The mountains of western North Carolina have been known to flood: The area is bursting with creeks and rivers and enjoys an abundance of rain. There are occasionally wildfires. But the ravages of the climate crisis’s worst impacts — including increasingly powerful hurricanes — felt like a problem for another place. Asheville sits almost 250 miles from the nearest coastline.

After Hurricane Helene roared across the state, causing historic flooding, downing trees, snapping power lines, decimating water infrastructure, and leading to the deaths of at least 72 people in Buncombe County alone, communities are still shaking off the shock of a storm they never thought could touch these mountains.

“People relocate to Asheville not just because it’s beautiful, but because it isn’t prone to natural disasters,” said Katie Gebely, an artist in Asheville. “But that sense of safety is gone.”

I live in Beech, a historic community in Weaverville, North Carolina, at the eastern end of a two-lane road called Reems Creek, which is named after the waterway running parallel to it. The town of Weaverville, just north of Asheville, is five miles down the road.

Helene’s destruction created a major problem for people dependent on insulin, power wheelchairs, oxygen CPAP machines for sleep apnea, or home dialysis equipment. Without electricity, their health is at risk.

To get to Weaverville from Beech in the days immediately after the storm, cars had to thump over dozens of downed power lines. Other lines were propped up with large, downed tree limbs or tied up with rope so cars could get under them. Utility poles were snapped in two. A transformer lay on the side of the road, as did a rather large boat, washed up from who knows where. Just last week, power crews arrived on Reems Creek Road, but there’s still no word on when everyone will regain electricity.

Jackie Martin of Canton, North Carolina, relies on supplemental oxygen for chronic obstructive pulmonary disease and emphysema. When the storm hit, she had four hours’ worth left. Because of her condition, Martin and her husband, David, have an electrical generator, which David checks every month to make sure it works.

“We keep enough gas to run about eight hours,” Jackie Martin said. But the Martins were without power for nearly a week. When they ran out of gasoline, their neighbors gave them the gas from their lawn mower. Then another neighbor evacuated and offered his propane generator. The Martins’ daughter came through with four tanks of propane.

“We went through tons of gas and propane,” Jackie Martin said. “Never did I think I would need every drop and then some. Thank goodness we got power back after a week.”

In Buncombe County, population 275,000, there were still more than 50,000 customers without electricity almost two weeks after the storm. Duke Energy reported that outages were down to about 1,600 customers in the Asheville area as of Wednesday.

In most places, the debris that littered the road has been cleared. Cars, trucks, and military vehicles can make their way through. But huge piles of trash still line the roadways. Buncombe County is asking residents not to burn it out of concern for air quality.

In a scene out of biblical end-times, yellow jackets swarmed in the days after the storm — displaced after falling trees and floodwaters destroyed their nests. Three or four days after the storm hit, an EMT drove through my neighborhood looking for Benadryl. My husband handed over what we had: a half-full bottle.

Overhead, helicopters fly day and night. The Federal Emergency Management Agency arrived in my neighborhood two Sundays ago to deliver bottled water and food rations. Potable water in some areas of western North Carolina, including Asheville, may take weeks or months to restore.

Weaverville’s residents were under a boil-water advisory until Oct. 11.

“We had sewer and water line breaks,” said Patrick Fitzsimmons, Weaverville’s mayor. “We had a lot of infrastructure destruction.”

Households with wells have fared no better. Well pumps don’t work without electricity. And storm-damaged or flooded wells may be compromised. Officials are urging residents to disinfect their wells before consuming water. The federal Environmental Protection Agency has given residents kits to test their well water.

A physical therapist at Asheville Specialty Hospital, who asked not to be identified out of concern for losing their job, told me that in the first days after the storm, crews hauled trash cans full of water into the facility so that staff could flush toilets with buckets.

“The water got shut off and we managed. We took care of people the best we could,” the therapist said. “But the amount of water that it takes to run a hospital is unsustainable for the length of time they think we’ll be out of water.”

The hospital is a 34-bed long-term acute care facility down the street from Asheville’s Mission Hospital. Nancy Lindell, a spokesperson for Mission Health, which operates both hospitals, said in a statement that fewer than 100 “low acuity patients in stable condition” at the organization’s facilities were transferred “to hospitals outside of the areas hardest hit by this disaster.”

“This decision, which was made in collaboration with more than 50 physicians and nursing leaders, helps ensure we have the capacity to meet the most critical needs of our region,” she said. “It also provides relief for our caregivers, who have been working around the clock in the wake of the storm.”

U.S. Rep. Chuck Edwards, who represents North Carolina’s 11th District, said FEMA has shipped 6 million liters of water and 4 million individual meals to western North Carolina. FEMA has promised 120 truckloads a day of food and water with no specified end date, the Republican congressman said.

The Biden administration has also opened an emergency program for uninsured North Carolinians to replace lost prescriptions and medical equipment.

Fitzsimmons, Weaverville’s mayor, said he’s concerned about the impact of the storm on mental health. “People are going for an extended period of time without power or water,” he said. “Their nerves are frayed.”

Richard Zenn, chief medical officer at North Carolina-based Vaya Health, said the recovery will be long.

“We’re now in the phase where we have to deal with the effects of this ongoing trauma we’ve all suffered,” Zenn said. “Connect with others. Don’t get too isolated. Eat. Sleep. Try to get back into a normal routine. Do whatever reduces stress for you.”

For me, that has always been hiking or running through these ancient mountains. But there are too many uprooted trees to safely do that now. Instead I take solace on my porch and give thanks that I still have a porch to sit on. It’s a near-perfect day in Appalachia. The sky is painfully blue. I listen for the songs of birds, but all I can hear are generators.

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).

The 2024 campaign — particularly the one for president — has been notably vague on policy. But health issues, especially those surrounding abortion and other reproductive health care, have nonetheless played a key role. And while the Affordable Care Act has not been the focus of debate the way it was over the previous three presidential campaigns, who becomes the next president will have a major impact on the fate of the 2010 health law.

The panelists for this week’s special election preview, taped before a live audience at KFF’s offices in Washington, are Julie Rovner of KFF Health News, Tamara Keith of NPR, Alice Miranda Ollstein of Politico, and Cynthia Cox and Ashley Kirzinger of KFF.

Panelists

Among the takeaways from this week’s episode:

• As Election Day nears, who will emerge victorious from the presidential race is anyone’s guess. Enthusiasm among Democratic women has grown with the elevation of Vice President Kamala Harris to the top of the ticket, with more saying they are likely to turn out to vote. But broadly, polling reveals a margin-of-error race — too close to call.
• Several states have abortion measures on the ballot. Proponents of abortion rights are striving to frame the issue as nonpartisan, acknowledging that recent measures have passed thanks in part to Republican support. For some voters, resisting government control of women’s health is a conservative value. Many are willing to split their votes, supporting both an abortion rights measure and also candidates who oppose abortion rights.
• While policy debates have been noticeably lacking from this presidential election, the future of Medicaid and the Affordable Care Act hinges on its outcome. Republicans want to undermine the federal funding behind Medicaid expansion, and former President Donald Trump has a record of opposition to the ACA. Potentially on the chopping block are the federal subsidies expiring next year that have transformed the ACA by boosting enrollment and lowering premium costs.
• And as misinformation and disinformation proliferate, one area of concern is the “malleable middle”: people who are uncertain of whom or what to trust and therefore especially susceptible to misleading or downright false information. Could a second Trump administration embed misinformation in federal policy? The push to soften or even eliminate school vaccination mandates shows the public health consequences of falsehood creep.

Also mentioned on this week’s podcast:

• The New York Times’ “Resistance to Public Health, No Longer Fringe, Gains Foothold in G.O.P. Politics,” by Sheryl Gay Stolberg.
• KFF Health News’ “‘What the Health?’: SCOTUS Ruling Strips Power From Federal Health Agencies.”
• KFF’s Health Misinformation and Trust Initiative, a program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Emmarie Huetteman: Please put your hands together and join me in welcoming our panel and our host, Julie Rovner. 

Julie Rovner: Hello, good morning, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the very best and smartest health reporters in Washington, along with some very special guests today. We’re taping this special election episode on Thursday, October 17th, at 11:30 a.m., in front of a live audience at the Barbara Jordan Conference Center here at KFF in downtown D.C. Say hi, audience. 

As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

So I am super lucky to work at and have worked at some pretty great places and with some pretty great, smart people. And when I started to think about who I wanted to help us break down what this year’s elections might mean for health policy, it was pretty easy to assemble an all-star cast. So first, my former colleague from NPR, senior White House correspondent Tamara Keith. Tam, thanks for joining us. 

Tamara Keith: Thank you for having me. 

Rovner: Next, our regular “What the Health?” podcast panelist and my right hand all year on reproductive health issues, Alice Ollstein of Politico. 

Alice Miranda Ollstein: Hi Julie. 

Rovner: Finally, two of my incredible KFF colleagues. Cynthia Cox is a KFF vice president and director of the program on the ACA [Affordable Care Act] and one of the nation’s very top experts on what we know as Obamacare. Thank you, Cynthia. 

Cynthia Cox: Great to be here. 

Rovner: And finally, Ashley Kirzinger is director of survey methodology and associate director of our KFF Public Opinion and Survey Research Program, and my favorite explainer of all things polling. 

Ashley Kirzinger: Thanks for having me. 

Rovner: So, welcome to all of you. Thanks again for being here. We’re going to chat amongst ourselves for a half hour or so, and then we will open the floor to questions. So be ready here in the room. Tam, I want to start with the big picture. What’s the state of the race as of October 17th, both for president and for Congress? 

Keith: Well, let’s start with the race for President. That’s what I cover most closely. This is what you would call a margin-of-error race, and it has been a margin-of-error race pretty much the entire time, despite some really dramatic events, like a whole new candidate and two assassination attempts and things that we don’t expect to see in our lifetimes and yet they’ve happened. And yet it is an incredibly close race. What I would say is that at this exact moment, there seems to have been a slight shift in the average of polls in the direction of former President [Donald] Trump. He is in a slightly better position than he was before and is in a somewhat more comfortable position than Vice President [Kamala] Harris. 

She has been running as an underdog the whole time, though there was a time where she didn’t feel like an underdog, and right now she is also running like an underdog and the vibes have shifted, if you will. There’s been a more dramatic shift in the vibes than there has been in the polls. And the thing that we don’t know and we won’t know until Election Day is in 2016 and 2020, the polls underestimated Trump’s support. So at this moment, Harris looks to be in a weaker position against Trump than either [Hillary] Clinton or [Joe] Biden looked to be. It turns out that the polls were underestimating Trump both of those years. But in 2022 after the Dobbs decision, the polls overestimated Republican support and underestimated Democratic support. 

So what’s happening now? We don’t know. So there you go. That is my overview, I think, of the presidential race. The campaigning has really intensified in the last week or so, like really intensified, and it’s only going to get more intense. I think Harris has gotten a bit darker in her language and descriptions. The joyful warrior has been replaced somewhat by the person warning of dire consequences for democracy. And in terms of the House and the Senate, which will matter a lot, a lot a lot, whether Trump wins or Harris wins, if Harris wins and Democrats lose the Senate, Harris may not even be able to get Cabinet members confirmed. 

So it matters a lot, and the conventional wisdom — which is as useful as it is and sometimes is not all that useful — the conventional wisdom is that something kind of unusual could happen, which is that the House could flip to Democrats and the Senate could flip to Republicans, and usually these things don’t move in opposite directions in the same year. 

Rovner: And usually the presidential candidate has coattails, but we’re not really seeing that either, are we? 

Keith: Right. In fact, it’s the reverse. Several of the Senate candidates in key swing states, the Democratic candidates are polling much better than the Republican candidates in those races and polling with greater strength than Harris has in those states. Is this a polling error, or is this the return of split-ticket voting? I don’t know. 

Rovner: Well, leads us to our polling expert. Ashley, what are the latest polls telling us, and what should we keep in mind about the limitations of polling? I feel like every year people depend a lot on the polls and every year we say, Don’t depend too much on the polls. 

Kirzinger: Well, can I just steal Tamara’s line and say I don’t know? So in really close elections, when turnout is going to matter a lot, what the polls are really good at is telling us what is motivating voters to turn out and why. And so what the polls have been telling us for a while is that the economy is top of mind for voters. Now, health care costs — we’re at KFF. So health care plays a big role in how people think about the economy, in really two big ways. The first is unexpected costs. So unexpected medical bills, health care costs, are topping the list of the public’s financial worries, things that they’re worried about, what might happen to them or their family members. And putting off care. What we’re seeing is about a quarter of the public these days are putting off care because they say they can’t afford the cost of getting that needed care. 

So that really shows the way that the financial burdens are playing heavily on the electorate. What we have seen in recent polling is Harris is doing better on the household expenses than Biden did and is better than the Democratic Party largely. And that’s really important, especially among Black women and Latina voters. We are seeing some movement among those two groups of the electorate saying that Harris is doing a better job and they trust her more on those issues. But historically, if the election is about the economy, Republican candidates do better. The party does better on economic issues among the electorate. 

What we haven’t mentioned yet is abortion, and this is the first presidential election since post-Dobbs, in the post-Dobbs era, and we don’t know how abortion policy will play in a presidential election. It hasn’t happened before, so that’s something that we’re also keeping an eye on. We know that Harris is campaigning around reproductive rights, is working among a key group of the electorate, especially younger women voters. She is seen as a genuine candidate who can talk about these issues and an advocate for reproductive rights. We’re seeing abortion rise in importance as a voting issue among young women voters, and she’s seen as more authentic on this issue than Biden was. 

Rovner: Talk about last week’s poll about young women voters. 

Kirzinger: Yeah, one of the great things that we can do in polling is, when we see big changes in the campaign, is we can go back to our polls and respondents and ask how things have changed to them. So we worked on a poll of women voters back in June. Lots have changed since June, so we went back to them in September to see how things were changing for this one group, right? So we went back to the same people and we saw increased motivation to turn out, especially among Democratic women. Republican women were about the same level of motivation. They’re more enthusiastic and satisfied about their candidate, and they’re more likely to say abortion is a major reason why they’re going to be turning out. But we still don’t know how that will play across the electorate in all the states. 

Because for most voters, a candidate’s stance on abortion policy is just one of many factors that they’re weighing when it comes to turnout. And so those are one of the things that we’re looking at as well. I will say that I’m not a forecaster, thank goodness. I’m a pollster, and polls are not good at forecasts, right? So polls are very good at giving a snapshot of the electorate at a moment in time. So two weeks out, that’s what I know from the polls. What will happen in the next two weeks, I’m not sure. 

Rovner: Well, Alice, just to pick up on that, abortion, reproductive health writ large are by far the biggest health issues in this campaign. What impact is it having on the presidential race and the congressional races and the ballot issues? It’s all kind of a clutter, isn’t it? 

Ollstein: Yeah, well, I just really want to stress what Ashley said about this being uncharted territory. So we can gather some clues from the past few years where we’ve seen these abortion rights ballot measures win decisively in very red states, in very blue states, in very purple states. But presidential election years just have a different electorate. And so, yes, it did motivate more people to turn out in those midterm and off-year elections, but that’s just not the same group of folks and it’s not the same groups the candidates need this time, necessarily. And also we know that every time abortion has been on the ballot, it has won, but the impact and how that spills over into partisan races has been a real mixed bag. 

So we saw in Michigan in 2022, it really helped Democrats. It helped Governor Gretchen Whitmer. It helped Michigan Democrats take back control of the Statehouse for the first time in decades. But that didn’t work for Democrats in all states. My colleagues and I did an analysis of a bunch of different states that had these ballot measures, and these ballot measures largely succeeded because of Republican voters who voted for the ballot initiative and voted for Republican candidates. And that might seem contradictory. You’re voting for an abortion rights measure, and you’re voting for very anti-abortion candidates. We saw that in Kentucky, for example, where a lot of people voted for (Sen.) Rand Paul, who is very anti-abortion, and for the abortion rights side of the ballot measure. 

I’ve been on the road the last few months, and I think you’re going to see a lot of that again. I just got back from Arizona, and a lot of people are planning to vote for the abortion rights measure there and for candidates who have a record of opposing abortion rights. Part of that is Donald Trump’s somewhat recent line of: I won’t do any kind of national ban. I’ll leave it to the states. A lot of people are believing that, even though Democrats are like: Don’t believe him. It’s not true. But also, like Ashley said, folks are just prioritizing other issues. And so, yes, when you look at certain slices of the electorate, like young women, abortion is a top motivating issue. But when you look at the entire electorate, it’s, like, a distant fourth after the economy and immigration and several other things. 

I found the KFF polling really illuminating in that, yes, most people said that abortion is either just one of many factors in deciding their vote on the candidates or not a factor at all. And most people said that they would be willing to vote for a candidate who does not share their views on abortion. So I think that’s really key here. And these abortion rights ballot measures, the campaigns behind them are being really deliberate about remaining completely nonpartisan. They need to appeal to Republicans, Democrats, independents in order to pass, but that also … So their motivation is to appeal to everyone. Democrats’ motivation is to say: You have to vote for us, too. Abortion rights won’t be protected if you just pass the ballot measure. You also have to vote for Democrats up and down the ballot. Because, they argue, Trump could pursue a national ban that would override the state protections. 

Rovner: We’ve seen in the past — and this is for both of you — ballot measures as part of partisan strategies. In the early 2000s, there were anti-gay-marriage ballot measures that were intended to pull out Republicans, that were intended to drive turnout. That’s not exactly what’s happening this time, is it? 

Keith: So I was a reporter in the great state of Ohio in 2004, and there was an anti-gay-rights ballot measure on the ballot there, and it was a key part of George W. Bush’s reelection plan. And it worked. He won the state somewhat narrowly. We didn’t get the results until 5 a.m. the next day, but that’s better than we’ll likely have this time. And that was a critical part of driving Republican turnout. It’s remarkable how much has changed since then in terms of public views. It wouldn’t work in the same way this time. 

The interesting thing in Arizona, for instance, is that there’s also an anti-immigration ballot measure that’s also polling really well that was added by the legislature in sort of a rush to try to offset the expected Democratic-based turnout because of the abortion measure. But as you say, it is entirely possible that there could be a lot of Trump abortion, immigration and [House Democrat and Senate candidate] Ruben Gallego voters. 

Ollstein: Absolutely. And I met some of those voters, and one woman told me, look, she gets offended when people assume that she’s liberal because she identified as pro-choice. We don’t use that terminology in our reporting, but she identified as pro-choice, and she was saying: Look, to me, this is a very conservative value. I don’t want the government in my personal business. I believe in privacy. And so for her, that doesn’t translate over into, And therefore I am a Democrat. 

Rovner: I covered two abortion-related ballot measures in South Dakota that were two years, I think it was 2006 and 2008. 

Ollstein: They have another one this year. 

Rovner: Right. There is another one this year. But what was interesting, what I discovered in 2006 and 2008 is exactly what you were saying, that there’s a libertarian streak, particularly in the West, of people who vote Republican but who don’t believe that the government has any sort of business in your personal life, not just on abortion but on any number of other things, including guns. So this is one of those issues where there’s sort of a lot of distinction. Cynthia, this is the first time in however many elections the Affordable Care Act has not been a huge issue, but there’s an awful lot at stake for this law, depending on who gets elected, right? 

Cox: Yeah, that’s right. I mean, it’s the first time in recent memory that health care in general, aside from abortion, hasn’t really been the main topic of conversation in the race. And part of that is that the Affordable Care Act has really transformed the American health care system over the last decade or so. The uninsured rate is at a record low, and the ACA marketplaces, which had been really struggling 10 years ago, have started to not just survive but thrive. Maybe also less to dislike about the ACA, but it’s also not as much a policy election as previous elections had been. But yes, the future of the ACA still hinges on this election. 

So starting with President Trump, I think as anyone who follows health policy knows, or even politics or just turned on the TV in 2016 knows that Trump has a very, very clear history of opposing the Affordable Care Act, or Obamacare. He supported a number of efforts in Congress to try to repeal and replace the Affordable Care Act. And when those weren’t successful, he took a number of regulatory steps, joined legal challenges, and proposed in his budgets to slash funding for the Affordable Care Act and for Medicaid. But now in 2024, it’s a little bit less clear exactly where he’s going. 

I would say earlier in the 2024 presidential cycle, he made some very clear comments about saying Obamacare sucks, for example, or that Republicans should never give up on trying to repeal and replace the ACA, that the failure to do so when he was president was a low point for the party. But then he also has seemed to kind of walk that back a little bit. Now he’s saying that he would replace the ACA with something better or that he would make the ACA itself much, much better or make it cost less, but he’s not providing specifics. Of course, in the debate, he famously said that he had “concepts” of a plan, but there’s no … Nothing really specific has materialized. 

Rovner: We haven’t seen any of those concepts. 

Cox: Yes, the concept is … But we can look at his record. And so we do know that he has a very, very clear record of opposing the ACA and really taking any steps he could when he was president to try to, if not repeal and replace it, then significantly weaken it or roll it back. Harris, by contrast, is in favor of the Affordable Care Act. When she was a primary candidate in 2020, she had expressed support for more-progressive reforms like “Medicare for All” or “Medicare for More.” But since becoming vice president, especially now as the presidential candidate, she’s taken a more incremental approach. 

She’s talking about building upon the Affordable Care Act. In particular, a key aspect of her record and Biden’s is these enhanced subsidies that exist in the Affordable Care Act marketplaces. They were first, I think … They really closely mirror what Biden had run on as president in 2019, 2020, but they were passed as part of covid relief. So they were temporary, then they were extended as part of the Inflation Reduction Act but, again, temporarily. And so they’re set to expire next year, which is setting up a political showdown of sorts for Republicans and Democrats on the Hill about whether or not to extend them. And Harris would like to make these subsidies permanent because they have been responsible for really transforming the ACA marketplaces. 

The number of people signing up for coverage has doubled since Biden took office. Premium payments were cut almost in half. And so this is, I think, a key part of, now, her record, but also what she wants to see go forward. But it’s going to be an uphill battle, I think, to extend them. 

Rovner: Cynthia, to sort of build on that a little bit, as we mentioned earlier, a Democratic president won’t be able to get a lot accomplished with a Republican House and/or Senate and a Republican president won’t be able to get that much done with a Democratic House and/or Senate. What are some of the things we might expect to see if either side wins a trifecta control of the executive branch and both houses of Congress? 

Cox: So I think, there … So I guess I’ll start with Republicans. So if there is a trifecta, the key thing there to keep in mind is while there may not be a lot of appetite in Congress to try to repeal and replace the ACA, since that wasn’t really a winning issue in 2017, and since then public support for the ACA has grown. And I think also it’s worth noting that the individual mandate penalty being reduced to $0. So essentially there’s no individual mandate anymore. There’s less to hate about the law. 

Rovner: All the pay-fors are gone, too. 

Cox: Yeah the pay-fors are gone, too. 

Rovner: So the lobbyists have less to hate. 

Cox: Yes, that too. And so I don’t think there’s a ton of appetite for this, even though Trump has been saying, still, some negative comments about the ACA. That being said, if Republicans want to pass tax cuts, then they need to find savings somewhere. And so that could be any number of places, but I think it’s likely that certain health programs and other programs are off-limits. So Medicare probably wouldn’t be touched, maybe Social Security, defense, but that leaves Medicaid and the ACA subsidies. 

And so if they need savings in order to pass tax cuts, then I do think in particular Medicaid is at risk, not just rolling back the ACA’s Medicaid expansion but also likely block-granting the program or implementing per capita caps or some other form of really restricting the amount of federal dollars that are going towards Medicaid. 

Rovner: And this is kind of where we get into the Project 2025 that we’ve talked about a lot on the podcast over the course of this year, that, of course, Donald Trump has disavowed. But apparently [Senate Republican and vice presidential candidate] JD Vance has not, because he keeps mentioning pieces of it. 

Ollstein: And they’re only … They’re just one of several groups that have pitched deep cuts to health safety net programs, including Medicaid. You also have the Paragon group, where a lot of former Trump officials are putting forward health policy pitches and several others. And so I also think given the uncertainty about a trifecta, it’s also worth keeping in mind what they could do through waivers and executive actions in terms of work requirements. 

Rovner: That was my next question. I’ve had trouble explaining this. I’ve done a bunch of interviews in the last couple of weeks to explain how much more power Donald Trump would have, if he was reelected, to do things via the executive branch than a President Harris would have. So I have not come up with a good way to explain that. Please, one of you give it a shot. 

Keith: Someone else. 

Rovner: Why is it that President Trump could probably do a lot more with his executive power than a President Harris could do with hers? 

Cox: I think we can look back at the last few years and just see. What did Trump do with his executive power? What did Biden do with his executive power? And as far as the Affordable Care Act is concerned or Medicaid. But Trump, after the failure to repeal and replace the ACA, took a number of regulatory steps. For example, trying to expand short-term plans, which are not ACA-compliant, and therefore can discriminate against people with preexisting conditions, or cutting funding for certain things in the ACA, including outreach and enrollment assistance. 

And so I think there were a number — and also we’ve talked about Medicaid work requirements in the form of state waivers. And a lot of what Biden did, regulatory actions, were just rolling that back, changing that, but it’s hard to expand coverage or to provide a new program without Congress acting to authorize that spending. 

Kirzinger: I think it’s also really important to think about the public’s view of the ACA at this point in time. I mean, what the polls aren’t mixed about is that the ACA has higher favorability than Harris, Biden, Trump, any politician, right? So we have about two-thirds of the public. 

Rovner: So Nancy Pelosi was right. 

Kirzinger: I won’t go that far, but about two-thirds of the public’s now view the law favorably, and the provisions are even more popular. So while, yes, a Republican trifecta will have a lot of power, the public — they’re going to have a hard time rolling back protections for people with preexisting conditions, which have bipartisan support. They’re going to have a hard time making it no longer available for adult children under the age of 26 to be on their parents’ health insurance. All of those components of the ACA are really popular, and once people are given protections, it’s really hard to take them away. 

Cox: Although I would say that there are at least 10 ways the ACA protects people with preexisting conditions. I think on the surface it’s easy to say that you would protect people with preexisting conditions if you say that a health insurer has to offer coverage to someone with a preexisting condition. But there’s all those other ways that they say also protects preexisting conditions, and it makes coverage more comprehensive, which makes coverage more expensive. 

And so that’s why the subsidies there are key to make comprehensive coverage that protects people with preexisting conditions affordable to individuals. But if you take those subsidies away, then that coverage is out of reach for most people. 

Rovner: That’s also what JD Vance was talking about with changing risk pools. I mean, which most people, it makes your eyes glaze over, but that would be super important to the affordability of insurance, right? 

Cox: And his comment about risk pools is — I think a lot of people were trying to read something into that because it was pretty vague. But what a lot of people did think about when he made that comment was that before the Affordable Care Act, it used to be that if you were declined health insurance coverage, especially by multiple insurance companies, if you were basically uninsurable, then you could apply to what existed in many states was a high-risk pool. 

But the problem was that these high-risk pools were consistently underfunded. And in most of those high-risk pools, there were even waiting periods or exclusions on coverage for preexisting conditions or very high premiums or deductibles. So even though these were theoretically an option for coverage for people with preexisting conditions before the ACA, the lack of funding or support made it such that that coverage didn’t work very well for people who were sick. 

Ollstein: And something conservatives really want to do if they gain power is go after the Medicaid expansion. They’ve sort of set up this dichotomy of sort of the deserving and undeserving. They don’t say it in those words, but they argue that childless adults who are able-bodied don’t need this safety net the way, quote-unquote, “traditional” Medicaid enrollees do. And so they want to go after that part of the program by reducing the federal match. That’s something I would watch out for. I don’t know if they’ll be able to do that. That would require Congress, but also several states have in their laws that if the federal matches decreased, they would automatically unexpand, and that would mean coverage losses for a lot of people. That would be very politically unpopular. 

It’s worth keeping in mind that a lot of states, mainly red states, have expanded Medicaid since Republicans last tried to go after the Affordable Care Act in 2017. And so there’s just a lot more buy-in now. So it would be politically more challenging to do that. And it was already very politically challenging. They weren’t able to do it back then. 

Rovner: So I feel like one of the reasons that Trump might be able to get more done than Harris just using executive authority is the makeup of the judiciary, which has been very conservative, particularly at the Supreme Court, and we actually have some breaking news on this yesterday. Three of the states who intervened in what was originally a Texas lawsuit trying to revoke the FDA’s [Federal Drug Administration’s] approval of the abortion pill mifepristone, officially revived that lawsuit, which the Supreme Court had dismissed because the doctors who filed it initially didn’t have standing, according to the Supreme Court. 

The states want the courts to invoke the Comstock Act, an 1873 anti-vice law banning the mailing and receiving of, among other things, anything used in an abortion, to effectively ban the drug. This is one of those ways that Trump wouldn’t even have to lift a finger to bring about an abortion ban, right? I mean, he’d just have to let it happen. 

Ollstein: Right. I think so much of this election cycle has been dominated by, Would you sign a ban? And that’s just the wrong question. I mean, we’ve seen Congress unable to pass either abortion restrictions or abortion protections even when one party controls both chambers. It’s just really hard. 

Rovner: And going back 60 years. 

Ollstein: And so I think it’s way more important to look at what could happen administratively or through the courts. And so yes, lawsuits like that, that the Supreme Court punted on but didn’t totally resolve this term, could absolutely come back. A Trump administration could also direct the FDA to just unauthorize abortion pills, which are the majority of abortions that take place within the U.S. 

And so — or there’s this Comstock Act route. There’s — the Biden administration put out a memo saying, We do not think the Comstock Act applies to the mailing of abortion pills to patients. A Trump administration could put out their own memo and say, We believe the opposite. So there’s a lot that could happen. And so I really have been frustrated. All of the obsessive focus on: Would you sign a ban? Would you veto a ban? Because that is the least likely route that this would happen. 

Kirzinger: Well, and all of these court cases create an air of confusion among the public, right? And so, that also can have an effect in a way that signing a ban — I mean, if people don’t know what’s available to them in their state based on state policy or national policy. 

Ollstein: Or they’re afraid of getting arrested. 

Kirzinger: Yeah, even if it’s completely legal in their state, we’re finding that people aren’t aware of whether — what’s available to them in their state, what they can access legally or not. And so having those court cases pending creates this air of confusion among the public. 

Keith: Well, just to amplify the air of confusion, talking to Democrats who watch focus groups, they saw a lot of voters blaming President Biden for the Dobbs decision and saying: Well, why couldn’t he fix that? He’s president. At a much higher level, there is confusion about how our laws work. There’s a lot of confusion about civics, and as a result, you see blame landing in sort of unexpected places. 

Rovner: This is the vaguest presidential election I have ever covered. I’ve been doing this since 1988. We basically have both candidates refusing to answer specific questions — as a strategy, I mean, it’s not that I don’t think — I think they both would have a pretty good idea of what it is they would do, and both of them find it to their political advantage not to say. 

Keith: I think that’s absolutely right. I think that the Harris campaign, which I spend more time covering, has the view that if Trump is not going to answer questions directly and he is going to talk about “concepts” of a plan, and he’s just going to sort of, like, Well, if I was president, this wouldn’t be a problem, so I’m not going to answer your question — which is his answer to almost every question — then there’s not a lot of upside for them to get into great specifics about policy and to have think tank nerds telling them it won’t work, because there’s no upside to it. 

Cox: We’re right here. 

Panel: [Laughing] 

Rovner: So regular listeners to the podcast will know that one of my biggest personal frustrations with this campaign is the ever-increasing amount of mis- and outright disinformation in the health care realm, as we discussed at some length on last week’s podcast. You can go back and listen. This has become firmly established in public health, obviously pushed along by the divide over the covid pandemic. The New York Times last week had a pretty scary story by Sheryl Gay Stolberg — who’s working on a book about public health — about how some of these more fringe beliefs are getting embedded in the mainstream of the Republican Party. 

It used to be that we saw most of these kind of fringe, anti-science, anti-health beliefs were on the far right and on the far left, and that’s less the case. What could we be looking forward to on the public health front if Trump is returned to power, particularly with the help of anti-vaccine activist and now Trump endorser R.F.K. [Robert F. Kennedy] Jr.? 

Kirzinger: Oh, goodness to me. Well, so I’m going to talk about a group that I think is really important for us to focus on when we think about misinformation, and I call them the “malleable middle.” So it’s that group that once they hear misinformation or disinformation, they are unsure of whether that is true or false, right? So they’re stuck in this uncertainty of what to believe and who do they trust to get the right information. It used to be pre-pandemic that they would trust their government officials. 

We have seen declining trust in CDC [Centers for Disease Control and Prevention], all levels of public health officials. Who they still trust is their primary care providers. Unfortunately, the groups that are most susceptible to misinformation are also the groups that are less likely to have a primary care provider. So we’re not in a great scenario, where we have a group that is unsure of who to trust on information and doesn’t have someone to go to for good sources of information. I don’t have a solution. 

Cox: I also don’t have a solution. 

Rovner: No, I wasn’t — the question isn’t about a solution. The question is about, what can we expect? I mean, we’ve seen the sort of mis- and disinformation. Are we going to actually see it embedded in policy? I mean, we’ve mostly not, other than covid, which obviously now we see the big difference in some states where mask bans are banned and vaccine mandates are banned. Are we going to see childhood vaccines made voluntary for school? 

Ollstein: Well, there’s already a movement to massively broaden who can apply for an exception to those, and that’s already had some scary public health consequences. I mean, I think there are people who would absolutely push for that. 

Kirzinger: I think regardless of who wins the presidency, I think that the misinformation and disinformation is going to have an increasing role. Whether it makes it into policy will depend on who is in office and Congress and all of that. But I think that it is not something that’s going away, and I think we’re just going to continue to have to battle it. And that’s where I’m the most nervous. 

Keith: And when you talk about the trust for the media, those of us who are sitting here trying to get the truth out there, or to fact-check and debunk, trust for us is, like, in the basement, and it just keeps getting worse year after year after year. And the latest Gallup numbers have us worse than we were before, which is just, like, another institution that people are not turning to. We are in an era where some rando on YouTube who said they did their research is more trusted than what we publish. 

Rovner: And some of those randos on YouTube have millions of viewers, listeners. 

Keith: Yes, absolutely. 

Rovner: Subscribers, whatever you want to call them. 

Ollstein: One area where I’ve really seen this come forward, and it could definitely become part of policy in the future, is there’s just a lot of mis- and disinformation around transgender health care. There’s polling that show a lot of people believe what Trump and others have been saying, that, Oh, kids can come home from school and have a sex change operation. Which is obviously ridiculous. Everyone who has kids in school knows that they can’t even give them a Tylenol without parental permission. And it obviously doesn’t happen in a day, but people are like, Oh, well, I know it’s not happening at my school, but it’s sure happening somewhere. And that’s really resonating, and we’re already seeing a lot of legal restrictions on that front spilling. 

Rovner: All right, well, I’m going to open it up to the audience. Please wait to ask your question until you have a microphone, so the people who will be listening to the podcast will be able to hear your question. And please tell us who you are, and please make your question or question. 

Madeline: Hi, I’m Madeline. I am a grad student at the Milken Institute of Public Health at George Washington. My question is regarding polling. And I was just wondering, how has polling methodologies or tendencies to over-sample conservatives had on polls in the race? Are you seeing that as an issue or …? 

Kirzinger: OK. You know who’s less trusted than the media? It’s pollsters, but you can trust me. So I think what you’re seeing is there are now more polls than there have ever been, and I want to talk about legitimate scientific polls that are probability-based. They’re not letting people opt into taking the survey, and they’re making sure their samples are representative of the entire population that they’re surveying, whether it be the electorate or the American public, depending on that. 

I think what we have seen is that there have been some tendencies when people don’t like the poll results, they look at the makeup of that sample and say, oh, this poll’s too Democratic, or too conservative, has too many Trump voters. Or whatever it may be. That benefits no pollster to make their sample not look like the population that they’re aiming to represent. And so, yes, there are lots of really, really bad polls out there, but the ones that are legitimate and scientific are still striving to aim to make sure that it’s representative. The problem with election polls is we don’t know who the electorate’s going to be. We don’t know if Democrats are going to turn out more than Republicans. We don’t know if we’re going to see higher shares of rural voters than we saw in 2022. 

We don’t know. And so that’s where you really see the shifts in error happen. 

Keith: And if former President Trump’s — a big part of his strategy is turning out unlikely voters. 

Kirzinger: Yeah. We have no idea who they are. 

Rovner: Well, yeah, we saw in Georgia, their first day of in-person early voting, we had this huge upswell of voters, but we have no idea who any of those are, right? I mean, we don’t know what is necessarily turning them out. 

Kirzinger: Exactly. And historically, Democrats have been more likely to vote early and vote by mail, but that has really shifted since the pandemic. And so you see these day voting totals now, but that really doesn’t tell you anything at this point in the race. 

Rovner: Lots we still don’t know. Another question. 

Rae Woods: Hi there. Rae Woods. I’m with Advisory Board, which means that I work with health leaders who need to implement based on the policies and the politics and the results of the election that’s coming up. My question is, outside some of the big things that we’ve talked about so far today, are there some more specific, smaller policies or state-level dynamics that you think today’s health leaders will need to respond to in the next six months, the next eight months? What do health leaders need to be focused on right now based on what could change most quickly? 

Ollstein: Something I’ve been trying to shine a light on are state Supreme Courts, which the makeup of them could change dramatically this November. States have all kinds of different ways to … Some elect them on a partisan basis. Some elect them on a nonpartisan basis. Some have appointments by the governor, but then they have to run in these retention elections. But they are going to just have so much power over … I mean, I am most focused on how it can impact abortion rights, but they just have so much power on so many things. 

And given the high likelihood of divided federal government, I think just a ton of health policy is going to happen at the state level. And so I would say the electorate often overlooks those races. There’s a huge drop-off. A lot of people just vote the top of the ticket and then just leave those races blank. But yes, I think we should all be paying more attention to state Supreme Court races. 

Rovner: I think the other thing that we didn’t, that nobody mentioned we were talking about, what the next president could do, is the impact of the change to the regulatory environment and what the Supreme Court’s decision overturning Chevron is going to have on the next president. And we did a whole episode on this, so I can link back to that for those who don’t know. But basically, the Supreme Court has made it more difficult for whoever becomes president next time to change rules via their executive authority, and put more onus back on Congress. And we will see how that all plays out, but I think that’s going to be really important next year. 

Natalie Bercutt: Hi. My name is Natalie Bercutt. I’m also a master’s student at George Washington. I study health policy. I wanted to know a little bit more about, obviously, abortion rights, a huge issue on the ballot in this election, but a little bit more about IVF [in vitro fertilization], which I feel like has kind of come to the forefront a little bit more, both in state races but also candidates making comments on a national level, especially folks who have been out in the field and interacting with voters. Is that something that more people are coming out to the ballot for, or people who are maybe voting split ticket but in support of IVF, but for Republican candidate? 

Ollstein: That’s been fascinating. And so most folks know that this really exploded into the public consciousness earlier this year when the Alabama Supreme Court ruled that frozen embryos are people legally under the state’s abortion ban. And that disrupted IVF services temporarily until the state legislature swooped in. So Democrats’ argument is that because of these anti-abortion laws in lots of different states that were made possible by the Dobbs decision, lots of states could become the next Alabama. Republicans are saying: Oh, that’s ridiculous. Alabama was solved, and no other state’s going to do it. But they could. 

Rovner: Alabama could become the next Alabama. 

Ollstein: Alabama could certainly become the next Alabama. Buy tons of states have very similar language in their laws that would make that possible. Even as you see a lot of Republicans right now saying: Oh, Republicans are … We’re pro-IVF. We’re pro-family. We’re pro-babies. There are a lot of divisions on the right around IVF, including some who do want to prohibit it and others who want to restrict the way it’s most commonly practiced in the U.S., where excess embryos are created and only the most viable ones are implanted and the others are discarded. 

And so I think this will continue to be a huge fight. A lot of activists in the anti-abortion movement are really upset about how Republican candidates and officials have rushed to defend IVF and promised not to do anything to restrict it. And so I think that’s going to continue to be a huge fight no matter what happens. 

Rovner: Tam, are you seeing discussion about the threats to contraception? I know this is something that Democratic candidates are pushing, and Republican candidates are saying, Oh, no, that’s silly. 

Keith: Yeah, I think Democratic candidates are certainly talking about it. I think that because of that IVF situation in Alabama, because of concerns that it could move to contraception, I think Democrats have been able to talk about reproductive health care in a more expansive way and in a way that is perhaps more comfortable than just talking about abortion, in a way that’s more comfortable to voters that they’re talking to back when Joe Biden was running for president. Immediately when Dobbs happened, he was like, And this could affect contraception and it could affect gay rights. And Biden seemed much more comfortable in that realm. And so— 

Rovner: Yeah, Biden, who waited, I think it was a year and a half, before he said the word “abortion.” 

Keith: To say the word “abortion.” Yes. 

Rovner: There was a website: Has Biden Said Abortion Yet? 

Keith: Essentially what I’m saying is that there is this more expansive conversation about reproductive health care and reproductive freedom than there had been when Roe was in place and it was really just a debate about abortion. 

Rovner: Ashley, do people, particularly women voters, perceive that there’s a real threat to contraception? 

Kirzinger: I think what Tamara was saying about when Biden was the candidate, I do think that that was part of the larger conversation, that larger threat. And so they were more worried about IVF and contraception access during that. When you ask voters whether they’re worried about this, they’re not as worried, but they do give the Democratic Party and Harris a much stronger advantage on these issues. And so if you were to be motivated by that, you would be motivated to vote for Harris, but it really isn’t resonating with women voters and the way now that abortion, abortion access is resonating for them. 

Rovner: Basically, it won’t be resonating until they take it away. 

Kirzinger: Exactly. If, I think, the Alabama Supreme Court ruling happened yesterday, I think it would be a much bigger issue in the campaign, but all of this is timing. 

Ollstein: Well, and people really talked about a believability gap around the Dobbs decision, even though the activists who were following it closely were screaming that Roe is toast, from the moment the Supreme Court agreed to hear the case, and especially after they heard the case and people heard the tone of the arguments. And then of course the decision leaked, and even then there was a believability gap. And until it was actually gone, a lot of people just didn’t think that was possible. And I think you’re seeing that again around the idea of a national ban, and you’re seeing it around the idea of restrictions on contraception and IVF. There’s still this believability gap despite the evidence we’ve seen. 

Rovner: All right. I think we have time for one more question. 

Meg: Hi, my name’s Meg. I’m a freelance writer, and I wanted to ask you about something I’m not hearing about this election cycle, and that’s guns. Where do shootings and school shootings and gun violence fit into this conversation? 

Keith: I think that we have heard a fair bit about guns. It’s part of a laundry list, I guess you could say. In the Kamala Harris stump speech, she talks about freedom. She talks about reproductive freedom. She talks about freedom from being shot, going to the grocery store or at school. That’s where it fits into her stump speech. And certainly in terms of Trump, he is very pro–Second Amendment and has at times commented on the school shootings in ways that come across as insensitive. But for his base — and he is only running for his base — for his base, being very strongly pro–Second Amendment is critical. And I think there was even a question maybe in the Univision town hall yesterday to him about guns. 

It is not the issue in this campaign, but it is certainly an issue if we talk about how much politics have changed in a relatively short period of time. To have a Democratic nominee leaning in on restrictions on guns is a pretty big shift. When Hillary Clinton did it, it was like: Oh, gosh. She’s going there. She lost. I don’t think that’s why she lost, but certainly the NRA [National Rifle Association] spent a lot of money to help her lose. Biden, obviously an author of the assault weapons ban, was very much in that realm, and Harris has continued moving in that direction along with him, though also hilariously saying she has a Glock and she’d be willing to use it 

Ollstein: And emphasizing [Minnesota governor and Democratic vice presidential candidate Tim] Walz’s hunting. 

Keith: Oh, look, Tim Walz, he’s pheasant hunting this weekend. 

Rovner: And unlike John Kerry, he looked like he’d done it before. John Kerry rather famously went out hunting and clearly had not. 

Keith: I was at a rally in 2004 where John Kerry was wearing the jacket, the barn jacket, and the senator, the Democratic senator from Ohio hands him a shotgun, and he’s like … Ehh. 

Kirzinger: I was taken aback when Harris said that she had a Glock. I thought that was a very interesting response for a Democratic presidential candidate. I do think it is maybe part of her appeal to independent voters that, As a gun owner, I support Second Amendment rights, but with limitations. And I do think that that part of appeal, it could work for a more moderate voting block on gun rights. 

Rovner: We haven’t seen this sort of responsible gun owner faction in a long time. I mean, that was the origin of the NRA. 

Keith: But then more recently, Giffords has really taken on that mantle as, We own guns, but we want controls. 

Rovner: All right, well, I could go on for a while, but this is all the time we have. I want to thank you all for coming and helping me celebrate my birthday being a health nerd, because that’s what I do. We do have cake for those of you in the room. For those of you out in podcast land, as always, if you enjoy the podcast, you could subscribe wherever you get your podcast. 

We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman, and our live-show coordinator extraordinaire, Stephanie Stapleton, and our entire live-show team. Thanks a lot. This takes a lot more work than you realize. As always, you can email us your comments or questions. We’re at whatthehealth, all one word, @KFF.org, or you can still find me. I’m at X at @jrovner. Tam, where are you on social media? 

Keith: I’m @tamarakeithNPR. 

Rovner: Alice. 

Ollstein: @AliceOllstein. 

Rovner: Cynthia. 

Cox: @cynthiaccox. 

Rovner: Ashley. 

Kirzinger: @AshleyKirzinger. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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KANSAS CITY, Mo. — Twenty-four minutes before the mass shooting at the Kansas City Chiefs Super Bowl victory parade in February left one person dead and at least 24 people injured, Jenipher Cabrera felt a bullet pierce the back of her right thigh.

The 20-year-old and her family were just four blocks from Union Station, in a river of red-shirted Chiefs fans walking toward the massive rally after the parade that warm Valentine’s Day. The bullet — fired by teen boys fighting in the street — thrust Cabrera forward.

She grabbed her mom by the shoulder and signaled in panic to her bleeding leg with her large brown eyes, not saying a word. Cabrera was being treated in an ambulance when she heard reports blasting from the police radio.

“My mom was trying to get on the ambulance,” Cabrera said. “I remember them saying, like, ‘You can’t get on. There might be other victims that we need to pick up.’”

Cabrera’s shooting happened before the one that garnered the big headlines that day and is one of hundreds that kill or injure Kansas City-area residents each year. That endless drumbeat of gun violence — from one-off incidents to mass shootings — has shattered the sense of safety for those who survive. As victims and their families try to move forward, reminders of gun violence are inescapable in the media, in their communities, in their daily lives.

“I look at people differently,” said James Lemons, who was shot in the thigh at the rally. Now when he’s around strangers he can’t help but wonder if they have a gun and if his kids are safe.

The new NFL season opened here with a moment of silence for Lisa Lopez-Galvan, the only person killed at the parade. Kansas City has recorded at least 124 homicides this year. Local police say there have been an additional 476 “bullet-to-skin victims” — people who were shot and survived. And there were at least 50 school shootings nationwide by mid-September.

Collectively it is all taking a toll.

Survivors suffer panic attacks and feel a heightened sense of danger in crowds and deep anxieties about the threat of violence anywhere in Kansas City.

Every shooting survivor responds in their own way to gun violence and even the threat of it, according to LJ Punch, a trauma surgeon by training and founder of the Bullet Related Injury Clinic in St. Louis.

For some, getting shot ensures they will always be on guard, perhaps even armed. Others want nothing to do with guns ever again.

“But what’s the common ground? That people desperately want to be safe,” Punch said.

Cabrera’s search to make meaning out of what happened has led her to work with a frustrated local lawmaker seeking new gun laws — something akin to impossible given Missouri state law, which prohibits nearly any local restrictions on firearms.

Learning of Other Shootings on the Phone

Feb. 14 is a movie in Cabrera’s mind, in slow motion, frame by frame, and the soundtrack is her voice, talking and talking. She sees a group of rowdy teenage boys running around her and her family. Then two pops — fireworks? Another pop. Finally, a fourth.

“I think that’s where the shock kicked in, and I grabbed my mom,” Cabrera remembered. “I didn’t say anything to her. I just, like, looked at her, and I had, like, my eyes were widened, and I kind of signaled with my eyes to look down at my leg.”

Cabrera fell and other fans rushed to her rescue, calling 911, and began cutting off her leggings. Four men instantly pulled off their belts when asked for a tourniquet. She remembers thinking that if she lost consciousness, she could die. So she talked and talked. Or so she thought.

One of her rescuers later said she actually didn’t say a word even when he asked how many fingers he was holding up.

“He told me [that] my eyes were huge, like oranges, and that all I was basically doing was, like, looking up and down four times since he had four fingers up,” Cabrera said.

Cabrera remembers being moved out of the emergency room at University Health to make room for 12 people who came in from the shooting at the rally, including eight with gunshot wounds. She checked social media on her phone — another shooting? Unreal. Finally her parents found her. She spent seven days in the hospital.

Cabrera is grateful to be alive. But she is triggered now when she sees groups of teenage boys cursing and playing, or when she sees red Chiefs shirts. Hearing four pops in a row — a regular occurrence in her northeast Kansas City neighborhood — makes Cabrera’s chest swell and she braces for a panic attack.

“It runs over and over and over and over in my mind,” she said.

‘An Increasing Sense of Threat?’

The U.S. surgeon general declared gun violence a public health crisis in June, but nearly any new regulation on guns is a political nonstarter in Missouri. In fact, a 2021 state law — signed at the Kansas City-area gun store where one of the weapons used in the parade shooting was purchased — would have barred local police from enforcing federal gun laws. The law was struck down by a federal appeals court in August.

Missouri has no age restrictions on gun use and possession, although federal law largely prohibits juveniles from carrying handguns.

Polling of Missouri voters shows support for requiring background checks and instituting age restrictions for gun purchases, but also nearly half were opposed to allowing counties and cities to pass their own gun rules.

Per capita, Kansas City, Missouri, is among the more violent places in the nation. From 2014 to 2023, there were at least 2,175 shootings in this city of 510,000, leaving 1,275 people dead and 1,624 injured. And while murder rates fell in more than 100 cities across the country last year, Kansas City recorded its deadliest year on record.

Shared with permission from The Trace.

Punch, of the Bullet Related Injury Clinic, likened the violence to a disease outbreak that goes unaddressed and spreads. The state’s permissive posture toward guns might supercharge the reality in Kansas City, Punch said, but it didn’t start it.

“So is there something going on? Is there an increasing sense of threat?” Punch asked.

Jason Barton was familiar with that violence growing up in Kansas City. Now settled in Osawatomie, Kansas, he thought long and hard about bringing his own gun for protection when he drove his family to the Super Bowl parade.

Ultimately he decided against it, surmising that if something happened and he pulled out a gun, he would be arrested or shot.

Barton responded quickly to the shooting, which happened right in front of him and his family. His wife found a bullet in her backpack. His stepdaughter’s legs were burned by sparks from a bullet ricochet.

Despite his worst fears coming true, Barton said not bringing his gun that day was the right decision.

“Guns don’t need to be brought into places like that,” he said.

‘A 12-Gauge With Teeth’

Mass shootings can derail survivors’ sense of safety, according to Heather Martin, a survivor of the Columbine High School shooting in 1999 and co-founder of The Rebels Project, which provides peer support to survivors of mass trauma.

“Trying to find a way to feel safe again is very common,” Martin said, “in the years following it.”

James Lemons had always felt trepidation about returning to Kansas City, where he grew up. He even brought his gun with him to the parade but left it in the car at the urging of his wife. His 5-year-old daughter was on his shoulders when a bullet entered the back of his thigh. He shielded her from the ground as he fell. What was he realistically going to do with a gun?

And yet he can’t help but wonder “what if.” He can’t shake the feeling that he failed to protect his family. Waking up from dreams about the parade, “I just start crying,” he said. He knows he hasn’t processed it yet but he doesn’t know how to start. He has focused on his family’s safety.

They got two American bulldogs this summer, making three total in the house now — one for each kid. Lemons described them as “like having a gun without having a gun.”

“I’ve got a 12-gauge with teeth,” Lemons joked, “just a big, softy protector.”

Most nights he sleeps only a few hours at a time before waking up to check on the kids. Usually he’s on the couch. It’s more comfortable for his leg that is still healing, and it helps him avoid the restless kicks of his 5-year-old, who has slept with her parents since the parade.

It also ensures he’ll be the one to intercept an intruder who breaks into the house.

Emily Tavis, who was shot through the leg, found solace at her church and from a sister congregation’s in-house therapist.

But then, the Sunday morning after the Donald Trump rally shooting in July, the preacher’s sermon turned to gun violence — triggering panic inside her.

“And it just, like, overwhelmed me so much, where I just went to the bathroom,” Tavis said, “and I just stayed in the bathroom for the rest of the sermon.” Now even attending church gives her pause.

Tavis recently moved into a new house in Leavenworth, Kansas, that she is renting from a friend. The friend’s husband cautioned that if Tavis was going to be alone she needed a gun for protection. She told him she just can’t deal with guns right now.

“And he’s like, ‘OK, well, take this.’ And he pulls out this giant machete,” Tavis recalled, laughing.

“So I have a machete now.”

A Search for Something Good

Cabrera, the young woman who couldn’t speak after being shot, is now trying to use her voice in the fight against gun violence.

Manny Abarca, a Jackson County, Missouri, legislator, lives down the street. One evening, he came to visit. Cabrera’s parents did most of the talking; she’s shy by nature. But then he turned and asked her directly: What did she want?

“I just want, like, some justice for my case,” she said, “or something good to happen.”

Before the parade, Cabrera was offered a factory job where her sister worked, but she hadn’t started because her leg was still healing. So Abarca offered her an internship, helping him establish a Jackson County Office of Gun Violence Prevention, a plan he introduced in July in response to the parade shootings.

Abarca was in the Chiefs victory parade with his 5-year-old daughter, Camila. They were in Union Station when shots were fired — and they huddled in a downstairs bathroom.

“I just said, ‘Hey, you know, just be calm. Just be quiet. Let’s just find out what’s going on. Something’s happened,’” Abarca said. “And then she said, ‘This is a drill.’ And hey, it tore everything out of me, because I was like, she’s referring to her training” at school.

They emerged shaken but safe, only to learn that Lopez-Galvan had died. Abarca knew the 43-year-old mother and popular Tejano DJ through the area’s tight-knit Hispanic community.

Abarca has taken advantage of this heated time after the Super Bowl parade shootings to work on anti-violence measures, despite knowing the severe limitations posed by state law.

In June, the Jackson County Legislature passed a measure that gives local teeth to a federal domestic violence law that allows judges to remove firearms from offenders.

But Abarca hasn’t been able to get the gun violence office approved, and county officials have refused to take up another measure that would establish age limits for purchasing or possessing firearms, fearing a lawsuit from a combative state attorney general. He hired Cabrera, he said, because she is bilingual and he wants her help as a survivor.

In a sense, the work makes Cabrera feel stronger in her fight to move forward from the shooting. Still, her family’s perception of safety has been shattered, and no one will be attending games or a possible Super Bowl victory parade anytime soon.

“We just never expected something like that to happen,” she said. “And so I think we’re gonna be more cautious now and maybe just watch it through TV.”

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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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The children, Deas said, often have been exposed to violence on hotel properties, exhibit aggression or anxiety from living in a crowded single room, and face food insecurity because some hotel rooms don’t have kitchens.

“Social trauma is the biggest challenge” when students first arrive, Deas said. “We hear a lot about sleep problems.” To meet students’ needs, Deas developed a schoolwide program featuring counselors, a food pantry, and special protocols for handling those who may fall asleep in class.

“Beyond the teaching, there’s a social part,” he said. “We have to find ways to support the families as well.”

Extended-stay hotels are often a last resort for low-income families trying to find housing. Nationally, more than 100,000 students lived in extended-stay hotels in 2022, according to the Department of Education, though officials say that is likely an undercount. Children living in hotels are considered homeless under federal law, and in some Atlanta-area counties about 40% of homeless students live in this kind of housing, according to local officials.

And with rising rents and evictions, and decreased access to federal public housing, the use of extended-stay hotels as a long-term option is becoming more frequent. Like other forms of homelessness, hotel living can lead to — or exacerbate — physical and mental health problems for children, say advocates for families and researchers who study homelessness.

In the Atlanta area, inspections of extended-stay hotels have revealed ventilation issues, insect infestations, mold, and other health threats. Children living there also can experience or witness crime and gun violence. The increasing use of extended-stay hotels is a warning sign, observers said, a reflection of the lack of sufficient affordable housing policy in the U.S.

And the crisis is having “lifelong consequences,” said Sarah Saadian of the National Low Income Housing Coalition. “The only way that we can really address that shortage is if there are significant federal resources at scale. Build more housing and bridge the gap between rents and wages.”

Often, evictions force families into hotels — and can keep them trapped there. Many landlords refuse to rent to people with evictions in their credit history, even if the tenant isn’t responsible for the displacement, said Joy Monroe, founder and CEO of the Single Parent Alliance & Resource Center, or SPARC, a nonprofit group in metro Atlanta that has helped hundreds of families move from hotels to apartments or rental homes.

Black women and other women of color, often with kids, are evicted at much higher rates and are more likely to find themselves living in extended-stay hotels, advocates say.

Some residents are also families fleeing domestic violence, they say.

Hotels often don’t require security deposits, application fees, or background checks, thus providing immediate relief for families seeking shelter. While there are higher-end options, the average rate for an economy-class extended-stay room was $56.68 a night during the first three months of 2024, according to the Highland Group, a research firm that focuses on the hotel sector — which works out to more than $1,700 a month.

And while the rooms offer respite from other forms of homelessness — like sleeping in a car or in a tent — a hotel “is no place to raise children,” said Michael Bryant, CEO of New Life Community Alliance, which helps families in South Dekalb, a part of metro Atlanta, move from hotels to homes.

Children living in hotels are often behind on vaccinations, and they may end up in the emergency room because of delays in care, said Gary Kirkilas, a pediatrician in Phoenix who helps children, teens, and families who are presently homeless or at risk of homelessness. About 75% of children with unstable housing whom he sees have at least one developmental delay, and others experience significant emotional and behavioral issues.

Tanazia Scott, who has bounced between two extended-stay hotels for several months, said her three children “feel depressed and upset” over hotel life.

An eviction sent Kassandra Norman, 58, and her two daughters into a months-long journey of staying in Atlanta-area hotels. For three months, they slept in a car outside a convenience store. “It’s hard to do homework in a car and in the hotel,” said 19-year-old Kazuri Taylor, Norman’s younger daughter.

Some hotels prohibit kids from playing outside in their parking lots, leading to additional stress, advocates say. That was the reason Yvonne Thomas, 45, and her family were evicted from an extended-stay hotel in DeKalb County, she said: “They put us out for nothing.”

And there are other problems. More than a dozen students at Dunaire Elementary live on an extended-stay property called Haven Hotel. In August, DeKalb County’s code enforcement division said the hotel had “not maintained minimum life safety standards.” Roaches and spiders live in rooms and breezeways, according to state health inspection reports. Residents say they have been charged $1 for a roll of toilet paper.

The hotel’s owner and manager could not be reached for comment after multiple attempts.

“No one is talking about these families,” said Sue Sullivan, a community advocate and a volunteer with the Motel to Home coalition in Atlanta, who brings toys, bookbags, food, and toiletries on her hotel visits.

A February public health inspection at another DeKalb County hotel found several rooms with poor ventilation, insect infestation, and mold, among other potential health threats. In May, two people were fatally shot there.

Children who witness violence can develop anxiety, depression, and other disorders, said Charles Moore, director of the Urban Health Initiative at Emory University School of Medicine. “They can feel emotional aftershocks,” said Moore, who has visited Atlanta-area hotels.

Closing such hotels, however, can hurt families, given the shortage of affordable housing, the absence of national federal renter protections, and a dearth of places to go, said Terri Lewinson, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice. Extended-stay hotels do “offer a low-barrier option for families who have no other options,” she said.

To alleviate the housing problem, county officials and nonprofit organizations around the country have been creatively filling the gap. In the Seattle area, for example, King County officials purchased hotels and converted them into affordable housing, said Mark Skinner of the Highland Group.

In metro Atlanta, SPARC and the local United Way’s Motel to Home offer funding to help people transition into an apartment.

In DeKalb County, where Dunaire Elementary School is located, more than a third of the 1,300 homeless students live in hotels, according to Commissioner Ted Terry.

“I hope we can rescue the children,” he said. “It’s not a safe environment for them.”

Advocates who seek to help people living in hotels propose the construction of more affordable housing and stronger protections for renters against eviction. The federal government has failed to invest in repairs needed to maintain current public housing units, and 25-year-old legislation effectively prohibits the construction of new public housing.

It’s also “extremely fast, easy, and cheap” to evict tenants in Georgia, said Taylor Shelton, an associate professor of geosciences at Georgia State University, whose research focuses on social inequalities and urban spaces. “The playing field is tilted heavily toward landlords.”

Under such circumstances, the cycle of poverty is difficult to break, said Jamie Rush, a senior staff attorney at the Southern Poverty Law Center. “Most parents would want their kids in a safe, stable home,” Rush said. “You can’t budget your way out of poverty.”

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They showed that in 2023, for example, there were four active tuberculosis cases in Clark County, which includes Springfield, up from three in 2022. HIV cases had risen, but sexually transmitted illnesses overall were decreasing.

“I wouldn’t call it skyrocketing,” said Cook, noting that there were 190 active cases in 2023 in all of Ohio. “You hear the rhetoric. But as a whole, reportable infectious diseases to the health department are decreasing.”

Tensions are running high in this industrial town of about 58,000 people. Bomb threats closed schools and public buildings after GOP presidential nominee Donald Trump falsely claimed that Haitian immigrants — who he alleged were there illegally — were stealing and eating household pets. City and county officials disputed the claims the former president levied during his Sept. 10 debate with Vice President Kamala Harris, his Democratic opponent.

Trump was amplifying comments made by Vance that — along with his claims about the immigration status of this population — were broadly panned as false. When asked during a CNN interview about the debunked pet-eating rumor, Vance, a U.S. senator from Ohio, acknowledged that the image he created was based not on facts but on “firsthand accounts from my constituents.” He said he was willing “to create” stories to focus attention on how immigration can overrun communities.

But Ohio Gov. Mike DeWine, also a Republican, has said immigrants have been an economic boon to Springfield. Many began arriving because businesses in the town, which had seen its population decrease, needed labor.

Largely lost in the political rancor is the way Springfield and the surrounding area responded to the influx of Haitian immigrants. Local health institutions tried to address the needs of this new population, which had lacked basic public health care such as immunization and often didn’t understand the U.S. health system.

The town is a microcosm of how immigration is reshaping communities throughout the United States. In the Springfield area, Catholic charities, other philanthropies, volunteers, and county agencies have banded together over the past three to four years to tackle the challenge and connect immigrants who have critical health needs with providers and care.

For instance, a community health center added Haitian Creole interpreters. The county health department opened a refugee health testing clinic to provide immunizations and basic health screenings, operating on such a shoestring budget that it’s open only two days a week.

And a coalition of groups to aid the Haitian community was created about two years ago to identify and respond to immigrant community needs. The group meets once a month with about 55 or 60 participants. On Sept. 18, about a week after Trump ramped up the furor at the debate, a record 138 participants joined in.

“We have all learned the necessity of collaboration,” said Casey Rollins, director of Springfield’s St. Vincent de Paul, a nonprofit Catholic social services organization that has become a lifeline for many of the town’s Haitian immigrants. “There’s a lot of medical need. Many of the people have high blood pressure, or they frequently have diabetes.”

Several factors have led Haitians to leave their Caribbean country for the United States, including a devastating earthquake in 2010, political unrest after the 2021 assassination of Haiti’s president, and ongoing gang violence. Even when health facilities in the country are open, it can be too treacherous for Haitians to travel for treatment.

“The gangs typically leave us alone, but it’s not a guarantee,” said Paul Glover, who helps oversee the St. Vincent’s Center for children with disabilities in Haiti. “We had a 3,000-square-foot clinic. It was destroyed. So was the X-ray machine. People have been putting off health care.”

An estimated 12,000 to 15,000 Haitian immigrants live in Clark County, officials said. About 700,000 Haitian immigrants lived in the United States in 2022, according to U.S. Census data.

Those who have settled in the Springfield area are generally in the country legally under a federal program that lets noncitizens temporarily enter and stay in the United States under certain circumstances, such as for urgent humanitarian reasons, according to city officials.

The influx of immigrants created a learning curve for hospitals and primary care providers in Springfield, as well as for the newcomers themselves. In Haiti, people often go directly to a hospital to receive care for all sorts of maladies, and county officials and advocacy groups said many of the immigrants were unfamiliar with the U.S. system of seeing primary care doctors first or making appointments for treatment.

Many sought care at Rocking Horse Community Health Center, a nonprofit, federally qualified health center that provides mental health, primary, and preventive care to people regardless of their insurance status or ability to pay. Federally qualified health centers serve medically underserved areas and populations.

The center treated 410 patients from Haiti in 2022, up more than 250% from 115 in 2021, according to Nettie Carter-Smith, the center’s director of community relations. Because the patients required interpreters, visits often stretched twice as long.

Rocking Horse hired patient navigators fluent in Haitian Creole, one of the two official languages of Haiti. Its roving purple bus provides on-site health screenings, vaccinations, and management of chronic conditions. And this school year, it’s operating a $2 million health clinic at Springfield High.

Many Haitians in Springfield have reported threats since Trump and Vance made their town a focus of the campaign. Community organizations were unable to identify any immigrants willing to be interviewed for this story.

Hospitals have also felt the impact. Mercy Health’s Springfield Regional Medical Center also saw a rapid influx of patients, spokesperson Jennifer Robinson said, with high utilization of emergency, primary care, and women’s health services.

This year, hospitals also have seen several readmissions for newborns struggling to thrive as some new mothers have trouble breastfeeding or getting supplemental formula, county officials said. One reason: New Haitian immigrants must wait six to eight weeks to get into a program that provides supplemental food for low-income pregnant, breastfeeding, or non-breastfeeding postpartum women, as well as for children and infants.

At Kettering Health Springfield, Haitian immigrants come to the emergency department for nonemergency care. Nurses are working on two related projects, one focusing on cultural awareness for staff and another exploring ways to improve communication with Haitian immigrants during discharge and in scheduling follow-up appointments.

Many of the immigrants are able to get health insurance. Haitian entrants generally qualify for Medicaid, the state-federal program for the low-income and disabled. For hospitals, that means lower reimbursement rates than with traditional insurance.

During 2023, 60,494 people in Clark County were enrolled in Medicaid, about 25% of whom were Black, according to state data. That’s up from 50,112 in 2017, when 17% of the enrollees were Black. That increase coincides with the rise of the Haitian population.

In September, DeWine pledged $2.5 million to help health centers and the county health department meet the Haitian and broader community’s needs. The Republican governor has pushed back on the recent national focus on the town, saying the spread of false rumors has been hurtful for the community.

Ken Gordon, a spokesperson for the Ohio Department of Health, acknowledged the difficulties Springfield’s health systems have faced and said the department is monitoring to avert potential outbreaks of measles, whooping cough, and even polio.

People diagnosed with HIV in the county increased from 142 residents in 2018 to 178 to 2022, according to state health department data. Cook, the Clark County health commissioner, said the data lags by about 1.5 years.

But Cook said, “as a whole, all reportable infections to the health department are not increasing.” Last year, he said, no one died of tuberculosis. “But 42 people died of covid.”

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This formed the multimedia “Silence in Sikeston” project from KFF Health News, Retro Report, and WORLD as told through a documentary film, educational videos, digital articles, and a limited-series podcast. Hear about Anthony’s journey and join this conversation about the toll of racialized violence on our health and our communities.

Explore more of the “Silence in Sikeston”project:

LISTEN: The limited-series podcast is available on PRX, Apple Podcasts, Spotify, iHeart, or wherever you get your podcasts.

• Episode 1: “Racism Can Make You Sick”
• Episode 2: “Hush, Fix Your Face”
• Episode 3: “Trauma Lives in the Body”
• Episode 4: “Is There a Cure for Racism”

WATCH: The documentary film “Silence in Sikeston,” a co-production of KFF Health News and Retro Report, is now available to stream on WORLD’s YouTube channel, WORLDchannel.org, and the PBS app.

READ: KFF Health News Midwest correspondent Cara Anthony wrote an essay about what her reporting for this project helped her learn about her own family’s hidden past.

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Indeed, it was a plotline on the sitcom Seinfeld. But for some it has been a tragedy.

People have died after drinking tea brewed from unwashed poppy seeds.

And after eating lemon poppy seed bread or an everything bagel, mothers reportedly have been separated from newborns because the women failed drug tests.

Poppy seeds come from the plant that produces opium and from which narcotics such as morphine and codeine are derived. During harvesting and processing, the seeds can become coated with the opium fluid.

Members of the House and Senate have proposed legislation “to prohibit the distribution and sale of contaminated poppy seeds in order to prevent harm, addiction, and further deaths from morphine-contaminated poppy seeds.” The bill was one of several on the agenda for a Sept. 10 House hearing.

The day before the hearing, The Marshall Project and Reveal reported on a woman who ate a salad with poppy seed dressing before giving birth, tested positive at the hospital for opiates, was reported to child welfare, and saw her baby taken into protective custody. Almost two weeks passed before she was allowed to bring her baby home, the story said.

“It’s not an urban legend: Eating poppy seeds can cause diners to test positive for codeine on a urinalysis,” the Defense Department warned military personnel in 2023.

The U.S. Anti-Doping Agency long ago issued a similar warning to athletes.

The Center for Science in the Public Interest, a watchdog group, petitioned the FDA in 2021 to limit the opiate content of poppy seeds. In May, after more than three years with no response, it sued the agency to force action.

“So far the FDA has been negligent in protecting consumers,” said Steve Hacala, whose son died after consuming poppy seed tea and who has joined forces with CSPI.

The lawsuit was put on hold in July, after the FDA said it would respond to the group’s petition by the end of February 2025.

The FDA did not answer questions for this article. The agency generally does not comment on litigation, spokesperson Courtney Rhodes said.

A 2021 study co-authored by CSPI personnel found more than 100 reports to poison control centers between 2000 and 2018 resulting from intentional abuse or misuse of poppy seeds, said CSPI scientist Eva Greenthal, one of the study’s authors.

Only rarely would baked goods or other food items containing washed poppy seeds trigger positive drug tests, doctors who have studied the issue said.

It’s “exquisitely doubtful” that the “relatively trivial” amount of morphine in an everything bagel or the like would cause anyone harm, said Irving Haber, a doctor who has written about poppy seeds, specializes in pain medicine, and signed the CSPI petition to the FDA.

On the other hand, tea made from large quantities of unwashed poppy seeds could lead to addiction and overdose, doctors said. The risks are heightened if the person drinking the brew is also consuming other opioids, such as prescription pain relievers.

Benjamin Lai, a physician who chairs a program on opioids at the Mayo Clinic in Rochester, Minnesota, said he has been treating a patient who developed long-term opioid addiction from consuming poppy seed tea. The patient, a man in his 30s, found it at a health food store and was under the impression it would help him relax and recover from gym workouts. After a few months, he tried to stop and experienced withdrawal symptoms, Lai said.

Another patient, an older woman, developed withdrawal symptoms under similar circumstances but responded well to treatment, Lai said.

Some websites tout poppy seed tea as offering health benefits. And some sellers “may use specific language such as ‘raw,’ ‘unprocessed,’ or ‘unwashed’ to signal that their products contain higher concentrations of opiates than properly processed seeds,” the CSPI lawsuit said.

Steve Hacala’s son, Stephen Hacala, a music teacher, had been experiencing anxiety and insomnia, for which poppy seed tea is promoted as a natural remedy, the lawsuit said. In 2016, at age 24, he ordered a bag of poppy seeds online, rinsed them with water, and consumed the rinse. He died of morphine poisoning.

The only source of morphine found in Stephen’s home, where he died, was commercially available poppy seeds, a medical examiner at the Arkansas State Crime Lab said in a letter to the father. The medical examiner wrote that poppy seeds “very likely” caused Stephen’s death.

Steve Hacala estimated that the quantity of poppy seeds found in a 1-liter plastic water bottle in his son’s home could have delivered more than 10 times a lethal dose.

Steve Hacala and his wife, Betty, have funded CSPI’s efforts to call attention to the issue. (The publisher of KFF Health News, David Rousseau, is on the CSPI board.)

The lawsuit also cited mothers who, like those in the investigation by The Marshall Project and Reveal, ran afoul of rules meant to protect newborns. For example, though Jamie Silakowski had not used opioids while pregnant, she was initially prevented from leaving the hospital with her baby, the suit said.

Silakowski recalled that, before going to the hospital, she had eaten lemon poppy seed bread at Tim Hortons, a fast-food chain, CSPI said in its petition. “No one in the hospital believed Ms. Silakowski or appeared to be aware that the test results could occur from poppy seeds.”

People from child protective services made unannounced visits to her home, interviewed her other children, and questioned teachers at their school, she said in an interview.

While on maternity leave, she had to undergo drug testing, Silakowski said. “Peeing in front of someone like I’m a criminal — it was just mortifying.”

Even family members were questioning her, and there was nothing she could do to dispel doubts, she said. “Relationships were torn apart,” she said.

The parent company of Tim Hortons, Restaurant Brands International, which also owns Burger King and Popeyes, did not respond to questions from KFF Health News.

In July, The Washington Post reported that Trader Joe’s Everything but the Bagel seasoning was banned and being confiscated in South Korea because it contains poppy seeds. Trader Joe’s did not respond to inquiries for this article. The seasoning is listed for sale on the company’s website.

The U.S. Drug Enforcement Agency says unwashed poppy seeds can kill when used alone or in combination with other drugs. While poppy seeds are exempt from drug control under the Controlled Substances Act, opium contaminants on the seeds are not, the agency says. The Justice Department has brought criminal prosecutions over the sale of unwashed poppy seeds.

Meanwhile, the legislation to control poppy seed contamination has not gained much traction.

The Senate bill, introduced by Sen. Tom Cotton (R-Ark.), has two co-sponsors.

The House bill, introduced by Rep. Steve Womack (R-Ark.), has none. Though it was on the agenda, it didn’t come up at the recent hearing.

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His mother, Deborah Melvin-Muse, doesn’t display photos of him, the second-youngest of six children. His brother’s birthday was the day after the crash — and he hasn’t celebrated it since. An older brother carries a deep sense of guilt because he was looking after John that morning.

And Cheek Road, in a predominantly Black neighborhood, still lacks sidewalks for children to safely make their way to the local elementary school.

This, despite the years community activists and academic researchers have spent pleading with city leaders for safety improvements along the busy thoroughfare with sloping shoulders where John died. Drivers zoom along Cheek Road in the Merrick-Moore neighborhood, which connects downtown Durham to industrial sites and newer suburban developments.

Melvin-Muse moved her family out of the neighborhood after John’s death. “Now when I go down there, I look and see, you know, nothing really changed,” she said. “It still looks the same.”

Cheek Road has been “identified as needing improvements” by a local metropolitan planning board, said Erin Convery, Durham’s transportation planning manager, in an email.

“The infrastructure that exists is not well implemented,” concluded a May preliminary report produced by University of North Carolina-Chapel Hill students who collected data on speeding, noise, and air quality along Cheek Road. “Poorly marked crosswalks and inadequately positioned bus stops show a need for safety and accessibility improvements,” the report said.

Data was difficult to collect because “there were areas we didn’t want to get out of our cars because of the dangerous conditions,” said Ari Schwartz, one of the researchers.

In the 1940s, Black military veterans returning from World War II helped establish the Merrick-Moore neighborhood. Since then, residents say they have endured everything from noisy industrial trucks and speeding cars to illegal tire dumping and air pollution that threaten their health and safety.

Pedestrian deaths are highest in formerly redlined areas, neighborhoods where Black people lived because of discriminatory federal mortgage lending practices, research shows. The lack of sidewalks, damaged walkways, and roads with high speed limits are concentrated in these neighborhoods, studies show, creating a little-recognized public health crisis.

Governments invest in roads for people driving through such neighborhoods, but not in safety measures — like sidewalks, crosswalks, traffic circles, and speed bumps — that protect people living in them, researchers and advocates say.

“People will talk about vulnerable communities as if there is a problem with these communities, when in fact it is our systems and policies that have created these failings,” said Darya Minovi, a senior analyst at the Union of Concerned Scientists who studies environmental health and justice.

While the share of Black residents in Merrick-Moore has dropped in recent decades, data shows the neighborhood remains more than 80% Black or Hispanic and households there are typically less well-off than in other parts of the city.

“Local government takes money from the neighborhood but does not invest in it,” said Bonita Green, head of the Merrick-Moore Community Development Corporation and a former City Council candidate.

Green said the community group had documented more than 100 auto crashes along Cheek Road during a recent four-year span and at least three pedestrian deaths before 2020. In this fast-growing city of roughly 300,000, students at Merrick-Moore Elementary and others at a nearby high school sometimes walk along the road — where traffic is heavy, drivers are known to disregard the 25-mph speed limit, and the shoulders slope steeply.

When longtime residents like Ponsella Brown see kids walking there or hear about another accident, they remember the death of John Parker, who was in first grade.

“I just cringe,” said Brown, who worked as an administrative assistant at Merrick-Moore Elementary when John died. “Every time it comes up, it’s like really vivid in my mind.”

On the day John died, someone rushed into the office and said a child had been hit by a car on Cheek Road, recalled Brown, who said she ran to the scene.

“I remember the way his head was turned. I remember the spot of blood on his face. Like one speck of blood,” said Brown, who also works for the Merrick-Moore Community Development Corporation and is now a counselor at another school.

Traffic on Cheek Road is expected to increase as the population grows in Durham and surrounding areas, according to a separate April report from UNC graduate students. It noted that during the morning school drop-off time, many cars driving on Cheek Road don’t observe the posted speed limits.

Under an equity program meant to reverse the harm done to communities of color, Convery said, Durham officials are considering traffic-calming measures, including traffic circles, speed cushions, and high-visibility crosswalks.

“We’re open to future conversations that will help us achieve zero traffic deaths and injuries,” Convery said.

Yet a 2017 plan that prioritized more than 600 sidewalk projects based on safety, equity, and demand did not include Merrick-Moore Elementary School on Cheek Road, she said.

A strike by Durham school bus drivers this year only heightened concerns about the lack of safe walking routes for the 650 students who attend the elementary school, according to the April report.

Melvin-Muse, now 67, was at work when she got a call that John had been struck by a truck in front of their house. Before she left home that late May morning in 1989, she put her older kids in charge of the younger ones. They passed the time before school riding bicycles near their house, a few blocks from Merrick-Moore Elementary School, when the accident occurred.

John died two months shy of his 7th birthday from “massive head injuries,” according to The (Raleigh) News & Observer, which wrote about his death on Cheek Road at the time. John was buried in Markham Memorial Gardens, according to his obituary in The (Durham) Herald-Sun.

Melvin-Muse said his death sent the family into a tailspin of grief, anger, and regret.

“It caused a big rip in the family,” Melvin-Muse said.

Melvin-Muse and John’s father later divorced. She said she paid for therapy for her other kids, but they still got in trouble at school and two of her children ended up living in a home for kids with behavioral health issues. “It was just a bad time,” she said.

Years after the accident, Melvin-Muse said, she worked up the courage to call the driver who had hit her son. When he answered, he didn’t recognize her name, or John’s, fueling her rage, she recalled.

“I wanted revenge. An eye-for-an-eye kind of thing,” she said. “And I plotted to take him out the same way my son was taken out.”

She went so far as to get a job where he worked, the Durham County tax department, only to find he had left a week before she started.

“God knows what was in my heart and what I planned on doing,” Melvin-Muse said. “God moved him out of that place before I got there.”

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