Here are some of our favorites, starting with the poem that stole our hearts like a $0 billing balance — and then was turned into a cartoon by KFF Health News staff illustrator Oona Zenda.

1st Place

Runner-Up

A box of chocolates?A dozen roses?Just the usual Valentine’s occurrence.I’d rather Cupid chip in for my rising insurance.

– Laura Wagner 

Other Newsroom Favorites 

Damn, girl.Are you a menopause expert?Because it’s been impossible to find you.

– Priya Bathija

Feeling lonely on Valentine’s with no PCPI call all the offices, but no one can see me.My insurance suggests telehealth to thicken the plot,but with no one around, I’ll seek care from an AI robot.

– Sara Culley

Roses are red,Violets are blue,If I had to choose health insurance or my house,I wouldn’t know what to do.

– Thy-Ann Nguyen 

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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A week earlier, immigration agents had grabbed Julio César Peña from his front yard in Glendale, California. Now, he was in a hospital after suffering a ministroke. He was shackled to the bed by his hand and foot, he told Romero, and agents were in the room, listening to the call. He was scared he would die and wanted his wife there.

“What hospital are you at?” Romero asked.

“I can’t tell you,” he replied.

Viridiana Chabolla, Peña’s attorney, couldn’t get an answer to that question, either. Peña’s deportation officer and the medical contractor at the Adelanto ICE Processing Center refused to tell her. Exasperated, she tried calling a nearby hospital, Providence St. Mary Medical Center.

“They said even if they had a person in ICE custody under their care, they wouldn’t be able to confirm whether he’s there or not, that only ICE can give me the information,” Chabolla said. The hospital confirmed this policy to KFF Health News.

Family members and attorneys for patients hospitalized after being detained by federal immigration officials said they are facing extreme difficulty trying to locate patients, get information about their well-being, and provide them emotional and legal support. They say many hospitals refuse to provide information or allow contact with these patients. Instead, hospitals allow immigration officers to call the shots on how much — if any — contact is allowed, which can deprive patients of their constitutional right to seek legal advice and leave them vulnerable to abuse, attorneys said.

Hospitals say they are trying to protect the safety and privacy of patients, staff, and law enforcement officials, even while hospital employees in Los Angeles, Minneapolis, and Portland, Ore., cities where Immigration and Customs Enforcement has conducted immigration raids, say it’s made their jobs difficult. Hospitals have used what are sometimes called blackout procedures, which can include registering a patient under a pseudonym, removing their name from the hospital directory, or prohibiting staff from even confirming that a patient is in the hospital.

“We’ve heard incidences of this blackout process being used at multiple hospitals across the state, and it’s very concerning,” said Shiu-Ming Cheer, the deputy director of immigrant and racial justice at the California Immigrant Policy Center, an advocacy group.

Some Democratic-led states, including California, Colorado, and Maryland, have enacted legislation that seeks to protect patients from immigration enforcement in hospitals. However, those policies do not address protections for people already in ICE custody.

More Detainees Hospitalized

Peña is among more than 350,000 people arrested by federal immigration authorities since President Donald Trump returned to the White House. As arrests and detentions have climbed, so too have reports of people taken to hospitals by immigration agents because of illness or injury — due to preexisting conditions or problems stemming from their arrest or detention.

ICE has faced criticism for using aggressive and deadly tactics, as well as for reports of mistreatment and inadequate medical care at its facilities. Sen. Adam Schiff (D-Calif.) told reporters at a Jan. 20 news conference outside a detention center he visited in California City that he spoke to a diabetic woman held there who had not received treatment in two months.

While there are no publicly available statistics on the number of people sick or injured in ICE detention, the agency’s news releases point to 32 people who died in immigration custody in 2025. Six more have died this year.

The Department of Homeland Security, which oversees ICE, did not respond to a request for information about its policies or Peña’s case.

According to ICE’s guidelines, people in custody should be given access to a telephone, visits from family and friends, and private consultation with legal counsel. The agency can make administrative decisions, including about visitation, when a patient is in the hospital, but should defer to hospital policies on contacting next of kin when a patient is seriously ill, the guidelines state.

Asked in detail about hospital practices related to patients in immigration custody and whether there are best practices that hospitals should follow, Ben Teicher, a spokesperson for the American Hospital Association, declined to comment.

David Simon, a spokesperson for the California Hospital Association, said that “there are times when hospitals will — at the request of law enforcement — maintain confidentiality of patients’ names and other identifying characteristics.”

Although policies vary, members of the public can typically call a hospital and ask for a patient by name to find out whether they’re there, and often be transferred to the patient’s room, said William Weber, an emergency physician in Minneapolis and medical director for the Medical Justice Alliance, which advocates for the medical needs of people in law enforcement custody. Family members and others authorized by the patient can visit. And medical staff routinely call relatives to let them know a loved one is in the hospital, or to ask for information that could help with their care.

But when a patient is in law enforcement custody, hospitals frequently agree to restrict this kind of information sharing and access, Weber said. The rationale is that these measures prevent unauthorized outsiders from threatening the patient or law enforcement personnel, given that hospitals lack the security infrastructure of a prison or detention center. High-profile patients such as celebrities sometimes also request this type of protection.

Several attorneys and health care providers questioned the need for such restrictions. Immigration detention is civil, not criminal, detention. The Trump administration says it’s focused on arresting and deporting criminals, yet most of those arrested have no criminal conviction, according to data compiled by the Transactional Records Access Clearinghouse and several news outlets.

Taken Outside His Home

According to Peña’s wife, Romero, he has no criminal record. Peña came to the United States from Mexico in sixth grade and has an adult son in the U.S. military. The 43-year-old has terminal kidney disease and survived a heart attack in November. He has trouble walking and is partially blind, his wife said. He was detained Dec. 8 while resting outside after coming home from dialysis treatment.

Initially, Romero was able to find her husband through the ICE Online Detainee Locator System. She visited him at a temporary holding facility in downtown Los Angeles, bringing him his medicines and a sweater. She then saw he’d been moved to the Adelanto detention center. But the locator did not show where he was after he was hospitalized.

When she and other relatives drove to the detention facility to find him, they were turned away, she said. Romero received occasional calls from her husband in the hospital but said they were less than 10 minutes long and took place under ICE surveillance. She wanted to know where he was so she could be at the hospital to hold his hand, make sure he was well cared for, and encourage him to stay strong, she said.

Shackling him and preventing him from seeing his family was unfair and unnecessary, she said.

“He’s weak,” Romero said. “It’s not like he’s going to run away.”

ICE guidelines say contact and visits from family and friends should be allowed “within security and operational constraints.” Detainees have a constitutional right to speak confidentially with an attorney. Weber said immigration authorities should tell attorneys where their clients are and allow them to talk in person or use an unmonitored phone line.

One of his clients was Bayron Rovidio Marin, a car wash worker injured during a raid in August. Immigration agents surveilled him for over a month at Harbor-UCLA Medical Center, a county-run facility, without charging him.

In November, the Los Angeles County Board of Supervisors voted to curb the use of blackout policies for patients under civil immigration custody at county-run hospitals. In a statement, Arun Patel, the chief patient safety and clinical risk management officer for the Los Angeles County Department of Health Services, said the policies are designed to reduce safety risks for patients, doctors, nurses, and custody officers.

“In some situations, there may be concerns about threats to the patient, attempts to interfere with medical care, unauthorized visitors, or the introduction of contraband,” Patel said. “Our goal is not to restrict care but to allow care to happen safely and without disruption.”

Leaving Patients Vulnerable

Thompson-Lleras said he’s concerned that hospitals are cooperating with federal immigration authorities at the expense of patients and their families and leaving patients vulnerable to abuse.

“It allows people to be treated suboptimally,” Thompson-Lleras said. “It allows people to be treated on abbreviated timelines, without supervision, without family intervention or advocacy. These people are alone, disoriented, being interrogated, at least in Bayron’s case, under pain and influence of medication.”

Such incidents are alarming to hospital workers. In Los Angeles, two health care professionals who asked not to be identified by KFF Health News, out of concern for their livelihoods, said that ICE and hospital administrators, at public and private hospitals, frequently block staff from contacting family members for people in custody, even to find out about their health conditions or what medications they’re on. That violates medical ethics, they said.

Blackout procedures are another concern.

“They help facilitate, whether intentionally or not, the disappearance of patients,” said one worker, a physician for the county’s Department of Health Services and part of a coalition of concerned health workers from across the region.

At Legacy Emanuel Medical Center in Portland, nurses publicly expressed outrage over what they saw as hospital cooperation with ICE and the flouting of patient rights. Legacy Health has sent a cease and desist letter to the nurses’ union, accusing it of making “false or misleading statements.”

“I was really disgusted,” said Blaire Glennon, a nurse who quit her job at the hospital in December. She said numerous patients were brought to the hospital by ICE with serious injuries they sustained while being detained. “I felt like Legacy was doing massive human rights violations.”

Handcuffed While Unconscious

Two days before Christmas, Chabolla, Peña’s attorney, received a call from ICE with the answer she and Romero had been waiting for. Peña was at Victor Valley Global Medical Center, about 10 miles from Adelanto, and about to be released.

Excited, Romero and her family made the two-hour-plus drive from Glendale to the hospital to take him home.

When they got there, they found Peña intubated and unconscious, his arm and leg still handcuffed to the hospital bed. He’d had a severe seizure on Dec. 20, but no one had told his family or legal team, his attorney said.

Tim Lineberger, a spokesperson for Victor Valley Global Medical Center’s parent company, KPC Health, said he could not comment on specific patient cases, because of privacy protections. He said the hospital’s policies on patient information disclosure comply with state and federal law.

Peña was finally cleared to go home on Jan. 5. No court date has been set, and his family is filing a petition to adjust his legal status based on his son’s military service. For now, he still faces deportation proceedings.

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Then 25 years old and six months pregnant, she drove herself to the emergency room in Ronan, Montana, on the Flathead Indian Reservation, where an ambulance transferred her to a larger hospital 60 miles away in Missoula. Once she arrived, the staff couldn’t detect her baby’s heartbeat. Swaney began to bleed heavily. She delivered a stillborn baby and was hospitalized for several days. At one point, doctors told her to call her family. They didn’t expect her to survive.

“It certainly changed my life — the experience — but my life has not been a bad life,” she told KFF Health News.

Though her experiences were nearly 50 years ago, Swaney, a member of the Confederated Salish and Kootenai Tribes, said Native Americans continue to receive inadequate maternal care. The data appears to support that belief.

In 2024, the most recent year for which data for the population is available, Native American and Alaska Native people had the highest pregnancy-related mortality ratio among major demographic groups, according to the Centers for Disease Control and Prevention.

In response to this disparity, Native organizations, the CDC, and some states are working to boost tribal participation in state maternal mortality review committees to better track and address pregnancy-related deaths in their communities. Native organizations are also considering ways tribes could create their own committees.

State maternal mortality review committees investigate deaths that occur during pregnancy or within a year after pregnancy, analyze data, and issue policy recommendations to lower death rates.

According to 2021 CDC data, compiled from 46 maternal mortality review committees, 87% of maternal deaths in the U.S. were deemed preventable. Committees reported that most, if not all, deaths among Native American and Alaska Native people were considered preventable.

Our matriarchs, our moms, are what carries a nation forward.

Kim Moore-Salas

State committees have received federal money through the Preventing Maternal Deaths Act, which President Donald Trump signed in 2018.

But the money is scheduled to dry up on Jan. 31, when the short-term spending bill that ended the government shutdown expires.

Funding for the committees is included in the Labor, Health and Human Services, Education, and Related Agencies appropriations bill for fiscal year 2026. That bill must be approved by the House, Senate, and president to take effect.

Native American leaders said including members of their communities in maternal mortality review committee activities is an important step in addressing mortality disparities.

In 2023, tribal leaders and federal officials met to discuss four models: a mortality review committee for each tribe, a committee for each of the 12 Indian Health Service administrative regions, a national committee to review all Native American maternal deaths, and the addition of Native American subcommittees to state committees.

Whatever the model, tribal sovereignty, experience, and traditional knowledge are important factors, said Kim Moore-Salas, a co-chair of the Arizona Maternal Mortality Review Committee. She’s also the chairperson of the panel’s American Indian/Alaska Native mortality review subcommittee and a member of the Navajo Nation.

“Our matriarchs, our moms, are what carries a nation forward,” she said.

Mental health conditions and infection were the leading underlying causes of pregnancy-related death among Native American and Alaska Native women as of 2021, according to the CDC report analyzing data from 46 states.

The CDC found an estimated 68% of pregnancy-related deaths among Native American and Alaska Native people happened within a week of delivery to a year postpartum. The majority of those happened between 43 days and a year after birth.

The federal government has a responsibility under signed treaties to provide health care to the 575 federally recognized tribes in the U.S. through the Indian Health Service. Tribal members can receive limited services at no cost, but the agency is underfunded and understaffed.

A study published in 2024 that analyzed data from 2016 to 2020 found that approximately 75% of Native American and Alaska Native pregnant people didn’t have access to care through the Indian Health Service around the time of giving birth, meaning many likely sought care elsewhere. More than 90% of Native American and Alaska Native births occur outside of IHS facilities, according to the agency. For those who did deliver at IHS facilities, a 2020 report from the Department of Health and Human Services’ Office of Inspector General found that 56% of labor and delivery patients received care that did not follow national clinical guidelines.

The 2024 study’s authors also found that members of the population were less likely to have stable insurance coverage and more likely to have a lapse in coverage during the period close to birth than non-Hispanic white people.

Cindy Gamble, who is Tlingit and a tribal community health consultant for the American Indian Health Commission in Washington, has been a member of the state’s maternal mortality review panel for about eight years. In the time she’s been on the state panel, she said, its composition has broadened to include more people of color and community members.

The panel also began to include suicide, overdose, and homicide deaths in its data analysis and added racism and discrimination to the risk factors considered during its case review process.

Solutions need to be tailored to the tribe’s identity and needs, Gamble said.

“It’s not a one-size-fits-all,” Gamble said, “because of all the beliefs and different cultures and languages that different tribes have.”

Gamble’s tenure on the state committee is distinctive. Few states have tribal representation on maternal mortality review committees, according to the National Indian Health Board, a nonprofit organization that advocates for tribal health.

The National Council of Urban Indian Health is also working to increase the participation of Urban Indian health organizations, which provide care for Native American people who live outside of reservations, in state maternal mortality review processes. As of 2025, the council had connected Urban Indian health organizations to state review committees in California, Kansas, Oklahoma, and South Dakota.

Native leaders such as Moore-Salas find the current efforts encouraging.

“It shows that state and tribes can work together,” she said.

In March 2024, Moore-Salas became the first Native American co-chair of Arizona’s Maternal Mortality Review Committee. In 2025 she and other Native American members of the committee developed guidelines for the American Indian/Alaska Native subcommittee and reviewed the group’s first cases.

The subcommittee is exploring ways to make the data collection and analysis process more culturally relevant to their population, Moore-Salas said.

But it takes time for policy changes to create widespread change in the health of a population, Gamble said. Despite efforts around the country, other factors may hinder the pace of progress. For example, maternity care deserts are growing nationally, caused by rapid hospital and labor and delivery unit closures. Health experts have raised concerns that upcoming cuts to Medicaid will hasten these closures.

Despite her experience and the ongoing crisis among Native American and Alaska Native people, Swaney hopes for change.

She had a second complicated pregnancy soon after her stillbirth. She went into labor about three months early, and the doctors said her son wouldn’t live to the next morning. But he did, and he was transferred about 525 miles away from Missoula to the nearest advanced neonatal unit, in Salt Lake City.

Her son, Kelly Camel, is now 48. He has severe cerebral palsy and profound deafness. He lives alone but has caregivers to help with cooking and other tasks, said Swaney, 73.

He “has a good sense of humor. He’s kind to other people. We couldn’t ask for a more complete child.”

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When Matthew Hurley was looking to take PrEP to prevent HIV, the doctor hadn’t heard of the medicine, and when he finally did prescribe PrEP, the bills sent to Hurley were expensive … and wrong. “I decided to write in because the process was really super frustrating.” At one point, Hurley asked, “Am I just going to stop this medication to stop having to deal with these coding issues and these scary bills?”

— Matthew Hurley, 30, from Berkeley, California

A couple of years ago, Matthew Hurley got the kind of text people fear.

It said: “When was the last time you were STD tested?”

Someone Hurley had recently had unprotected sex with had just tested positive for HIV.

Hurley went to a clinic and got tested. “Luckily, I had not caught HIV, but it was a wake-up call,” they said.

That experience moved Hurley to seek out PrEP, shorthand for preexposure prophylaxis. The antiretroviral medication greatly reduces the chance of getting HIV, the virus that causes AIDS. The therapy is 99% effective at protecting people against sexual transmission when taken as prescribed.

Hurley started PrEP and all was well for the first nine months — until their health insurance changed and they started seeing a new doctor: “When I brought PrEP up to him, he said, ‘What’s that?’ And I was like, oh boy.”

Hurley, who is a librarian, went into teaching mode. They explained that the PrEP regimen they’d been on required daily pills and lab work every three months to look out for breakthrough infections or other health issues.

Hurley was surprised they knew more about PrEP than the physician. The FDA approved the first drug, Truvada, back in 2012, and Hurley lives in the San Francisco Bay Area, a place with one of the highest concentrations of LGBTQ+ people in the nation and a deep history of HIV and health care activism. Hurley said older friends and acquaintances who survived the AIDS epidemic shared the horror of living through a time when there was no effective treatment or drugs for prevention. Deciding to take PrEP felt like an empowering way to protect their health and their community.

So Hurley pushed the doctor, and after the physician did his own research, he agreed to prescribe PrEP.

Hurley got the care they needed, but they had to be the expert in the exam room.

“That’s a big burden,” said Beth Oller, a family medicine physician and board member of GLMA, a national organization of LGBTQ+ and allied health care professionals focused on health equity. “You really want someone you can just go in and talk [to] about your health concerns without feeling like you are having to educate and advocate for yourself at every turn.”

Oller said many queer people have had negative experiences during health care visits.

“I have a lot of patients who had not done preventive care for years because of the medical stigma,” she said.

Billing Headaches

Clearing the access hurdles to HIV prevention medicine was just the beginning. Hurley started receiving a string of bills for PrEP-related care. Blood test: $271.80. Office visit: $263.

Again, Hurley was surprised. They knew — even if the billing office didn’t — that under the Affordable Care Act most private insurance plans and Medicaid expansion programs are required to cover PrEP and ancillary services, like lab tests, as preventive with no cost sharing.

The bills for doctor visits and blood draws piled up.

Hurley would appeal the bill and get a denial almost every time. Then, they would appeal again.

Hurley shared a series of appeal letters for one service, in which the billing office acknowledged that blood work had been initially incorrectly coded as diagnostic. Once that was corrected, Hurley said, the insurer paid for the service.

That might sound quick or easy to resolve, but Hurley said it took “forever to get through the process.” They dealt with at least six incorrect bills over several months. Hurley estimated they spent more than 60 hours contesting the bills.

During that time, Hurley said, the billing department “is continuing to send me emails and bills that are saying, You’re overdue. You’re overdue. You’re overdue.”

Fed up with the hassles, Hurley decided to find a health provider (and billing office) better informed about PrEP. They settled on the AIDS Healthcare Foundation. The care team there was able to discuss the pros and cons of different PrEP regimens and knew how to navigate the formulary for Hurley’s insurance.

Hurley hasn’t gotten an unexpected bill since.

But siloing sexual health care and PrEP off from primary care hasn’t been ideal.

“I have multiple organizations that I have to deal with to get my holistic health dealt with,” Hurley said.

A provider doesn’t need to be an HIV specialist, an infectious disease expert, or a physician to prescribe PrEP. The Centers for Disease Control and Prevention encourages primary care providers to treat PrEP like other preventive medications.

To avoid some of the headaches Hurley faced, try these tips:

1. Find Out if PrEP Is Right for You

The CDC estimates 2.2 million Americans could benefit from HIV prevention drugs, but just over a quarter of that group have been prescribed them.

“Not enough people know about PrEP, and there are a number of people who know about PrEP but do not realize it’s for them,” said Jeremiah Johnson, executive director of PrEP4All, an organization dedicated to universal access to HIV prevention and medication.

According to the CDC’s clinical guidelines, PrEP can be prescribed as part of a preventive health plan to anyone who’s sexually active. It’s especially recommended for people who don’t use condoms consistently, intravenous drug users who share needles, men who have sex with men, and people in relationships with partners living with HIV or whose HIV status is unclear.

The vast majority of PrEP users are men. There are big race, gender, and geographical disparities in the distribution of HIV and the populations taking the prevention medicine. For example, based on the patterns of new infection in the U.S., a group that would benefit from PrEP is cisgender Black women, whose gender identity aligns with their sex assigned at birth.

2. Don’t Assume Your Provider Knows About PrEP

If your doctors aren’t well informed, start by educating yourself. There are also clinical guidelines and information you can share with your provider. Check your state or local health department for a how-to guide for prescribing PrEP. For example, the New York State Department of Health AIDS Institute has information for providers.

The CDC also has PrEP guidelines, but many of the agency’s websites dealing with LGBTQ+ health are in flux. Under the Trump administration, some HIV/AIDS resources have been taken down from federal websites. Others now have headers saying: “This page does not reflect biological reality and therefore the Administration and this Department rejects it.”

3. Get Lab Work In-Network

Johnson said Hurley’s experience with billing mistakes is common. “The lab expenses in particular end up being very tricky,” Johnson said.

For example, a doctor’s office may mistakenly code the lab work required for PrEP as a diagnostic test instead of preventive care. Patients like Hurley can end up with a bill they shouldn’t have to pay. If your doctor’s office is making mistakes, share the PrEP billing and coding guide from NASTAD, an association of public health officials who administer HIV and hepatitis programs.

Try to get your lab work done in-network. If the lab is out-of-network, Johnson said, it can be difficult to appeal.

If the bills keep coming, appeal them. And if you can’t resolve the dispute, Johnson said, file a complaint with the agency that regulates your insurance plan.

4. Look for Ways To Save

There are different kinds of PrEP. There are lower-cost, generic versions of Truvada, for example, sold as emtricitabine/tenofovir disoproxil fumarate, often shortened to FTC/TDF. Newer PrEP drugs Apretude and Yeztugo have list prices in the thousands of dollars. Check your insurance formulary and ask your doctor to prescribe medicine your plan will cover.

With many health care premiums dramatically increasing and millions at risk of losing Medicaid coverage, many people may go without health insurance this year. Drug manufacturers such as Gilead and ViiV have assistance programs for qualifying patients. If you have to pay out-of-pocket, prescription price comparison websites, like GoodRx, can help you find the pharmacies with the cheapest price.

5. Consider Telehealth

Telehealth is an increasingly popular option if you don’t live near an affirming provider or are looking for a more private way to get PrEP. In 2024, roughly 1 in 5 people on PrEP used telemedicine. Online pharmacies like Mistr and Q Care Plus offer PrEP without an in-person appointment, and lab work can be done at home. Some telehealth options have ways to lower the cost if you’re uninsured.

Telehealth can also broaden the number of doctors who are ready to prescribe PrEP. And some patients say speaking with a remote provider feels like a safer setting to talk about sexual health. “They’re in the comfort of their own bedroom or living room but can interface virtually with a provider. It can open up a lot of doors for honesty and trust,” said Alex Sheldon, executive director of GLMA.

6. Seek Out Affirming Care

GLMA created the LGBTQ+ Healthcare Directory, a searchable database of health care providers across the nation who identify as queer-friendly. As Hurley discovered, living in a major metro area is no guarantee your doctor is up to date on LGBTQ+ health care.

Ask locals you trust for recommendations. You might be surprised to find good options nearby.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and KFF Health News.

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Both patients, a man and a woman, had agreed to donate their brains after they died for further research. “An amazing gift,” said Edward Lee, the neuropathologist who directs the brain bank at the university’s Perelman School of Medicine. “They were both very dedicated to helping us understand Alzheimer’s disease.”

The man, who died at 83 with dementia, had lived in the Center City neighborhood of Philadelphia with hired caregivers. The autopsy showed large amounts of amyloid plaques and tau tangles, the proteins associated with Alzheimer’s disease, spreading through his brain.

Researchers also found infarcts, small spots of damaged tissue, indicating that he had suffered several strokes.

By contrast, the woman, who was 84 when she died of brain cancer, “had barely any Alzheimer’s pathology,” Lee said. “We had tested her year after year, and she had no cognitive issues at all.”

The man had lived a few blocks from Interstate 676, which slices through downtown Philadelphia. The woman had lived a few miles away in the suburb of Gladwyne, Pennsylvania, surrounded by woods and a country club.

The amount of air pollution she was exposed to — specifically, the level of fine particulate matter called PM2.5 — was less than half that of his exposure. Was it a coincidence that he had developed severe Alzheimer’s while she had remained cognitively normal?

With increasing evidence that chronic exposure to PM2.5, a neurotoxin, not only damages lungs and hearts but is also associated with dementia, probably not.

“The quality of the air you live in affects your cognition,” said Lee, the senior author of a recent article in JAMA Neurology, one of several large studies in the past few months to demonstrate an association between PM2.5 and dementia.

Scientists have been tracking the connection for at least a decade. In 2020, the influential Lancet Commission added air pollution to its list of modifiable risk factors for dementia, along with common problems like hearing loss, diabetes, smoking, and high blood pressure.

Yet such findings are emerging when the federal government is dismantling efforts by previous administrations to continue reducing air pollution by shifting from fossil fuels to renewable energy sources.

“‘Drill, baby, drill’ is totally the wrong approach,” said John Balmes, a spokesperson for the American Lung Association who researches the effects of air pollution on health at the University of California-San Francisco.

“All these actions are going to decrease air quality and lead to increasing mortality and illness, dementia being one of those outcomes,” Balmes said, referring to recent environmental moves by the White House.

Many factors contribute to dementia, of course. But the role of particulates — microscopic solids or droplets in the air — is drawing closer scrutiny.

Particulates arise from many sources: emissions from power plants and home heating, factory fumes, motor vehicle exhaust, and, increasingly, wildfire smoke.

Of the several particulate sizes, PM2.5 “seems to be the most damaging to human health,” Lee said, because it is among the smallest. Easily inhaled, the particles enter the bloodstream and circulate through the body; they can also travel directly from the nose to the brain.

The research at the University of Pennsylvania, the largest autopsy study to date of people with dementia, included more than 600 brains donated over two decades.

Previous research on pollution and dementia mostly relied on epidemiological studies to establish an association. Now, “we’re linking what we actually see in the brain with exposure to pollutants,” Lee said, adding, “We’re able to do a deeper dive.”

The study participants had undergone years of cognitive testing at Penn Memory. With an environmental database, the researchers were able to calculate their PM2.5 exposure based on their home addresses.

The scientists also devised a matrix to measure how severely Alzheimer’s and other dementias had damaged donors’ brains.

Lee’s team concluded that “the higher the exposure to PM2.5, the greater the extent of Alzheimer’s disease,” he said. The odds of more severe Alzheimer’s pathology at autopsy were almost 20% greater among donors who had lived where PM2.5 levels were high.

Another research team recently reported a connection between PM2.5 exposure and Lewy body dementia, which includes dementia related to Parkinson’s disease. Generally considered the second most common type after Alzheimer’s, Lewy body accounts for an estimated 5% to 15% of dementia cases.

In what the researchers believe is the largest epidemiological study to date of pollution and dementia, they analyzed records from more than 56 million beneficiaries with traditional Medicare from 2000 to 2014, comparing their initial hospitalizations for neurodegenerative diseases with their exposure to PM2.5 by ZIP codes.

“Chronic PM2.5 exposure was linked to hospitalization for Lewy body dementia,” said Xiao Wu, an author of the study and a biostatistician at the Mailman School of Public Health at Columbia University.

After controlling for socioeconomic and other differences, the researchers found that the rate of Lewy body hospitalizations was 12% higher in U.S. counties with the worst concentrations of PM2.5 than in those with the lowest.

To help verify their findings, the researchers nasally administered PM2.5 to laboratory mice, which after 10 months showed “clear dementia-like deficits,” senior author Xiaobo Mao, a neuroscientist at the Johns Hopkins School of Medicine, wrote in an email.

The mice got lost in mazes that they had previously dashed through. They had earlier built nests quickly and compactly; now their efforts were sloppy, disorganized. At autopsy, Mao said, their brains had atrophied and contained accumulations of the protein associated with Lewy bodies in human brains, called alpha-synuclein.

A third analysis, published this summer in The Lancet, included 32 studies conducted in Europe, North America, Asia, and Australia. It also found “a dementia diagnosis to be significantly associated with long-term exposure to PM2.5” and to certain other pollutants.

Whether so-called ambient air pollution — the outdoor kind — increases dementia because of inflammation or other physiological causes awaits the next round of research.

Although air pollution has declined in the United States over two decades, scientists are calling for still stronger policies to promote cleaner air. “People argue that air quality is expensive,” Lee said. “So is dementia care.”

President Donald Trump, however, reentered office vowing to increase the extraction and use of fossil fuels and to block the transition to renewable energy. His administration has rescinded tax incentives for solar installations and electric vehicles, Balmes noted, adding, “They’re encouraging continuing to burn coal for power generation.”

The administration has halted new offshore wind farms, announced oil and gas drilling in the Arctic National Wildlife Refuge in Alaska, and moved to stop California’s plan to transition to electric cars by 2035. (The state has challenged that action in court.)

“If policy goes in the opposite direction, with more air pollution, that’s a big health risk for older adults,” Wu said.

Last year, under the Biden administration, the Environmental Protection Agency set tougher annual standards for PM2.5, noting that “the available scientific evidence and technical information indicate that the current standards may not be adequate to protect public health and welfare, as required by the Clean Air Act.”

In March, the EPA’s new chairman announced that the agency would be “revisiting” those stricter standards.

The New Old Age is produced through a partnership with The New York Times.

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Vought has exerted extraordinary control over government spending this year, usurping congressional decisions on how the nation’s money is used. His push for more layoffs during the government shutdown is only the latest blow, following months of firings, canceled grants, and withheld funds.

By cutting and freezing public health funds, in particular, the Trump administration has already begun to undercut efforts to provide medical care, outbreak response, housing assistance, and research across the U.S., according to health officials, nonprofit directors, and federal agency staffers interviewed by KFF Health News.

Since most federal funds for public health flow to states, Vought is rivaling the Department of Health and Human Services secretary, Robert F. Kennedy Jr., in his ability to upend government-led efforts to keep Americans healthy. In Texas, Centers for Disease Control and Prevention funds to stem a measles outbreak weren’t available until after the crisis had subsided and two children had died. A project to protect Alabamans from raw sewage and hookworm was abandoned. People with HIV have had to delay medical care as clinics scale back hours. Time-dependent surveys on HIV and maternal mortality were halted. Food banks have canceled events. Tobacco prevention programs lapsed. Initiatives to protect older adults at risk of falling have been harried.

No matter what budget Congress ultimately passes for next year, the Trump administration may continue to thwart financial support for such programs in ways that will harm people’s health. “The White House has shown that they are willing to unilaterally exert control over funding,” said Gillian Metzger, a constitutional law professor at Columbia University.

“This is a huge deal,” she added, “because the power of the purse is central to Congress’ ability to shape and direct policy.”

Before he was appointed to lead the White House’s Office of Management and Budget this year, Vought outlined budgetary strategies the executive branch could deploy to wrest power from Congress and federal agencies in Project 2025, the Heritage Foundation’s conservative blueprint.

Vought’s tactics unfolded this year, often below the radar. They include abrupt grant cancellations, extraordinary constraints on how funds can be spent, and excessive layers of review, agency officials say, at every step in the grantmaking process. Getting money out the door has been further complicated by layoffs that have gutted offices overseeing grants on chronic disease prevention, HIV, maternal mortality, and more.

Government employees have described these tactics to members of Congress, said Abigail Tighe, executive director of the National Public Health Coalition, a group that includes current and former staffers at the CDC and HHS. “We want Congress to act, because this is preventing states and communities from doing critical public health work to keep our country safe,” she said. “If they don’t have capacity, we all collectively suffer.”

Democrats on the House and Senate appropriations committees have pushed for transparency, but the extent to which money Congress appropriated for public health in 2024 and 2025 has gone unspent because of the administration’s disruptions is not yet known. “This is a sophisticated strategy to cause money to lapse and then say, ‘If they can’t spend it, they don’t need it,’” said Robert Gordon, a public policy specialist at Georgetown University and a former assistant finance secretary at HHS.

“No one thought this was possible or legal, but that is what’s happening,” he said.

Details on how the administration has subverted health spending have received little attention because many changes have been made quietly — and people who rely on federal funds fear retribution. The Trump administration has defunded and threatened federal offices that hold the government accountable and fired whistleblowers. It has abruptly revoked funds for local governments and organizations.

Vought and spokespeople at the White House and the OMB did not respond to queries from KFF Health News. However, Vought described his intentions in a Sept. 3 speech. He said that federal agencies and Congress had gained more power over spending since the 1970s and that their control became “woke and weaponized” under Presidents Barack Obama and Joe Biden.

“Thankfully, President Trump won,” he said. “And we have now been embarked on deconstructing this administrative state.”

Many Parts, Many Malfunctions

Like a car, the federal budget process has many components that can break down. Through the OMB and its partner, Trump’s Department of Government Efficiency, or DOGE, the administration has intervened at various junctures. “There are so many ways in which money is not operating in the way it is supposed to operate,” said Bobby Kogan, the senior director of federal budget policy at the Center for American Progress, a left-leaning think tank, and a former OMB adviser.

Typically, Congress passes a budget that appropriates money for the next fiscal year to federal agencies. For many public health programs, ranging from housing assistance to cancer screening, agencies then post open calls online for states, local governments, and organizations to apply for funding. Agency experts select winners and send notices of awards — or notices of ongoing funding to groups that previously won multiyear awards.

Next, the OMB, which administers the federal budget, activates money for agencies, like a bank activates a credit card, so that grantees can spend and get reimbursed rapidly. Auditors keep an eye on spending, but the government has in the past limited interruptions so that programs run smoothly.

Early on, the Trump administration canceled billions of dollars in awards granted in 2024 and early 2025 for research and global health. In March, it clawed back $11.4 billion in covid-era funds that Congress had earmarked for health departments that were using the money for disease surveillance, vaccinations, and more.

Although some funds have been restored because of lawsuits, the Supreme Court has allowed other cuts by the administration to stand while the cases move through the courts.

Beyond these “shotgun” cancellations, the administration has taken a quieter, “in-the-weeds, slowing, cutting, conditioning” approach that’s frozen funds for public health, said Matthew Lawrence, a law professor specializing in health policy at Emory University.

By August, the CDC’s center for HIV and tuberculosis prevention had doled out $167 million less than the historical average, according to an analysis by the Center on Budget and Policy Priorities, a think tank focused on reducing inequality. The CDC’s funding for chronic disease prevention lagged by $259 million, the Ryan White HIV/AIDS Program had underspent by $105 million, and funds for mental health at the Substance Abuse and Mental Health Services Administration were more than $860 million behind what was expected.

An unknown amount of Congress’ 2025 funding for research and public health has yet to be awarded and will probably lapse this year, said Joe Carlile, an author of the center’s analysis and an associate OMB director during the Biden administration. The obstructions appear to be concentrated in areas where the White House proposed cutting the federal budget next year. “The administration may be executing their 2026 budget request through administrative controls,” Carlile said.

“This is boring but crazy-high stakes,” he added. “A one-branch veto of spending neuters the power of the purse in the Constitution that Madison said was the fundamental check on the executive branch.”

Incremental Chaos

A key tactic Vought described in Project 2025 occurs when the OMB activates funds for agencies in installments, called apportionments. Vought wrote that “apportioned funding” could “ensure consistency with the President’s agenda.”

Under Vought, the OMB shrank the size of apportionments, HHS and CDC staffers said. It’s illegal for agencies to let grantees withdraw money before the total amount is in the metaphorical bank, so that delayed agencies’ ability to greenlight spending.

The OMB and DOGE also placed conditions on apportionments through memos, footnotes, and spoken directives telling agencies to ensure that spending “aligns with Administration priorities,” according to reports and HHS employees who said that notices of funding opportunities and awards required excessive layers of sign-off. The CDC and other agencies circulated lists of priorities that reflect White House stances, including those targeting diversity, equity, and inclusion efforts; immigration; and transgender rights. Public health efforts have been especially caught up in red tape, since many focus on populations bearing an unequal burden of death, disease, and injury.

Groups that rely on federal funds have largely been unaware of the reasons grants were held up, but they’ve fielded what they viewed as unsettling queries. For example, Kathy Garner, the head of a Mississippi nonprofit, said officials asked her to defend the exclusion of men from a program to shelter women who experienced domestic violence.

Delays were made worse by uncertainty. Grantees said they’ve been unable to reach program officers because tens of thousands of federal workers have been laid off. Agency officials said firings slow funding further.

“Everyone’s inbox is full of letters from grant recipients asking, ‘How do we proceed?’” one high-ranking CDC official told KFF Health News, which granted agency officials anonymity because of their fears of retaliation. “We just say, ‘Please wait.’”

Time was critical as a measles outbreak surged in West Texas early this year. The state asked for federal funding for the response in March, but it didn’t arrive until May, after the outbreak had largely faded in Texas, according to an investigation by KFF Health News. Apportionment control was a key reason, CDC staffers said.

In July, 81 HIV organizations sent a letter to Kennedy. “With every day of delayed FY2025 funding release, the delivery of essential HIV services is compromised,” said the letter, which was reviewed by KFF Health News. Because of delays and uncertainty, it said, HIV clinics had laid off case managers and reduced clinician hours, closed sites, and pared down hotlines that patients call with urgent questions. The funds arrived about a month later, but HIV providers remain shaken.

Lauren Richey, medical director at University Medical Center’s HIV clinic in New Orleans, backed out of hiring a sorely needed dentist she had recruited. “I was afraid to tell someone to move across the country for a job when I wasn’t sure if or when we’d get the funding for their salary,” she said. “The wait is now three to four months for dental services, when it was usually a couple of weeks at most.”

Tamachia Davenport, program director at the St. John AIDS outreach ministry in New Orleans, said that “a lot of us are having to rob Peter to pay Paul.”

When the group didn’t get CDC funds it expected this summer, Davenport had to decide between cutting staff or supplies. Concerned her top employees would take jobs elsewhere, she stopped buying the condoms they distribute throughout the city to prevent the spread of sexually transmitted infections.

Louisiana already has one of the highest rates of HIV, chlamydia, and gonorrhea in the country. Condoms cost far less than treating these diseases. For a person infected by HIV at age 35, such costs exceed $326,000.

Groups focused on cancer, diabetes, and heart disease also report lasting repercussions from delays, as well as ongoing fears that they will happen again. Louisiana State University’s Healthy Aging Research Center canceled some of its workshops to train health workers on caring for people with dementia. “There may be fewer people who have this very specific expertise next year in Louisiana and Mississippi,” said Scott Wilks, the director of the center. “That’s on top of the big shortage we have already.”

Nationwide surveys tallying maternal and infant mortality froze for about five months because of funding delays, causing an irrecoverable gap in data that had been collected continuously since 1987, CDC officials say.

“We are seeing the administration get their way with or without an approved budget,” one said. “It’s such a terrible shame to play with people’s health this way.”

DOGE also inserted itself into grant reimbursements this year, stalling the rapid turnaround that public health groups typically expect to cover salaries, rent, and other monthly costs outlined in budgets that have already been approved. In what’s now labeled Departmental Efficiency Review, itemized expenses must be regularly justified by multiple government officials, according to documents reviewed by KFF Health News.

DOGE posted on its website expense reports covering about a month’s span from April to May. Nearly 230 of the individual expenses filed to federal agencies during that period are for $1 or less. Other entries break down monthly salaries for individual employees and petty costs for postage or monthly subscriptions.

“Public funds deserve scrutiny, but this is different from audit practices I’ve been a part of,” Carlile said.

DOGE also stalled calls for applications for 2025 funding — and some calls never appeared as the fiscal year came to a close on Sept. 30. Among them are programs for groups that provide housing assistance. People will be evicted when these organizations run out of money left over from 2024, said Steve Berg, chief policy officer at the National Alliance to End Homelessness.

Other solicitations came out months behind schedule, leaving groups with a few weeks to put together complicated applications for multimillion-dollar awards, including for Alzheimer’s care, addiction recovery, senior support, and chronic disease management.

“They’ve set projects up to fail,” one HHS official said.

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

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The judges’ favorites were inspired by tick migration, Medicaid work requirements, and rising copays.

Follow KFF Health News’ social media accounts (X, Instagram, and Facebook) for more of our favorites. Enjoy!

1st Place

Checkups turn to fright.Copays rise like witching flames.My wallet screams “Boo!”

— Arnav Shah

2nd Place

No rest after death.Even the ghosts must work nowTo get benefits.

— Kristen Hayashi

3rd Place

Questing legs, and teethHitching rides on their blood-brides,All ticks and no treat!

— Carrie Moores

While Halloween may be coming to an end, KFF Health News reporting continues year-round. Send us your haikus at any time for possible inclusion in our Morning Briefing: https://kffhealthnews.org/contact-haiku/. 

2024 Halloween Haiku Contest Winners

2023 Halloween Haiku Contest Winners

2022 Halloween Haiku Contest Winners

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).

Last winter, Amber Wingler started getting a series of increasingly urgent messages from the local hospital in Columbia, Missouri, letting her know her family’s health care might soon be upended.

MU Health Care, where most of her family’s doctors work, was mired in a contract dispute with Wingler’s health insurer, Anthem. The existing contract was set to expire.

Then, on March 31, Wingler received an email alerting her that the next day Anthem was dropping the hospital from its network. It left her reeling.

“I know that they go through contract negotiations all the time … but it just seemed like bureaucracy that wasn’t going to affect us. I’d never been pushed out-of-network like that before,” she said.