. Sylvie is “the most affectionate, the most sensitive, of the three of them,” O’Neill said. “But their bond is so amazing to watch. And we’re so lucky to be their dads.”

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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Ruckle, who has worked in the neonatal intensive care unit at Ascension Via Christi St. Joseph for two decades, said it was “hard to decipher which was the correct dose” on the medication record. He’d “never seen that happen,” he said, “when we were on the computer system” before the cyberattack.

A May 8 ransomware attack against Ascension, a Catholic health system with 140 hospitals in at least 10 states, locked providers out of systems that track and coordinate nearly every aspect of patient care. They include its systems for electronic health records, some phones, and ones “utilized to order certain tests, procedures and medications,” the company said in a May 9 statement.

More than a dozen doctors and nurses who work for the sprawling health system told Michigan Public and KFF Health News that patient care at its hospitals across the nation was compromised in the fallout of the cyberattack over the past several weeks. Clinicians working for hospitals in three states described harrowing lapses, including delayed or lost lab results, medication errors, and an absence of routine safety checks via technology to prevent potentially fatal mistakes.

Despite a precipitous rise in cyberattacks against the health sector in recent years, a weeks-long disruption of this magnitude is beyond what most health systems are prepared for, said John Clark, an associate chief pharmacy officer at the University of Michigan health system.

“I don’t believe that anyone is fully prepared,” he said. Most emergency management plans “are designed around long-term downtimes that are into one, two, or three days.”

Ascension in a public statement May 9 said its care teams were “trained for these kinds of disruptions,” but did not respond to questions in early June about whether it had prepared for longer periods of downtime. Ascension said June 14 it had restored access to electronic health records across its network, but that patient “medical records and other information collected between May 8” and when the service was restored “may be temporarily inaccessible as we work to update the portal with information collected during the system downtime.”

Ruckle said he “had no training” for the cyberattack.

Back to Paper

Lisa Watson, an intensive care unit nurse at Ascension Via Christi St. Francis hospital in Wichita, described her own close call. She said she nearly administered the wrong medication to a critically ill patient because she couldn’t scan it as she normally would. “My patient probably would have passed away had I not caught it,” she said.

Watson is no stranger to using paper for patients’ medical charts, saying she did so “for probably half of my career,” before electronic health records became ubiquitous in hospitals. What happened after the cyberattack was “by no means the same.”

“When we paper-charted, we had systems in place to get those orders to other departments in a timely manner,” she said, “and those have all gone away.”

Melissa LaRue, an ICU nurse at Ascension Saint Agnes Hospital in Baltimore, described a close call with “administering the wrong dosage” of a patient’s blood pressure medication. “Luckily,” she said, it was “triple-checked and remedied before that could happen. But I think the potential for harm is there when you have so much information and paperwork that you have to go through.”

Clinicians say their hospitals have relied on slapdash workarounds, using handwritten notes, faxes, sticky notes, and basic computer spreadsheets — many devised on the fly by doctors and nurses — to care for patients.

More than a dozen other nurses and doctors, some of them without union protections, at Ascension hospitals in Michigan recounted situations in which they say patient care was compromised. Those clinicians spoke on the condition that they not be named for fear of retaliation by their employer.

An Ascension hospital emergency room doctor in Detroit said a man on the city’s east side was given a dangerous narcotic intended for another patient because of a paperwork mix-up. As a result, the patient’s breathing slowed to the point that he had to be put on a ventilator. “We intubated him and we sent him to the ICU because he got the wrong medication.”

A nurse in a Michigan Ascension hospital ER said a woman with low blood sugar and “altered mental status” went into cardiac arrest and died after staff said they waited four hours for lab results they needed to determine how to treat her, but never received. “If I started having crushing chest pain in the middle of work and thought I was having a big one, I would grab someone to drive me down the street to another hospital,” the same ER nurse said.

Similar concerns reportedly led a travel nurse at an Ascension hospital in Indiana to quit. “I just want to warn those patients that are coming to any of the Ascension facilities that there will be delays in care. There is potential for error and for harm,” Justin Neisser told CBS4 in Indianapolis in May.

Several nurses and doctors at Ascension hospitals said they feared the errors they’ve witnessed since the cyberattack began could threaten their professional licenses. “This is how a RaDonda Vaught happens,” one nurse said, referring to the Tennessee nurse who was convicted of criminally negligent homicide in 2022 for a fatal drug error.

Reporters were not able to review records to verify clinicians’ claims because of privacy laws surrounding patients’ medical information that apply to health care professionals.

Ascension declined to answer questions about claims that care has been affected by the ransomware attack. “As we have made clear throughout this cyber attack which has impacted our system and our dedicated clinical providers, caring for our patients is our highest priority,” Sean Fitzpatrick, Ascension’s vice president of external communications, said via email on June 3. “We are confident that our care providers in our hospitals and facilities continue to provide quality medical care.”

The federal government requires hospitals to protect patients’ sensitive health data, according to cybersecurity experts. However, there are no federal requirements for hospitals to prevent or prepare for cyberattacks that could compromise their electronic systems.

Hospitals: ‘The No.1 Target of Ransomware’

“We’ve started to think about these as public health issues and disasters on the scale of earthquakes or hurricanes,” said Jeff Tully, a co-director of the Center for Healthcare Cybersecurity at the University of California-San Diego. “These types of cybersecurity incidents should be thought of as a matter of when, and not if.”

Josh Corman, a cybersecurity expert and advocate, said ransom crews regard hospitals as the perfect prey: “They have terrible security and they’ll pay. So almost immediately, hospitals went to the No. 1 target of ransomware.”

In 2023, the health sector experienced the largest share of ransomware attacks of 16 infrastructure sectors considered vital to national security or safety, according to an FBI report on internet crimes. In March, the federal Department of Health and Human Services said reported large breaches involving ransomware had jumped by 264% over the past five years.

A cyberattack this year on Change Healthcare, a unit of UnitedHealth Group’s Optum division that processes billions of health care transactions every year, crippled the business of providers, pharmacies, and hospitals.

In May, UnitedHealth Group CEO Andrew Witty told lawmakers the company paid a $22 million ransom as a result of the Change Healthcare attack — which occurred after hackers accessed a company portal that didn’t have multifactor authentication, a basic cybersecurity tool.

The Biden administration in recent months has pushed to bolster health care cybersecurity standards, but it’s not clear which new measures will be required.

In January, HHS nudged companies to improve email security, add multifactor authentication, and institute cybersecurity training and testing, among other voluntary measures. The Centers for Medicare & Medicaid Services is expected to release new requirements for hospitals, but the scope and timing are unclear. The same is true of an update HHS is expected to make to patient privacy regulations.

HHS said the voluntary measures “will inform the creation of new enforceable cybersecurity standards,” department spokesperson Jeff Nesbit said in a statement.

“The recent cyberattack at Ascension only underscores the need for everyone in the health care ecosystem to do their part to secure their systems and protect patients,” Nesbit said.

Meanwhile, lobbyists for the hospital industry contend cybersecurity mandates or penalties are misplaced and would curtail hospitals’ resources to fend off attacks.

“Hospitals and health systems are not the primary source of cyber risk exposure facing the health care sector,” the American Hospital Association, the largest lobbying group for U.S. hospitals, said in an April statement prepared for U.S. House lawmakers. Most large data breaches that hit hospitals in 2023 originated with third-party “business associates” or other health entities, including CMS itself, the AHA statement said.

Hospitals consolidating into large multistate health systems face increased risk of data breaches and ransomware attacks, according to one study. Ascension in 2022 was the third-largest hospital chain in the U.S. by number of beds, according to the most recent data from the federal Agency for Healthcare Research and Quality.

And while cybersecurity regulations can quickly become outdated, they can at least make it clear that if health systems fail to implement basic protections there “should be consequences for that,” Jim Bagian, a former director of the National Center for Patient Safety at the Veterans Health Administration, told Michigan Public’s Stateside.

Patients can pay the price when lapses occur. Those in hospital care face a greater likelihood of death during a cyberattack, according to researchers at the University of Minnesota School of Public Health.

Workers concerned about patient safety at Ascension hospitals in Michigan have called for the company to make changes.

“We implore Ascension to recognize the internal problems that continue to plague its hospitals, both publicly and transparently,” said Dina Carlisle, a nurse and the president of the OPEIU Local 40 union, which represents nurses at Ascension Providence Rochester. At least 125 staff members at that Ascension hospital have signed a petition asking administrators to temporarily reduce elective surgeries and nonemergency patient admissions, like under the protocols many hospitals adopted early in the covid-19 pandemic.

Watson, the Kansas ICU nurse, said in late May that nurses had urged management to bring in more nurses to help manage the workflow. “Everything that we say has fallen on deaf ears,” she said.

“It is very hard to be a nurse at Ascension right now,” Watson said in late May. “It is very hard to be a patient at Ascension right now.”

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The question has never been exactly how Ann Picha-Lillard died on Nov. 19, 2022: She succumbed to respiratory failure after an infection put too much strain on her weakened lungs. She was 65.

For Tim Lillard, the question has been why.

Lillard had been in the hospital with his wife every day for a month. Nurses in the intensive care unit had told him they were short-staffed, and were constantly rushing from one patient to the next.

Lillard tried to pitch in where he could: brushing Ann’s shoulder-length blonde hair or flagging down help when her tracheostomy tube gurgled — a sign of possible respiratory distress.

So the day he walked into the ICU and saw staff members huddled in Ann’s room, he knew it was serious. He called the couple’s adult children: “It’s Mom,” he told them. “Come now.”

All he could do then was sit on Ann’s bed and hold her hand, watching as staff members performed chest compressions, desperately trying to save her life.

A minute ticked by. Then another. Lillard’s not sure how long the CPR continued — long enough for the couple’s son to arrive and take a seat on the other side of Ann’s bed, holding her other hand.

Finally, the intensive care doctor called it and the team stopped CPR. Time of death: 12:37 p.m.

Lillard didn’t know what to do in a world without Ann. They had been married almost 25 years. “We were best friends,” he said.

Just days before her death, nurses had told Lillard that Ann could be discharged to a rehabilitation center as soon as the end of the week. Then, suddenly, she was gone. Lillard didn’t understand what had happened.

Lillard said he now believes that overwhelmed, understaffed nurses hadn’t been able to respond in time as Ann’s condition deteriorated. And he has made it his mission to fight for change, joining some nursing unions in a push for mandatory ratios that would limit the number of patients in a nurse’s care. “I without a doubt believe 100% Ann would still be here today if they had staffing levels, mandatory staffing levels, especially in ICU,” Lillard said.

Last year, Oregon became the second state after California to pass hospital-wide nurse ratios that limit the number of patients in a nurse’s care. Michigan, Maine, and Pennsylvania are now weighing similar legislation.

But supporters of mandatory ratios are going up against a powerful hospital industry spending millions of dollars to kill those efforts. And hospitals and health systems say any staffing ratio regulations, however well-intentioned, would only put patients in greater danger.

Putting Patients at Risk

By next year, the United States could have as many as 450,000 fewer nurses than it needs, according to one estimate. The hospital industry blames covid-19 burnout, an aging workforce, a large patient population, and an insufficient pipeline of new nurses entering the field.

But nursing unions say that’s not the full story. There are now 4.7 million registered nurses in the country, more than ever before.

The problem, the unions say, is a hospital industry that’s been intentionally understaffing their units for years in order to cut costs and bolster profits. The unions say there isn’t a shortage of nurses but a shortage of nurses willing to work in those conditions.

The nurse staffing crisis is now affecting patient care. The number of Michigan nurses who say they know of a patient who has died because of understaffing has nearly doubled in recent years, according to a Michigan Nurses Association survey last year.

Just months before Ann Picha-Lillard’s death, nurses and doctors at the health system where she died had asked the Michigan attorney general to investigate staffing cuts they believed were leading to dangerous conditions, including patient deaths, according to The Detroit News.

But Lillard didn’t know any of that when he drove his wife to the hospital in October 2022. She had been feeling short of breath for a few weeks after she and Lillard had mild covid infections. They were both vaccinated, but Ann was immunocompromised. She suffered from rheumatoid arthritis, a condition that had also caused scarring in her lungs.

To be safe, doctors at DMC Huron Valley-Sinai Hospital wanted to keep Ann for observation. After a few days in the facility, she developed pneumonia. Doctors told the couple that Ann needed to be intubated. Ann was terrified but Lillard begged her to listen to the doctors. Tearfully, she agreed.

With Ann on a ventilator in the ICU, it seemed clear to Lillard that nurses were understaffed and overwhelmed. One nurse told him they had been especially short-staffed lately, Lillard said.

“The alarms would go off for the medications, they’d come into the room, shut off the alarm when they get low, run to the medication room, come back, set them down, go to the next room, shut off alarms,” Lillard recalled. “And that was going on all the time.”

Lillard felt bad for the nurses, he said. “But obviously, also for my wife. That’s why I tried doing as much as I could when I was there. I would comb her hair, clean her, just keep an eye on things. But I had no idea what was really going on.”

Finally, Ann’s health seemed to be stabilizing. A nurse told Lillard they’d be able to discharge Ann, possibly by the end of that week.

By Nov. 17, Ann was no longer sedated and she cried when she saw Lillard and her daughter. Still unable to speak, she tried to mouth words to her husband “but we couldn’t understand what she was saying,” Lillard said.

The next day, Lillard went home feeling hopeful, counting down the days until Ann could leave the hospital.

Less than 24 hours later, Ann died.

Lillard couldn’t wrap his head around how things went downhill so fast. Ann’s underlying lung condition, the infection, and her weakened state could have proved fatal in the best of circumstances. But Lillard wanted to understand how Ann had gone from nearly discharged to dying, seemingly overnight.

He turned his dining room table into a makeshift office and started with what he knew. The day Ann died, he remembered her medical team telling him that her heart rate had spiked and she had developed another infection the night before. Lillard said he interviewed two DMC Huron Valley-Sinai nurse administrators, and had his own doctor look through Ann’s charts and test results from the hospital. “Everybody kept telling me: sepsis, sepsis, sepsis,” he said.

Sepsis is when an infection triggers an extreme reaction in the body that can cause rapid organ failure. It’s one of the leading causes of death in U.S. hospitals. Some experts say up to 80% of sepsis deaths are preventable, while others say the percentage is far lower.

Lives can be saved when sepsis is caught and treated fast, which requires careful attention to small changes in vital signs. One study found that for every additional patient a nurse had to care for, the mortality rate from sepsis increased by 12%.

Lillard became convinced that had there been more nurses working in the ICU, someone could have caught what was happening to Ann.

“They just didn’t have the time,” he said.

DMC Huron Valley-Sinai’s director of communications and media relations, Brian Taylor, declined a request for comment about the 2022 staffing complaint to the Michigan attorney general.

Following the Money

When Lillard asked the hospital for copies of Ann’s medical records, DMC Huron Valley-Sinai told him he’d have to request them from its parent company in Texas.

Like so many hospitals in recent years, the Lillards’ local health system had been absorbed by a series of other corporations. In 2011, the Detroit Medical Center health system was bought for $1.5 billion by Vanguard Health Systems, which was backed by the private equity company Blackstone Group.

Two years after that, in 2013, Vanguard itself was acquired by Tenet Healthcare, a for-profit company based in Dallas that, according to its website, operates 480 ambulatory surgery centers and surgical hospitals, 52 hospitals, and approximately 160 additional outpatient centers.

As health care executives face increasing pressure from investors, nursing unions say hospitals have been intentionally understaffing nurses to reduce labor costs and increase revenue. Also, insurance reimbursements incentivize keeping nurse staffing levels low. “Hospitals are not directly reimbursed for nursing services in the same way that a physician bills for their services,” said Karen Lasater, an associate professor of nursing in the Center for Health Outcomes and Policy Research at the University of Pennsylvania. “And because hospitals don’t perceive nursing as a service line, but rather a cost center, they think about nursing as: How can we reduce this to the lowest denominator possible?” she said.

Lasater is a proponent of mandatory nurse ratios. “The nursing shortage is not a pipeline problem, but a leaky bucket problem,” she said. “And the solutions to this crisis need to address the root cause of the issue, which is why nurses are saying they’re leaving employment. And it’s rooted in unsafe staffing. It’s not safe for the patients, but it’s also not safe for nurses.”

A Battle Between Hospitals and Unions

In November, almost one year after Ann’s death, Lillard told a room of lawmakers at the Michigan State Capitol that he believes the Safe Patient Care Act could save lives. The health policy committee in the Michigan House was holding a hearing on the proposed act, which would limit the amount of mandatory overtime a nurse can be forced to work, and require hospitals to make their staffing levels available to the public.

Most significantly, the bills would require hospitals to have mandatory, minimum nurse-to-patient ratios. For example: one nurse for every patient in the ICU; one for every three patients in the emergency room; a nurse for triage; and one nurse for every four postpartum birthing patients and well-baby care.

Efforts to pass mandatory ratio laws failed in Washington and Minnesota last year after facing opposition from the hospital industry. In Minnesota, the Minnesota Nurses Association accused the Mayo Clinic of using “blackmail tactics”: Mayo had told lawmakers it would pull billions of dollars in investment from the state if mandatory ratio legislation passed. Soon afterward, lawmakers removed nurse ratios from the legislation.

While Lillard waited for his turn to speak to Michigan lawmakers about the Safe Patient Care Act in November, members of the Michigan Nurses Association, which says it represents some 13,000 nurses, told lawmakers that its units were dangerously understaffed. They said critical care nurses were sometimes caring for up to 11 patients at a time.

“Last year I coded someone in an ICU for 10 minutes, all alone, because there was no one to help me,” said the nurses association president and registered nurse Jamie Brown, reading from another nurse’s letter.

“I have been left as the only specially trained nurse to take care of eight babies on the unit: eight fragile newborns,” said Carolyn Clemens, a registered nurse from the Grand Blanc area of Michigan.

Nikia Parker said she has left full-time emergency room nursing, a job she believes is her calling. After her friend died in the hospital where she worked, she was left wondering whether understaffing may have contributed to his death.

“If the Safe Patient Care Act passed, and we have ratios, I’m one of those nurses who would return to the bedside full time,” Parker told lawmakers. “And so many of my co-workers who have left would join me.”

But not all nurses agree that mandatory ratios are a good idea. 

While the American Nurses Association supports enforceable ratios as an “essential approach,” that organization’s Michigan chapter does not, saying there may not be enough nurses in the state to satisfy the requirements of the Safe Patient Care Act.

For some lawmakers, the risk of collateral damage seems too high. State Rep. Graham Filler said he worries that mandating ratios could backfire.

“We’re going to severely hamper health care in the state of Michigan. I’m talking closed wards because you can’t meet the ratio in a bill. The inability for a hospital to treat an emergent patient. So it feels kind of to me like a gamble we’re taking,” said Filler, a Republican.

Michigan hospitals are already struggling to fill some 8,400 open positions, according to the Michigan Health & Hospital Association. That association says that complying with the Safe Patient Care Act would require hiring 13,000 nurses.

Every major health system in the state signed a letter opposing mandatory ratios, saying it would force them to close as many as 5,100 beds.

Lillard watched the debate play out in the hearing. “That’s a scare tactic, in my opinion, where the hospitals say we’re going to have to start closing stuff down,” he said.

He doesn’t think legislation on mandatory ratios — which are still awaiting a vote in the Michigan House’s health policy committee — are a “magic bullet” for such a complex, national problem. But he believes they could help.

“The only way these hospitals and the administrations are gonna make any changes, and even start moving towards making it better, is if they’re forced to,” Lillard said.

Seated in the center of the hearing room in Lansing, next to a framed photo of Ann, Lillard’s hands shook as he recounted those final minutes in the ICU.

“Please take action so that no other person or other family endures this loss,” he said. “You can make a difference in saving lives.”

Grief is one thing, Lillard said, but it’s another thing to be haunted by doubts, to worry that your loved one’s care was compromised before they ever walked through the hospital doors. What he wants most, he said, is to prevent any other family from having to wonder, “What if?”

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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This story can be republished for free (details).

“Patients tell me, ‘Doctor, why are you stopping me from getting the care that I need?’” said Crissman, an OB-GYN who provides abortions as part of her practice and is also an assistant professor at the University of Michigan. “The answer is that Prop 3 made access to abortion care a right in Michigan. But these [other] laws remain on the books.”

Ever since the Supreme Court overturned Roe v. Wade, abortion patients have traveled to Michigan in record numbers for care. Voters passed what’s known as Proposal 3 last November, enshrining abortion rights in the state’s constitution. But it can still be difficult to get abortion care in Michigan, and even patients who have secured appointments are regularly turned away, doctors say.

That’s because of remaining legal restrictions, including an informed consent form that must be printed and signed 24 hours before an appointment begins.

This fall, Democrats in Michigan pledged to change those older state laws. They introduced the Reproductive Health Act, which would repeal the state’s 24-hour mandatory waiting period, get rid of the informed consent form, allow Medicaid to cover abortions for low-income patients, and make it easier for private insurance to cover abortions. The legislation would also lift regulations on abortion clinics that advocates say are unnecessary and burdensome.

The time is ripe, Democrats say. Since the 2022 election, the party controls both chambers of the legislature and the governorship, positioning them to pass what they consider a landmark victory for reproductive health.

But now that legislation is stalled — not because of opposition from the Republican minority, but because of dissension within the Democrats’ ranks. Michigan is one of the few remaining Midwestern states where abortion remains legal, so Democrats’ efforts to make the procedure more accessible in the state will have wide-ranging consequences.

Pre-Visit Paperwork Requires Internet Access, a Printer, and Exact Timing

Crissman has a request for anyone who thinks Michigan’s 24-hour mandatory waiting period and informed consent form laws are reasonable: See if you can figure them out.

“Try to figure out what you’re supposed to print. See if you get it right,” said Crissman, “because every day I see patients who’ve driven five hours for abortion care. And they haven’t gotten it right.”

A pamphlet distributed to patients relies heavily on a Q&A format that appears focused on helping them navigate potential difficulties during a pregnancy. One question reads: “How am I supposed to eat healthy food when it costs so much?” The answer: Try food stamps. Q: “What if my house or apartment is in an unsafe neighborhood?” A: Have a “safety plan in mind” and “lock your doors.”

The pamphlet features pictures of smiling pregnant women cradling their bellies and beaming parents holding sleeping newborns. At a statehouse hearing last month, Sarah Wallett, chief medical operating officer of Planned Parenthood of Michigan, said state law mandates these materials be provided to all patients, regardless of their circumstances. One patient was ending a much-wanted pregnancy because of a fetal “anomaly incompatible with life,” Wallett said. “She asked me with tears in her eyes why I had forced her to look at information that wasn’t relevant to her, that only made this harder for her and her family going through this heartbreak. I could only reply, ‘Because Michigan law requires me to.’”

Once patients have reviewed the required materials, they need to click “finish.” That automatically generates a signature form, with a date and time stamp of the exact moment they clicked “finish.” That time stamp must be at least 24 hours, but no more than two weeks, before their appointment. Otherwise, under Michigan law, the appointment must be canceled.

Patients must then print and bring a copy of that signed, time-stamped page to the appointment.

Cancellations Over Paperwork Can Lead to Increased Risks

Planned Parenthood of Michigan reports turning away at least 150 patients a month because of mistakes with that form: The patient didn’t sign it in the proper time window, or printed the wrong page, or didn’t have a printer.

That delay in care can be medically risky, said OB-GYN Charita Roque, who testified at the hearing for the Reproductive Health Act. Roque explained that a patient had developed peripartum cardiomyopathy, a potentially life-threatening heart problem that can occur during pregnancy.

“Not wanting to risk her life, or leave the young child she already had without a mother, she decided to get an abortion,” said Roque, who is also an assistant professor at Western Michigan University’s medical school. “But by the time she finally got to me, she was 13 weeks pregnant, and the clock was ticking due to her high-risk health status.”

The patient didn’t have a printer, so when she arrived at her appointment, she hadn’t brought a hard copy of the required form. Her appointment was postponed.

“During that time, her cardiac status became even higher risk, and it was evident that she would need a higher level of care in a hospital setting,” Roque said. “This meant that the cost would be much, much higher: over $10,000. And since her insurance was legally prohibited from covering abortion care, she anticipated she would have to incur significant medical debt. In the end, she suffered a five-week delay from the first day I saw her [to] when her procedure was finally completed. The delay was entirely unnecessary.”

A Democrat Breaks With Her Party

Republicans and abortion opponents have called the Reproductive Health Act a political overreach, pointing out that the bills go far beyond Proposal 3’s promise, which was to “#RestoreRoe.”

“The so-called Reproductive Health Act, with its dangerous and unpopular changes, goes far beyond what Michigan voters approved in Proposal 3 of 2022,” Republican state Rep. Ken Borton said in a statement. “While claiming to promote reproductive health, this plan ultimately risks hurting Michigan residents by undermining patients and decriminalizing the worst parts of abortion practices.”

Still, until a few weeks ago, Democrats appeared poised to pass the Reproductive Health Act through their majorities in the House and Senate. Gov. Gretchen Whitmer vowed to sign it.

Then, on Sept. 20, state Rep. Karen Whitsett stunned her party: She cast the lone Democratic “no” vote in the House of Representatives health policy committee. The bills still passed out of committee, but the Democrats’ majority in the House is so slim, they can’t afford to lose a single vote.

Whitsett said that she’s not alone in her concerns, and that other Democrats in the state legislature have privately voiced similar doubts about the legislation.

At first, Whitsett said, she thought her discussions with Democratic leadership were productive, “that we were actually getting somewhere. But it was pushed through. And I was asked to either not come to work, or to pass on my vote. I’m not doing either of those.”

It’s not that Whitsett doesn’t support abortion rights, she said. “I’ve been raped. I’ve gone through the process of trying to make the hard decision. I did the 24-hour pause. I did all these things that everyone else is currently going through.”

And because she’s had an abortion, she said, she is proof the current restrictions aren’t so unreasonable. If the current online forms are confusing, she said, “let’s bring this into 2023: How about you DocuSign? But I still do not think that 24 hours of a pause, to make sure you’re making the right decision, is too much to ask.”

Most of all, Whitsett said, her constituents in Detroit and Dearborn do not want Medicaid — and, therefore, their tax dollars — funding elective abortions. Medicaid is jointly funded by state and federal dollars, and the long-standing federal “Hyde Amendment” prohibits federal funds from paying for abortions except in the case of rape or incest, or to save the life of the patient. But states have the option to use their own funding to cover abortion care for Medicaid recipients.

In Michigan, voters approved a ban in 1988 on state funding for abortion, but the new legislation would overturn that. The change would increase state Medicaid costs by an estimated $2 million-$6 million, according to a Michigan House Fiscal Agency analysis.

“People are saying, ‘I agree to reproductive health. But I never agreed to pay for it,’” Whitsett said. “And I think that’s very fair. … I just do not think that that’s something that should be asked of anyone as a taxpayer.”

As Legislative Clock Ticks, Political Pressures Ramp Up

Whitsett is now the target of a public pressure campaign by advocacy groups such as the American Civil Liberties Union of Michigan and Planned Parenthood of Michigan. A virtual event targeted Detroit voters in Whitsett’s district. Paula Thornton-Greer, president and CEO of Planned Parenthood of Michigan, issued a public statement claiming Whitsett would be “solely responsible for the continued enforcement of dozens of anti-abortion restrictions that disproportionately harm women of color and people who are struggling to make ends meet.”

Crissman, the OB-GYN, said she’s tired of not being able to give her patients the care they seek.

“I wish Rep. Whitsett could sit with me and tell a patient to their face: ‘No, we can’t provide your abortion care today, because you printed the wrong page on this 24-hour consent,’” Crissman said. “Or ‘No, mother of five trying to make ends meet and feed your kids, you can’t use your Medicaid to pay for abortion care.’ Because I don’t want to tell patients that anymore.”

But abortion opponents say they’re not surprised the legislation has stalled.

“These hastily crafted bills present a real danger to women and our broader communities,” said Genevieve Marnon, legislative director of Right to Life of Michigan, in an email. “I have no doubt many people of good conscience are finding cause for hesitation, for a whole host of reasons.”

On Monday, Gov. Whitmer told reporters she still expects “the whole package” of legislation in the Reproductive Health Act to pass.

“Any and every bill of the RHA that hits my desk, I’m going to sign. I’d like to see them come as a package. It’s important, and I think that the voters expect that. It was a result of an overwhelming effort to enshrine these rights into our constitution. But also with an expectation that additional barriers are going to be leveled. So I’m not going to pick and choose. I’m not going to say that I can live with this and not that. I want to see the whole package hit my desk.”

This article is from a partnership that includes Michigan Radio, 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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