But public health leaders quickly identified a familiar boom-and-bust funding cycle as they warned about an incoming fiscal cliff once the federal grants sunset. Now, more than a year since the federal Department of Health and Human Services declared the end of the coronavirus emergency, states — such as Montana, California and Washington — face tough decisions about laying off workers and limiting public health services.

In California, Democratic Gov. Gavin Newsom proposed cutting the state’s public health funding by $300 million. And the Department of Health in Washington state slashed more than 350 positions at the end of last year and more than 200 this year.

Public health experts warn that losing staff who perform functions like disease investigation, immunization, family planning, restaurant inspection and more could send communities into crisis.

“You cannot hire the firefighters when the house is already burning,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, an organization that advocates for public health policy.

In late September, HHS Secretary Xavier Becerra declared a public health emergency for states affected by Hurricane Helene, allowing state and local health authorities in Florida, Georgia, North Carolina, South Carolina and Tennessee to more easily access federal resources. Last week, ahead of Hurricane Milton’s landfall in Florida, Becerra declared another public health emergency to aid the state’s response.

If states don’t have robust public health resources ready when disasters like this hit their communities, it can have devastating effects.

Local health department staffing grew by about 19 percent from 2019 to 2022, according to a report from the National Association of County and City Health Officials that examined 2,512 of the nation’s roughly 3,300 local departments. The same report found that half of those departments’ revenue in 2022 came from federal sources.

But in some places, the pandemic cash did little more than keep small health departments afloat. The Central Montana Health District, a public health agency serving five rural counties, received enough money to retain a staff member to help handle testing, contact tracing and rolling out the coronavirus vaccines. It wasn’t enough to hire extra workers, but it allowed officials to fill a position left empty when a staffer left the department, said Susan Woods, the district’s public health director.

Now, five full-time employees work for the health district — enough to scrape by, Woods said.

“Any kind of crisis, any kind of, God forbid, another pandemic, would probably send us crashing,” she said.

Adriane Casalotti, chief of government and public affairs for the national health officials’ group, said she expects layoffs and health department budget cuts to intensify. Those cuts come as health officials work to address issues that took a back seat in the pandemic, such as increases in rates of sexually transmitted infections, suicide and substance misuse.

And rural health departments deserve more attention, Casalotti said, as they are likely to be the most vulnerable and face compounding factors such as hospital closures and the loss of services including maternity and other women’s care.

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Congress allotted more than $800 billion to support states’ covid responses, fueling a surge in the public health workforce nationwide.

Local health department staffing grew by about 19% from 2019 to 2022, according to a report from the National Association of County and City Health Officials that studied 2,512 of the nation’s roughly 3,300 local departments. That same report explained that half of their revenue in 2022 came from federal sources.

But those jobs, and the safety net they provide for the people in the communities served, are vulnerable as the money dries up, worrying public health leaders — particularly in sparsely populated, rural areas, which already faced long-standing health disparities and meager resources.

Officials in such states as Montana, California, Washington, and Texas now say they face budget cuts and layoffs. Public health experts warn the accompanying service cuts — functions like contact tracing, immunizations, family planning, restaurant inspections, and more — could send communities into crisis.

In California, Democratic Gov. Gavin Newsom proposed cutting the state’s public health funding by $300 million. And the Washington Department of Health slashed more than 350 positions at the end of last year and anticipated cutting 349 more this year as the state’s federal covid funding runs dry.

“You cannot hire the firefighters when the house is already burning,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, an organization that advocates for public health policy.

In some places, that pandemic cash did little more than keep small health departments afloat. The Central Montana Health District, the public health agency for five rural counties, did not receive the same flood of money others saw but did get enough to help the staff respond to an increased workload, including testing, contact tracing, and rolling out covid vaccines.

The department filled a vacancy with a federal grant funneled through the state when a staffer left during the pandemic. The federal funding allowed the department to break even, said Susan Woods, the district’s public health director.

Now, there are five full-time employees working for the health district. Woods said the team is getting by with its slim resources, but a funding dip or another public health emergency could tip the balance in the wrong direction.

“Any kind of crisis, any kind of, God forbid, another pandemic, would probably send us crashing,” Woods said.

Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, said she expects to see layoffs and health department budget cuts intensify. Those cuts will come as health officials address issues that took a back seat during the pandemic, like increases in rates of sexually transmitted diseases, suicide, and substance misuse.

“There’s tons of work being done right now to pick up the pieces on those types of other public health challenges,” she said. But it’ll be hard to catch up with whittled resources.

From 2018 to 2022, reports of chlamydia, gonorrhea, syphilis, and congenital syphilis increased by nearly 2% nationwide, adding up to more than 2.5 million cases. A recent KFF report found that routine vaccination rates for kindergarten-age children have not rebounded to pre-pandemic levels while the number of families claiming exemptions has increased. Nearly three-quarters of states did not meet the federal target vaccination rate of 95% for the 2022-23 school year for measles, mumps, and rubella, increasing the risk of outbreaks.

Amid these challenges, public health leaders are clinging to the resources they gained during the past few years.

The health district in Lubbock, Texas, a city of more than 250,000 people in the state’s Panhandle, hired four disease intervention specialists focused on sexually transmitted diseases during the pandemic due to a five-year grant from the Centers for Disease Control and Prevention.

The positions came as syphilis cases in the state skyrocket past levels seen in the past decade and the increases in congenital syphilis surpass the national average, according to the CDC. State officials recorded 922 congenital syphilis cases in 2022, with a 246.8 rate per 100,000 live births.

But federal officials, facing their own shrinking budget, cut the grant short by two years, leaving the district scrambling to fill a nearly $400,000 annual budget gap while working to tamp down the outbreak.

“Even with the funding, it’s very hard for those staff to keep up with cases and to actually make sure that we get everybody treated,” said Katherine Wells, director of public health for Lubbock.

Wells said state officials may redirect other federal money from the budget to keep the program going when the grant ends in December. Wells and other health leaders in the state consistently plead with state officials for more money but, Wells said, “whether or not we’ll be successful with that in a state like Texas is very much in the air.”

Making public health a priority in the absence of a national crisis is a challenge, Castrucci said. “The boom-and-bust funding cycle is a reflection of the attention of the American public,” he said; as the emergency sunsetted, so too did enthusiasm wane for public health issues.

And rural health departments, like the one in central Montana, deserve more attention, said Casalotti, the advocate for county and city health officials. That’s because they serve a critical function in communities that continue to see hospital closures and lose other health services, such as maternity and women’s care. Local health departments can function as a “safety net for the safety net,” she said.

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Ahora, esa escasez se ha convertido en realidad, y los gobiernos estatales están destinando menos recursos a los departamentos de salud locales.

Ante la pandemia, el Congreso asignó más de $800 mil millones para fortalecer la respuesta de los estados ante covid. Esto resultó en un notable aumento del número de trabajadores de salud pública en todo el país.

El personal de las áreas de salud locales creció alrededor del 19% entre 2019 y 2022, según un informe de la Asociación Nacional de Funcionarios de Salud de Condados y Ciudades que analizó 2,512 de los aproximadamente 3,300 departamentos locales en todo el país.

Ese mismo informe explicaba que, en 2022, la mitad de los ingresos de las oficinas de salud pública regionales provino de fuentes federales.

Pero, a medida que desaparece el dinero, esos puestos de trabajo y la red de apoyo que brinda a las comunidades que atienden se vuelven más frágiles.

Esta situación genera una gran preocupación en los responsables de la salud pública, especialmente en las zonas rurales escasamente pobladas, donde ya se trabaja con pocos recursos, arrastrando disparidades de larga data en la atención de la salud.

En estados como Montana, California, Washington y Texas, los funcionarios enfrentan restricciones presupuestarias y despidos. Expertos en salud pública advierten que los recortes en servicios como el rastreo de contactos, los programas de vacunación, la planificación familiar, las inspecciones de restaurantes y otros podrían poner a las comunidades en situaciones de crisis

En California, el gobernador demócrata Gavin Newsom propuso recortar $300 millones de los fondos para la salud pública. El Departamento de Salud de Washington eliminó más de 350 puestos de trabajo a finales del año pasado, y planea recortar otros 349 este año, a medida que se agotan los fondos federales para covid que recibió el estado.

“No se pueden contratar bomberos cuando la casa ya está ardiendo”, afirmó Brian Castrucci, presidente y director ejecutivo de la Fundación Beaumont, una organización que promueve las políticas de salud pública.

En algunos lugares, el dinero recibido durante la pandemia hizo poco más que mantener a flote los pequeños departamentos de salud. El Distrito Sanitario Central de Montana, una agencia de salud pública que cubre cinco condados rurales, no recibió la misma cantidad de dinero que otros, pero sí lo suficiente como para que el personal pudiera responder a una mayor carga de trabajo, incluyendo testeos, rastreo de contactos y distribución de vacunas contra covid.

El departamento cubrió una vacante con una subvención federal canalizada a través del estado cuando, durante la pandemia, un miembro del personal renunció a su trabajo. La financiación federal permitió que el departamento llegara a un punto de equilibrio, dijo Susan Woods, directora de salud pública del distrito.

Ahora, el distrito tiene cinco empleados a tiempo completo. Woods explicó que el equipo está gestionando con recursos limitados y que otra emergencia de salud pública podría desestabilizar a situación.

“Cualquier tipo de crisis, cualquier nueva pandemia, Dios no lo quiera, probablemente nos haría colapsar”, advirtió Woods.

Adriane Casalotti, jefa de asuntos públicos y gubernamentales de la Asociación Nacional de Funcionarios de Salud de Condados y Ciudades, admitió que es posible que haya más despidos y recortes de dinero.

Esos recortes se producen mientras los funcionarios de salud están tratando de resolver cuestiones muy importantes que quedaron relegadas durante la pandemia, como el aumento de las tasas de enfermedades de transmisión sexual, suicidios y adicciones.

“Hay mucho por hacer para enfrentar estos otros problemas de salud pública que quedaron en un segundo plano”, explicó. Pero será difícil ponerse al día si los recursos de los que se dispone son cada vez más escasos.

Entre 2018 y 2022, los informes mostraron un significativo incremento de las enfermedades de transmisión sexual. Por ejemplo, la clamidia, la gonorrea, la sífilis y la sífilis congénita aumentaron casi un 2% en todo el país, sumando más de 2,5 millones de casos.

Un informe reciente del KFF reveló que las tasas de vacunación en niños de edad preescolar no han recuperado los niveles anteriores a la pandemia. Y aumentó el número de familias que solicitan que se excuse a sus hijos de los programas de vacunación.

Casi tres cuartas partes de los estados no alcanzaron la tasa del 95% de vacunación contra el sarampión, las paperas y la rubéola propuesta por el gobierno federal para el año escolar 2022-23. Este déficit aumenta el riesgo de brotes.

En medio de estos desafíos, las autoridades de salud pública se aferran a los recursos obtenidos durante los últimos años.

El distrito sanitario de Lubbock, Texas, una ciudad de más de 250.000 habitantes situada en el Panhandle del estado, contrató durante la pandemia a cuatro especialistas en enfermedades de transmisión sexual gracias a una subvención por cinco años otorgada por los Centros para el Control y la Prevención de Enfermedades (CDC).

Esos puestos se han creado debido a que los casos de sífilis en Texas se han disparado por encima de los niveles registrados en la última década y, según los CDC, el aumento de la sífilis congénita superó la media nacional.

En 2022, los registros oficiales detectaron 922 casos de sífilis congénita, con una tasa de 246,8 por cada 100.000 nacidos vivos.

Pero los funcionarios federales, que están expuestos a su propia reducción presupuestaria, recortaron la subvención dos años antes de lo previsto. Esto dejó al distrito luchando por subsanar un déficit presupuestario anual de casi $ 400,000 mientras trabajaban para controlar el brote.

“Incluso cuando se recibe financiamiento es muy difícil para el personal de salud sostener el seguimiento de los casos ya detectados y asegurarse de que todos reciben tratamiento”, dijo Katherine Wells, directora de salud pública de Lubbock.

Wells comentó que es probable que, en diciembre, cuando la subvención termine, los funcionarios estatales reorienten otros aportes federales para mantener el programa en marcha.

“Si tendremos o no éxito en un estado como Texas es algo muy incierto”, admitió Wells. Y subrayó que tanto ella como otras autoridades sanitarias solicitan constantemente más recursos a los funcionarios estatales.

El desafío es que se considere la salud pública como una prioridad aunque no exista una emergencia nacional, opinó Castrucci. “El ciclo de auge y caída de la financiación es un reflejo de la atención del público estadounidense”, agregó. Y explicó que a medida que se extinguió la emergencia por covid también se apagó el entusiasmo por las cuestiones de salud pública.

Los departamentos de salud rurales, como el del centro de Montana, merecen más atención, aseguró Casalotti, defensora de los agentes de salud de condados y ciudades. Porque esos departamentos desempeñan una función esencial en comunidades que siguen sufriendo el cierre de hospitales y la pérdida de muchos servicios de salud, como los de maternidad y atención a la mujer.

Los departamentos de salud locales pueden funcionar como una “red de apoyo para la red de apoyo más amplia”, afirmó.

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American Indians and Alaska Natives face life expectancy about 10 years shorter than the national average and, in early 2020, had a covid-19 infection rate 3½ times that of non-Hispanic Whites.

While tribal health leaders have fought for years for better access to data from federal agencies, the pandemic underscored the urgency of making data available to tribes and tribal epidemiology centers.

But even after the public health emergency put a spotlight on the data inequity, tribal public health officials say not much has changed and they still have trouble accessing data on infectious-disease outbreaks, substance use and suicide.

“We’re being blinded,” said Meghan Curry O’Connell, chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation. O’Connell’s work fighting for greater access to data has been highlighted in recent years as the region faces a devastating and ongoing syphilis outbreak.

In 2022, the Government Accountability Office published a report documenting obstacles keeping federal public health information from tribes, including confusion about data-sharing policies, inconsistent processes for requesting information, poor data quality and strict rules for sensitive data on health issues such as substance misuse.

In one example, officials said that as of November 2021, 10 of the 12 tribal epidemiology centers in the United States had varying levels of access to covid data from the Centers for Disease Control and Prevention. While all 10 were given case surveillance data that included information on positive cases, hospitalizations and deaths, only six said they also had access to covid vaccination data from the Department of Health and Human Services.

The GAO report also found that staffers responding to data requests at HHS, the CDC and the Indian Health Service did not consistently recognize tribal epidemiology centers as public health authorities, forcing some to ask for data as researchers or file public records requests.

HHS officials agreed with all of the recommendations the GAO made as a result of its investigation, and after consulting with tribal leaders, this year published a draft policy outlining the types of data the agency would make available to tribes and tribal epidemiology centers, and establishing expectations for agency staffers about responding to data requests.

Some tribal leaders say the proposal is a step in the right direction but is incomplete. Jim Roberts, senior executive liaison in intergovernmental affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization that provides care and advocacy for Alaskan tribes, said the GAO report didn’t address how federal agencies treat tribal governments, which also have a right to their data as sovereign nations.

While HHS continues to work on its policy, Roberts said a strong federal policy on data-use agreements would help tribes’ relationships with state governments, too.

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The 2010 reauthorization of the Indian Health Care Improvement Act gave tribal epidemiology centers public health authority and requires the federal Department of Health and Human Services to grant them access to and use of data and other protected health information that’s regularly distributed to state and local officials. But tribal epidemiology center workers have told government investigators that’s not often the case.

By July 2020, American Indians and Alaskan Natives had a covid-19 infection rate 3½ times that of non-Hispanic whites. Problems accessing data predated the pandemic, but the alarming infection and death rates in Native American communities underscored the importance of making data-sharing easier so tribal health leaders and epidemiologists have the information they need to make lifesaving decisions.

Tribal health officials have repeatedly said data denials impeded their responses to disease outbreaks, including slowing contact tracing during the pandemic and an ongoing syphilis outbreak in the Midwest and Southwest.

“We’re being blinded,” said Meghan Curry O’Connell, the chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation. The sharing of data has improved somewhat in recent years, she said, but not enough.

Federal investigators and tribal epidemiologists have documented a litany of obstacles keeping state and federal public health information from tribes, including confusion about data-sharing policies, inconsistent processes for requesting information, data that’s of poor quality or outdated, and strict privacy rules for sensitive data on health issues like HIV and substance misuse.

Limiting the ability of tribes and tribal epidemiology centers to monitor and respond to public health issues makes historical health disparities difficult to address. Life expectancy among American Indians and Alaskan Natives is at least 5½ years shorter than the national average.

Sarah Shewbrooks and her colleagues at the Great Plains Tribal Epidemiology Center are among those who’ve found themselves blinded by bureaucratic walls. Shewbrooks said the data dearth was particularly evident during the covid pandemic, when her team couldn’t access public health data available to other public health workers in state and local agencies. Her team was forced to manually record positive cases and deaths in the 311 counties of North Dakota, South Dakota, Nebraska, and Iowa — the region the center serves.

Shewbrooks, director of the center’s data-coordinating unit and its lead epidemiologist, estimates staffers spent more than a year’s worth of their time during the pandemic scraping together their own datasets to steer information to tribal leaders making decisions about closing down reservations and asking residents to isolate at home.

She said the process was frustrating and stressful, especially since it robbed her team of hours they could’ve spent trying to save lives in the communities they serve. The tribes in their region were doing “incredible things,” she said, by providing food and shelter for people who needed to quarantine.

“But they were having to do it all without being given real-time understanding of what’s going on around them,” Shewbrooks said.

Contact tracers who work for state governments cover Native American populations, but it’s important to have people from within the community take the lead, Shewbrooks said. Tribal workers are better equipped to move around within their communities and meet people where they are.

Shewbrooks said state contact tracers relied on calling and texting patients, which is often not the most effective method. Tribal members can be a hard-to-reach community for state workers whose protocol is to move on to the next case if they don’t get a response.

“So many cases were just getting closed,” Shewbrooks said.

In 2022, the Government Accountability Office published a report that confirmed concerns raised by tribal health officials, including at the Great Plains tribal epidemiology center. Federal investigators found that health officials working to address public health issues in Native American communities dealt with federal agencies lacking clear processes, policies, and guidelines for sharing data with tribal officials.

In one example, officials said that as of November 2021, 10 of the 12 tribal epidemiology centers in the U.S. had access to Centers for Disease Control and Prevention covid data, but not all had full data. Some centers had access to case surveillance data that included information on positive cases, hospitalizations, and deaths. Only half said they also had access to covid vaccination data from HHS.

The GAO report also found that staffers responding to data requests at HHS, the CDC, and the Indian Health Service did not consistently recognize tribal epidemiology centers as public health authorities. Center officials told federal investigators that they’d sometimes been asked to request data they needed as outside researchers or through the Freedom of Information Act.

The report recommended agencies make several corrections, including responding to tribal epidemiology centers as required by law and clarifying how agency staffers should handle requests from epidemiology centers.

HHS officials agreed with all the recommendations. The agency consulted with tribal leaders in fall 2022 and, this year, published a draft policy that clarifies what data centers can access.

Some tribal leaders say the proposal is a step in the right direction but is incomplete. Jim Roberts, senior executive liaison in intergovernmental affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization that provides care and advocacy for Alaskan tribes, said the GAO report focused on tribal epidemiology centers, which operate separately from tribal governments, each serving dozens of tribes divided into regions. The report left out tribes, which he said have a right to their data as sovereign nations.

HHS officials declined an interview request, but Samira Burns, principal deputy assistant secretary for public affairs, said the agency is reviewing feedback and recommendations it received from tribal leaders during consultation on the draft policy and will continue to consult with tribes before it’s finalized.

Stronger federal policy on tribal data sharing would help with relationships with states, too, Roberts said. Tribal officials say problems they’ve experienced at the federal level are often worse in states, where laws might not recognize tribes or tribal epidemiology centers as authorities that can receive data.

At the Northwest Tribal Epidemiology Center, which works on behalf of tribes in Washington, Oregon, and Idaho, forging a data-use agreement with state governments in Washington and Oregon before the pandemic helped their response by providing immediate access to near real-time data on emergency room and other health care facility visits. The center’s staff used this data to monitor for suspected covid-related visits that could be shared with tribal leaders.

It took seven months for the center to get access to covid surveillance data from the CDC, said Sujata Joshi, director of the Northwest center’s Improving Data and Enhancing Access project, and about nine months for HHS vaccination data after vaccinations became available. Even after getting the information, she said, there were concerns about its quality.

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That was before Idaho’s near-total abortion ban went into effect almost two years ago, criminalizing most abortions. All four of Bonner’s OB/GYNs left by last summer, some citing fears that the state’s ban exposed them to legal peril for doing their jobs.

The exodus forced Bonner General to shutter its labor and delivery unit and sent patients scrambling to seek new providers more than 40 miles away in Coeur d’Alene or Post Falls, or across the state border to Spokane, Wash. It has made Sandpoint a “double desert,” meaning it lacks access to both maternity care and abortion services.

One patient, Jonell Anderson, was referred to an OB-GYN in Coeur d’Alene, roughly an hour’s drive from Sandpoint, after an ultrasound showed a mass growing in her uterus. Anderson made multiple trips to the out-of-town provider. Previously, she would have found that care close to home.

The experience isn’t limited to this small Idaho town.

A 2023 analysis by ABC News and Boston Children’s Hospital found that more than 1.7 million women of reproductive age in the United States live in a “double desert.” About 3.7 million women live in counties with no access to abortion and little to no maternity care.

Texas, Mississippi and Kentucky have the highest numbers of women of reproductive age living in double deserts, according to the analysis.

Amelia Huntsberger, one of the OB/GYNs who chose to leave Sandpoint — despite having practiced there for a decade — did so because she felt she couldn’t provide the care her patients needed under a law as strict as Idaho’s.

The growing provider shortages in rural states affect not only pregnant and postpartum women, but all women, said Usha Ranji, an associate director for Women’s Health Policy at KFF, a health information nonprofit that includes KFF Health News.

“Pregnancy is obviously a very intense period of focus, but people need access to this care before, during and after, and outside of pregnancy,” Ranji said.

The problem is expected to worsen.

In Idaho, the number of applicants to fill spots left by departing doctors has “absolutely plummeted,” said Susie Keller, CEO of the Idaho Medical Association.

“We are witnessing the dismantling of our health system,” she said.

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For Anderson and other patients in this rural community who need gynecological care, stress over discovering an illness is compounded by the challenges they face getting to a doctor.

After that initial ultrasound, Anderson’s primary care provider referred her to an OB-GYN nearly an hour’s drive away in Coeur d’Alene for more testing.

Getting care for more serious gynecological issues, like a hysteroscopy, endometriosis, or polycystic ovary syndrome, has become much more difficult in Sandpoint, a town of about 10,000 people in Idaho’s panhandle region. A state law criminalizing abortions drove multiple OB-GYNs to leave town about a year ago.

The effects have been far-reaching. The OB-GYNs who left Sandpoint were also providing care to patients in nearby outlying areas, like Bonners Ferry, a roughly 40-minute drive into Idaho’s northernmost county. Doctors have spoken out about not feeling safe practicing medicine where they could face criminal charges for providing care to their patients. Republican lawmakers in Idaho contend doctors are being used in an effort to roll back the ban, and they declined to amend the law this year.

According to the Idaho Coalition for Safe Healthcare, a group advocating for a rollback of the state’s strict abortion ban, at least two hospitals, including Bonner General Health in Sandpoint, ended labor and delivery services in the 15 months after the state criminalized abortion in 2022. During that same time period, the number of OB-GYNs practicing in Idaho dropped by 22%. The report’s authors noted that many rural residents rely on consultations from medical specialists in urban parts of the state that are already struggling to provide care.

Those departures have expanded care deserts and added obstacles between patients and care, including for Anderson, 49.

Anderson’s car broke down when she was on the way to see an OB-GYN in Coeur d’Alene a few weeks after her initial ultrasound. Her husband took off work to drive her to a rescheduled appointment the same day. After hours of mishaps, she arrived for the visit, which lasted about 15 minutes. There, the doctor told her she’d need to come back for a hysteroscopy — an exam that shows the inside of the cervix and uterus — a few weeks later, followed by another appointment to go over results.

Four months later, in June, early results showed that the mass in Anderson’s uterus did not appear to be cancerous. She’s relieved, she said, but still concerned about nearing menopause and not having the support of an OB-GYN nearby to help her manage any symptoms or health issues that could come up.

“It sure was a whole level of stress that just added on because I had so much further to transport,” Anderson said. “Three years ago I would have been 10 minutes away from my appointment, not 60 minutes away.”

Those hardships patients face weigh heavily on the specialists who left.

Amelia Huntsberger, an OB-GYN, said that she and her husband are still grappling with a feeling of grief after being “forced out of Idaho” last year. They had lived in the state for more than a decade and practiced in Sandpoint. While leaving was a difficult decision, she said, she has no doubt it was the right one for her; her husband, who was a doctor in the emergency room at Bonner General; and their children.

“I think about things like who we are as a people,” Huntsberger said. “What do we value, and do our actions reflect our values?” Limiting access to care for women, pregnant or not, and their infants suggests lawmakers do not consider them important, she said.

Usha Ranji, an associate director for Women’s Health Policy at KFF, said she has heard anecdotally about providers leaving states with strict abortion bans like Idaho’s. Some recent medical graduates are also avoiding residency positions in states restricting abortion, making it harder to replace the outgoing providers, Ranji said.

Sandy Brower, a spokesperson for Bonner General, said the hospital is working to hire a gynecologist and is focused on building out its family provider team. She said other providers at the hospital are still treating women before and after pregnancy, but not during delivery unless it’s an emergency and the person cannot be transported.

Susie Keller, CEO of the Idaho Medical Association, said there’s a growing number of doctor vacancies in the state and that the number of applicants has “absolutely plummeted and those jobs are taking about twice as long as normal to fill.

“We are witnessing the dismantling of our health system,” Keller said.

As more community members feel the effects of a strained health system, some are following in the path of the doctors — they’re considering leaving. Anderson is among them.

Local education issues play a large part in that decision-making process, she said, as she considers her 9-year-old daughter’s future. But access to women’s health care is another piece of the puzzle.

“If I don’t have the care I need and she doesn’t have the care she needs,” Anderson said, “is that really somewhere we want to live?”

Ranji said polling indicates health care is a priority for people, so it could play into decisions about where they want to plant roots. And that leads into another way community members could respond to the changes in local care — by voting in state elections.

Primary election results from May in northern Idaho, where Sandpoint is located, showed signs of voters backing Republican candidates who hold more moderate views on abortion. Former state Sen. Jim Woodward narrowly beat Sen. Scott Herndon, a fellow Republican who sought reelection to his seat in the legislature.

Woodward, a self-described pro-life candidate with a stance against elective abortions, supports efforts to include exceptions for the health of the mother and removing the threat of felony charges against doctors who perform abortions. Herndon, on the other hand, provoked strong reactions during last year’s legislative session when he sponsored a bill that would have removed the already strict law’s current narrow exceptions for rape and incest.

Kathryn Larson, 66, has been campaigning as a Democrat for a seat representing most of Boundary and Bonner counties, the two northernmost in the panhandle region, in the state’s House of Representatives. She also has had recent firsthand experience falling into the care gap created by the exodus of OB-GYNs in Sandpoint.

In January, Larson went to the emergency room at Bonner General, a 25-bed critical access hospital, with severe chest pains. A cardiologist suggested an infection could be to blame. Larson said she also experienced vertigo and rapid heartbeat and later developed symptoms of a urinary tract infection. She was given rounds of antibiotics to treat the infection, but the symptoms returned.

More testing finally revealed the crux of the issue — Larson was dealing with a prolapsed bladder, which is not life-threatening but causes discomfort or pain and affects 1 in 3 women in their 60s.

After about five months of back-and-forth communication with providers in Post Falls and the eastern Washington city of Spokane, she scheduled an appointment for surgery in early June in Spokane, more than an hour’s drive from Sandpoint. Following surgery, during which doctors implanted a mesh structure to support her bladder, Larson is spending six to eight weeks recovering before heading into the final stretches of election season.

She said the November election will help others in her party tell if it will be possible to work across the aisle to loosen restrictions on the abortion policy during next year’s legislative session. She wants to slow the loss of needed providers across the state.

“People don’t feel safe,” Larson said.

The U.S. Supreme Court ruled on June 27 that Idaho must for now continue to allow abortions in medical emergencies. The ruling came in a lawsuit filed by the Biden administration, which argued that the federal Emergency Medical Treatment and Labor Act requires such care.

But the ruling does not provide a permanent solution. It kicks the case back to lower courts. Confusion remains over a doctor’s ability to perform abortions even in emergency settings, and the Idaho Medical Association said it will continue to work toward a clear health-of-the-mother exception within state law during next year’s legislative session.

“We still need more clarity for our state’s doctors,” OB-GYN Megan Kasper said in a medical association press release.

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A chorus of stories recount the ways the unwinding has upended people’s lives, but Native Americans are proving particularly vulnerable to losing coverage and face greater obstacles to reenrolling in Medicaid or finding other coverage.

“From my perspective, it did not work how it should,” said Kristin Melli, a pediatric nurse practitioner in rural Kalispell, Montana, who also provides telehealth services to tribal members on the Fort Peck Reservation.

The redetermination process has compounded long-existing problems people on the reservation face when seeking care, she said. She saw several patients who were still eligible for benefits disenrolled. And a rise in uninsured tribal members undercuts their health systems, threatening the already tenuous access to care in Native communities.

One teenager, Melli recalled, lost coverage while seeking lifesaving care. Routine lab work raised flags, and in follow-ups Melli discovered the girl had a condition that could have killed her if untreated. Melli did not disclose details, to protect the patient’s privacy.

Melli said she spent weeks working with tribal nurses to coordinate lab monitoring and consultations with specialists for her patient. It wasn’t until the teen went to a specialist that Melli received a call saying she had been dropped from Medicaid coverage.

The girl’s parents told Melli they had reapplied to Medicaid a month earlier but hadn’t heard back. Melli’s patient eventually got the medication she needed with help from a pharmacist. The unwinding presented an unnecessary and burdensome obstacle to care.

Pat Flowers, Montana Democratic Senate minority leader, said during a political event in early April that 13,000 tribal members had been disenrolled in the state.

Native American and Alaska Native adults are enrolled in Medicaid at higher rates than their white counterparts, yet some tribal leaders still didn’t know exactly how many of their members had been disenrolled as of a survey conducted in February and March. The Tribal Self-Governance Advisory Committee of the Indian Health Service conducted and published the survey. Respondents included tribal leaders from Alaska, Arizona, Idaho, Montana, and New Mexico, among other states.

Tribal leaders reported many challenges related to the redetermination, including a lack of timely information provided to tribal members, patients unaware of the process or their disenrollment, long processing times, lack of staffing at the tribal level, lack of communication from their states, concerns with obtaining accurate tribal data, and in cases in which states have shared data, difficulties interpreting it.

Research and policy experts initially feared that vulnerable populations, including rural Indigenous communities and families of color, would experience greater and unique obstacles to renewing their health coverage and would be disproportionately harmed.

“They have a lot at stake and a lot to lose in this process,” said Joan Alker, executive director of the Georgetown University Center for Children and Families and a research professor at the McCourt School of Public Policy. “I fear that that prediction is coming true.”

Cammie DuPuis-Pablo, tribal health communications director for the Confederated Salish and Kootenai Tribes in Montana, said the tribes don’t have an exact number of their members disenrolled since the redetermination began, but know some who lost coverage as far back as July still haven’t been reenrolled.

The tribes hosted their first outreach event in late April as part of their effort to help members through the process. The health care resource division is meeting people at home, making calls, and planning more events.

The tribes receive a list of members’ Medicaid status each month, DuPuis-Pablo said, but a list of those no longer insured by Medicaid would be more helpful.

Because of those data deficits, it’s unclear how many tribal members have been disenrolled.

“We are at the mercy of state Medicaid agencies on what they’re willing to share,” said Yvonne Myers, consultant on the Affordable Care Act and Medicaid for Citizen Potawatomi Nation Health Services in Oklahoma.

In Alaska, tribal health leaders struck a data-sharing agreement with the state in July but didn’t begin receiving information about their members’ coverage for about a month — at which point more than 9,500 Alaskans had already been disenrolled for procedural reasons.

“We already lost those people,” said Gennifer Moreau-Johnson, senior policy adviser in the Department of Intergovernmental Affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization. “That’s a real impact.”

Because federal regulations don’t require states to track or report race and ethnicity data for people they disenroll, fewer than 10 states collect such information. While the data from these states does not show a higher rate of loss of coverage by race, a KFF report states that the data is limited and that a more accurate picture would require more demographic reporting from more states.

Tribal health leaders are concerned that a high number of disenrollments among their members is financially undercutting their health systems and ability to provide care.

“Just because they’ve fallen off Medicaid doesn’t mean we stop serving them,” said Jim Roberts, senior executive liaison in the Department of Intergovernmental Affairs of the Alaska Native Tribal Health Consortium. “It means we’re more reliant on other sources of funding to provide that care that are already underresourced.”

Three in 10 Native American and Alaska Native people younger than 65 rely on Medicaid, compared with 15% of their white counterparts. The Indian Health Service is responsible for providing care to approximately 2.6 million of the 9.7 million Native Americans and Alaska Natives in the U.S., but services vary across regions, clinics, and health centers. The agency itself has been chronically underfunded and unable to meet the needs of the population. For fiscal year 2024, Congress approved $6.96 billion for IHS, far less than the $51.4 billion tribal leaders called for.

Because of that historical deficit, tribal health systems lean on Medicaid reimbursement and other third-party payers, like Medicare, the Department of Veterans Affairs, and private insurance, to help fill the gap. Medicaid accounted for two-thirds of third-party IHS revenues as of 2021.

Some tribal health systems receive more federal funding through Medicaid than from IHS, Roberts said.

Tribal health leaders fear diminishing Medicaid dollars will exacerbate the long-standing health disparities — such as lower life expectancy, higher rates of chronic disease, and inferior access to care — that plague Native Americans.

The unwinding has become “all-consuming,” said Monique Martin, vice president of intergovernmental affairs for the Alaska Native Tribal Health Consortium.

“The state’s really having that focus be right into the minutiae of administrative tasks, like: How do we send text messages to 7,000 people?” Martin said. “We would much rather be talking about: How do we address social determinants of health?”

Melli said she has stopped hearing of tribal members on the Fort Peck Reservation losing their Medicaid coverage, but she wonders if that means disenrolled people didn’t seek help.

“Those are the ones that we really worry about,” she said, “all of these silent cases. … We only know about the ones we actually see.”

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PRESQUE ISLE, Maine — Outside the Mi’kmaq Nation’s health department sits a dome-shaped tent, built by hand from saplings and covered in black canvas. It’s one of several sweat lodges on the tribe’s land, but this one is dedicated to helping people recover from addiction.

Up to 10 people enter the lodge at once. Fire-heated stones — called grandmothers and grandfathers, for the spirits they represent — are brought inside. Water is splashed on the stones, and the lodge fills with steam. It feels like a sauna, but hotter. The air is thicker, and it’s dark. People pray and sing songs. When they leave the lodge, it is said, they reemerge from the mother’s womb. Cleansed. Reborn.

The experience can be “a vital tool” in healing, said Katie Espling, health director for the roughly 2,000-member tribe.

She said patients in recovery have requested sweat lodges for years as a cultural element to complement the counseling and medications the tribe’s health department already provides. But insurance doesn’t cover sweat ceremonies, so, until now, the department couldn’t afford to provide them.

In the past year, the Mi’kmaq Nation received more than $150,000 from settlements with companies that made or sold prescription painkillers and were accused of exacerbating the overdose crisis. A third of that money was spent on the sweat lodge.

Health care companies are paying out more than $1.5 billion to hundreds of tribes over 15 years. This windfall is similar to settlements that many of the same companies are paying to state governments, which total about $50 billion.

To some people, the lower payout for tribes corresponds to their smaller population. But some tribal citizens point out that the overdose crisis has had a disproportionate effect on their communities. Native Americans had the highest overdose death rates of any racial group each year from 2020 to 2022. And federal officials say those statistics were likely undercounted by about 34% because Native Americans’ race is often misclassified on death certificates.

Still, many tribal leaders are grateful for the settlements and the unique way the money can be spent: Unlike the state payments, money sent to tribes can be used for traditional and cultural healing practices — anything from sweat lodges and smudging ceremonies to basketmaking and programs that teach tribal languages.

“To have these dollars to do that, it’s really been a gift,” said Espling of the Mi'kmaq tribe. “This is going to absolutely be fundamental to our patients’ well-being” because connecting with their culture is “where they’ll really find the deepest healing.”

Public health experts say the underlying cause of addiction in many tribal communities is intergenerational trauma, resulting from centuries of brutal treatment, including broken treaties, land theft, and a government-funded boarding school system that sought to erase the tribes’ languages and cultures. Along with a long-running lack of investment in the Indian Health Service, these factors have led to lower life expectancy and higher rates of addiction, suicide, and chronic diseases.

Using settlement money to connect tribal citizens with their traditions and reinvigorate pride in their culture can be a powerful healing tool, said Andrea Medley, a researcher with the Johns Hopkins Center for Indigenous Health and a member of the Haida Nation. She helped create principles for how tribes can consider spending settlement money.

Medley said that having respect for those traditional elements outlined explicitly in the settlements is “really groundbreaking.”

‘A Drop in the Bucket’

Of the 574 federally recognized tribes, more than 300 have received payments so far, totaling more than $371 million, according to Kevin Washburn, one of three court-appointed directors overseeing the tribal settlements.

Although that sounds like a large sum, it pales in comparison with what the addiction crisis has cost tribes. There are also hundreds of tribes that are excluded from the payments because they aren’t federally recognized.

“These abatement funds are like a drop in the bucket compared to what they’ve spent, compared to what they anticipate spending,” said Corey Hinton, a lawyer who represented several tribes in the opioid litigation and a citizen of the Passamaquoddy Tribe. “Abatement is a cheap term when we’re talking about a crisis that is still engulfing and devastating communities.”

Even leaders of the Navajo Nation — the largest federally recognized tribe in the United States, which has received $63 million so far — said the settlements can’t match the magnitude of the crisis.

“It’ll do a little dent, but it will only go so far,” said Kim Russell, executive director of the Navajo Department of Health.

The Navajo Nation is trying to stretch the money by using it to improve its overall health system. Officials plan to use the payouts to hire more coding and billing employees for tribe-operated hospitals and clinics. Those workers would help ensure reimbursements keep flowing to the health systems and would help sustain and expand services, including addiction treatment and prevention, Russell said.

Navajo leaders also want to hire more clinicians specializing in substance use treatment, as well as primary care doctors, nurses, and epidemiologists.

“Building buildings is not what we want” from the opioid settlement funds, Russell said. “We’re nation-building.”

High Stakes for Small Tribes

Smaller nations like the Poarch Band of Creek Indians in southern Alabama are also strategizing to make settlement money go further.

For the tribe of roughly 2,900 members, that has meant investing $500,000 — most of what it has received so far — into a statistical modeling platform that its creators say will simulate the opioid crisis, predict which programs will save the most lives, and help local officials decide the most effective use of future settlement cash.

Some recovery advocates have questioned the model’s value, but the tribe’s vice chairman, Robert McGhee, said it would provide the data and evidence needed to choose among efforts competing for resources, such as recovery housing or peer support specialists. The tribe wants to do both, but realistically, it will have to prioritize.

“If we can have this model and we put the necessary funds to it and have the support, it'll work for us,” McGhee said. “I just feel it in my gut.”

The stakes are high. In smaller communities, each death affects the whole tribe, McGhee said. The loss of one leader marks decades of lost knowledge. The passing of a speaker means further erosion of the Native language.

For Keesha Frye, who oversees the Poarch Band of Creek Indians’ tribal court and the sober living facility, using settlement money effectively is personal. “It means a lot to me to get this community well because this is where I live and this is where my family lives,” she said.

Erik Lamoreau in Maine also brings personal ties to this work. More than a decade ago, he sold drugs on Mi’kmaq lands to support his own addiction.

“I did harm in this community and it was really important for me to come back and try to right some of those wrongs,” Lamoreau said.

Today, he works for the tribe as a peer recovery coordinator, a new role created with the opioid settlement funds. He uses his experience to connect with others and help them with recovery — whether that means giving someone a ride to court, working on their résumé, exercising together at the gym, or hosting a cribbage club, where people play the card game and socialize without alcohol or drugs.

Beginning this month, Lamoreau’s work will also involve connecting clients who seek cultural elements of recovery to the new sweat lodge service — an effort he finds promising.

“The more in tune you are with your culture — no matter what culture that is — it connects you to something bigger,” Lamoreau said. “And that’s really what we look at when we’re in recovery, when we talk about spiritual connection. It’s something bigger than you.”

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Obviously, there’s a lot more going on in the nation’s towns than that tired stereotype suggests. But a new report from the Agriculture Department’s Economic Research Service gives credence to the “sicker” part of the trope.

Rural Americans ages 25 to 54 — considered the prime working-age population — are dying of natural causes such as chronic diseases and cancer at wildly higher rates than their age-group peers in urban areas, according to the report.

The USDA researchers analyzed mortality data from the Centers for Disease Control and Prevention from two three-year periods — 1999 through 2001, and 2017 through 2019. In 1999, the natural-cause mortality rate for rural working-age adults was only 6 percent higherthan that of their city-dwelling peers. By 2019, the gap had widened to 43 percent.

The disparity was significantly worse for women — and for Native American women, in particular. The gap highlights how persistent difficulties accessing health care, and a dispassionate response from national leaders, can eat away at the fabric of rural communities.

A possible Medicaid link

USDA researchers and other experts noted that states in the South that have declined to expand Medicaid under the Affordable Care Act had some of the highest natural-cause mortality rates for rural areas. But the researchers didn’t pinpoint the causes of the overall disparity.

Seven of the 10 states that have not expanded Medicaid are in the South, though that could change soon because some lawmakers are rethinking their opposition, as KFF Health News previously reported.

The USDA’s findings were shocking but not surprising, said Alan Morgan, CEO of the National Rural Health Association. He and other health experts have maintained for years that rural America needs more attention and investment in its healthcare systems by national leaders and lawmakers.

Another recent report, from the health analytics and consulting firm Chartis, identified 418 rural hospitals that are “vulnerable to closure.” Congress, trying to slow the collapse of rural health infrastructure, enacted the Rural Emergency Hospital designation, which became available last year.

That new classification aimed to keep some facilities from shuttering in smaller towns by allowing hospitals to discontinue many inpatient services. But it has so far attracted only about 21of the hundreds of hospitals that qualify.

It’s unlikely that things have improved for rural Americans since 2019, the last year in the periods the USDA researchers examined. The coronavirus pandemic was particularly devastating in rural parts of the country. 

Morgan wondered: How wide is the gap today? Congress, Morgan said, should direct the CDC to examine life expectancy in rural America before and after the pandemic: “Covid really changed the nature of public health in rural America.”

The National Rural Health Association’s current advocacy efforts include raising support on policies before Congress, including strengthening the rural health workforce and increasing funding for various initiatives focused on rural hospitals, sustaining obstetrics services, expanding physician training and addressing the opioid response, among others. 

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