He signed legislation mandating that insurance companies cover in vitro fertilization. He supported restricting students’ cellphone use in schools and signed a nation-leading ban on food dye in school snacks and drinks. And he endorsed a bill allowing businesses to operate Amsterdam-style cannabis cafés.

Still, in a heated election cycle with Vice President Kamala Harris, a Californian, on the presidential ticket, the Democratic governor was noticeably reluctant to impose additional industry regulations.

Newsom vetoed several health and safety bills, frequently citing cost concerns. But many of these proposals risked perpetuating California stereotypes trumpeted by presidential nominee Donald Trump and other Republicans. The governor rejected gas stove warning labels, as well as speeding alerts for new cars, even drawing tepid praise on social media from GOP Assembly leader James Gallagher, who credited Newsom for vetoing “some pretty bad/stupid bills.”

Most of the laws Newsom approved take effect Jan. 1, 2025, while some have longer phase-in times. Here are the governor’s actions on key health bills:

Health Care

Group health care service plans and disability insurance must cover infertility and fertility services under SB 729, including for LGBTQ+ people, generally starting in mid-2025. The California Association of Health Plans warns of higher premiums as a result.

Local health officers can inspect private detention facilities, including six immigration detention centers, under SB 1132.

And the governor signed AB 869, allowing small, rural, or “distressed” hospitals to get an extension of up to three years on a 2030 legal deadline for earthquake retrofits. But he vetoed SB 1432, which would have allowed all hospitals to apply for an extension of the deadline for up to five years.

Newsom also vetoed SB 966, which would have regulated the middlemen known as pharmacy benefit managers and banned some business practices that critics say increase costs and limit consumers’ choices. He also rejected AB 2467, which would have mandated health care coverage for menopause, and AB 3129, which would have required the state attorney general’s approval for transactions involving health care providers and private equity firms. And he vetoed AB 2104 and SB 895, which would have allowed some community college districts to offer bachelor’s degrees in nursing.

Medical Debt

Credit reporting agencies will be prohibited from including medical debt in consumers’ credit reports under SB 1061, but last-minute amendments weakened the protections. Earlier this year, the Biden administration proposed federal rules barring unpaid medical bills from affecting patients’ credit scores.

Medi-Cal

Medi-Cal, which provides health care for about 15 million low-income people, will cover hospital emergency rooms’ treatment of psychiatric emergencies under AB 1316.

But Newsom rejected AB 1975, which would have made medically supportive food and nutrition a Medi-Cal benefit, and AB 2339, which would have expanded Medi-Cal coverage of telehealth.

Mental Health

Newsom signed more than a dozen bills aimed at boosting behavioral health care, including through California’s new court-ordered treatment program.

But citing costs, Newsom rejected an annual scholarship fund for students pursuing a mental health profession if they worked for three years in that new treatment program. Critics say SB 26 should have broadened the scholarship to all county behavioral health programs.

Abortion

California will increase penalties for obstructing or impeding access to reproductive health care services, and for posting personal information or photographs of a patient or provider. These are currently misdemeanors; AB 2099 would make them punishable as misdemeanors or felonies.

Planned Parenthood Affiliates of California also backed AB 2085, smoothing approval of new health centers, and SB 1131, supporting California’s Family PACT (Planning, Access, Care, and Treatment) program for people with family incomes below 200% of the federal poverty level.

Aging

Newsom approved a dozen bills related to aging, including measures requiring increased training for law enforcement (AB 2541) and health care professionals (SB 639) in helping people with dementia. AB 1902 requires better access to prescription labels for those who have trouble seeing or who need translated instructions. And he signed another package of bills aimed more broadly at helping people with disabilities.

Violence Prevention

Assault or battery against a doctor, physician, nurse, or other health care worker within an ER could bring up to a year in county jail, a $2,000 fine, or both under AB 977. That makes it the same maximum punishment as for assaulting a medical worker in the field. California law previously set a lesser penalty for assault within an ER.

The state is taking more steps to deter gun violence with two dozen new laws. Among them, SB 53 increases requirements for safely storing firearms, in keeping with a push from the White House. AB 2621 will increase law enforcement training and revise policies on using gun violence restraining orders, while AB 2917 expands when courts can impose gun violence restraining orders.

And hospitals will eventually have to screen patients, family members, and visitors for weapons at entrances under AB 2975.

Substance Use

AB 1976 will require workplace first-aid kits to include naloxone or other drugs that can reverse opioid overdoses, while protecting those who administer the naloxone from civil liability.

Under AB 1775, local jurisdictions will allow retailers to sell noncannabis food and beverages and have live music and other performances in areas where cannabis consumption is allowed. Assembly member Matt Haney, a Democrat from San Francisco, said his intent is to allow Dutch-style cannabis coffeehouses. Newsom approved the measure despite vetoing Haney’s similar bill last year, amid critics’ concern that the measure would undermine California’s nation-leading effort outlawing indoor smoking.

And AB 3218 furthers enforcement of California’s ban on flavored tobacco, passed in 2020.

Youth Welfare

California is the first state to generally bar public schools from providing food containing red dye 40 or any of five other synthetic food dyes used in products including Froot Loops and Flamin’ Hot Cheetos. AB 2316 is Democratic Assembly member Jesse Gabriel’s follow-up to his legislation last year that banned a chemical found in Skittles candy.

A bill to increase transparency with the use of restraints and seclusion rooms in state-licensed short-term residential therapeutic programs became law with some high-profile help from celebrity Paris Hilton. She backed SB 1043, which will also require the state Department of Social Services to post the information on a public dashboard.

And school districts’ sex education curricula must include menstrual health under AB 2229.

But Newsom vetoed AB 2442, which would have sped licensing for providers of gender-affirming care, and SB 954, which would have provided free condoms in high schools.

Women’s Health

Selling menstrual products with intentionally added PFAS, also known as “forever chemicals,” will be banned under AB 2515. PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, have been linked to serious health problems.

AB 2319 was passed in an effort to improve enforcement of a 2019 law aimed at reducing the disproportionate rate of maternal mortality among Black women and other pregnant women of color.

AB 2527 is aimed at improving treatment of pregnant women who are incarcerated. Critics wanted the original version, which banned solitary confinement, and were upset when it was amended to allow up to five days of confinement if prison officials find a safety or security threat.

AB 518 is aimed at increasing participation in the CalFresh nutrition program, part of a package of healthy-food bills.

And under SB 1300, the public will get more notice when hospitals plan to close their maternity wards. The measure will increase the notice requirement to 120 days, up from the current 90.

But Newsom rejected AB 1895, which would have required six months’ notice to state agencies of potential maternity ward closures. The agencies would then have been required to conduct a community impact assessment.

Social Media

SB 1504 broadens California’s Cyberbullying Protection Act regulating social media platforms to apply to minors instead of pupils. Social media platforms that intentionally violate the law could face civil penalties of up to $10,000, along with compensatory and punitive damages. Those damages could be sought by a parent, a legal guardian, or various prosecutors. Under current law, damages are capped at $7,500 and may be pursued only by the state attorney general.

SB 976 restricts “addictive feeds” to minors, including banning social media notifications to minors during school hours.

And AB 3216 will limit the use of smartphones in schools.

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

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.

That was on Tuesday, Oct. 8. The next morning a social worker and a doctor woke Trumble to say her discharge was canceled. CVS would no longer provide her home nutrition, and she had to stay in the hospital. “I was dropped between Tuesday night and Wednesday morning with no care for my life or my health,” Trumble said from her hospital bed eight days later.

After this article was published, on Oct. 18, Trumble said she was being discharged, after her caregivers found a replacement service. “I’m just afraid their supplies will run out,” she said. “My backup plan is always to go back to the hospital.”

Trumble is among 25,000 U.S. patients whose survival depends on parenteral nutrition, or PN — IV bags containing life-sustaining amino acids, sugars, fats, vitamins, and electrolytes. Hurricane Helene wrecked a factory in North Carolina that produced 60% of the fluids their sustenance is mixed from. About two weeks later, CVS announced that its Coram division, a leading infusion pharmacy, was exiting the PN and IV antibiotics business.

The hurricane led Baxter International to ration its dwindling supplies. Pharmacies that supply Trumble and other patients like her were already plagued by shortages, and the rationing means the remaining infusion pharmacies can’t take on the customers cut off by CVS, said David Seres, director of medical nutrition at Columbia University Medical Center in New York.

At the Mayo Clinic in Rochester, Minnesota, seven or eight patients were ready to go home Tuesday but couldn’t be discharged because no infusion company would accept them, said Manpreet Mundi, a Mayo endocrinologist. The patients would fall ill within a day or two without this nutrition, he said.

By Oct. 18, home supplies had been located for all but a few of them, Mundi said. “A lot of public pressure” on Coram was starting to have an effect, he said.

Although the FDA is allowing emergency imports of IV fluids wiped out by Helene, as well as production of some of the fluids by U.S. compounding pharmacies, it’s unclear how long it will take to replenish supplies, said Mundi, who is a board member of the American Society for Parenteral and Enteral Nutrition and medical adviser to the Oley Foundation, which advocates for PN patients. “We’re trying to raise awareness that this could get worse before it gets better,” he said.

The patients who rely on PN have a variety of conditions that render them unable to digest food. Some have congenital abnormalities or disorders like Crohn’s disease that led to surgical removal of bowel sections. Others were scarred by cancer, car accidents, or gunfire, or are preemies born with underdeveloped intestines. In most patients, the fluid is pumped through a catheter into a large vein near the heart.

A crisis hit this community two years ago when CVS Health announced that it was shutting half of the 71 Coram pharmacies.

CVS, which recently announced nearly 3,000 layoffs amid reports of a possible restructuring, on Oct. 8 began telling its remaining 800 to 1,000 PN customers that they would have to find other infusion pharmacies. A news release provided to KFF Health News suggested the phaseout would last into January, but for patients like Trumble, the impact was immediate.

Highly specialized infusion medicine is “a challenging environment” for all companies “and Coram has not been immune to these challenges,” the CVS release said. “As such, we have reevaluated our service offerings.”

When asked about Trumble’s case, CVS Health spokesperson Mike DeAngelis said the company would “try to resolve it.” The next day, a company called Optum stepped in to replace Coram, Trumble said.

It’s hard enough normally for such patients to find new suppliers for their materials, which can include 120 pounds of IV fluid per week.

Coram’s departure “made a big crisis that much worse,” Mundi said. “It’s become kind of a double whammy.”

The Baxter International North Cove plant produced most of the country’s high-concentration dextrose, a major source of energy for PN patients, as well as saline solution and sterile water, also vital supplies. A week after Helene hit, Hurricane Milton threatened sterile IV fluid supplier B. Braun Medical’s facility in Daytona Beach, Florida. The federal government helped truck 60 loads of the company’s inventory to a safe location, but the plant was spared the storm’s worst. It restarted production on Oct. 11.

That was a huge relief for Beth Gore, CEO of the Oley Foundation. She, her husband, and their six adopted children braved the storm’s seven hours of lashing wind in their home near Ruskin, Florida. Milton wrecked a car and part of the roof, but the family prayed through it all and somehow never lost power, though their neighbors did, Gore said. That kept the IV fluids fresh and the internet on, which calmed the kids.

Coram has supplied her youngest son, 15-year-old Manny, with PN for 13 years, and the family will need to find another supplier, she said.

“There’s been no relief” since Coram reduced its services in 2022, Gore said. “Now there’s this new twist.”

Her son gets care through Medicaid, whose reimbursement provides barely break-even margins for many infusion pharmacies, she said. Insurance limits, state licensing differences, and highly specific nutritional needs pose challenges for patients seeking new IV suppliers in the best of times, she said.

The FDA announced Oct. 9 that it would allow Baxter to import emergency supplies from Canada, China, Ireland, and the U.K. In the meantime, Baxter is prioritizing hospital patients over the home infusion companies — which lack backup supplies, Mundi said.

“We’re all on the phone 24/7,” said Kathleen Gura, president-elect of the American Society for Parenteral and Enteral Nutrition and pharmacy clinical research program manager at Boston Children’s Hospital. Her team is struggling to find new suppliers of IV nutrition at home for the 20 Coram patients among the 150 she sees.

“Some kids have a situation where they can’t absorb at all through their intestines and will die of dehydration if they can’t get IV,” Gura said.

The IV fluids lost in the Baxter disaster are key to all kinds of inpatient care. Many U.S. hospitals are conserving fluid by giving some patients oral hydration instead of IVs, or by delaying surgeries, said Soumi Saha, senior vice president of government affairs at Premier, which negotiates group hospital purchases.

President Joe Biden has invoked the Defense Production Act, which will enable the government to order companies to prioritize rebuilding the Baxter plant.

The military is flying in supplies from Baxter plants overseas, Saha said. Premier has also asked the FDA to put additional PN ingredients on its shortage list, which would allow large compounding facilities to produce the materials.

Ellie Rogers, 17, of Simpsonville, South Carolina, fears the worst if she can’t get her supplies. She suffers from a host of immunological and neurological ailments that require her to get four liters of IV fluid daily to stay alive, she said.

Her supplier, an Option Care Health pharmacy in South Carolina, informed the family Oct. 14 that instead of her weekly supply it was sending her enough bags for a day or two. “They really don’t know when they’re going to get what they need,” she said. Reducing the infusions in the past has led to dizziness, nausea, and pooling of her blood that “felt like my veins were going to explode.”

On Oct. 7, Crohn’s disease patient Hannah Hale’s infusion pharmacy called and said it couldn’t fill her standing weekly order of IV bags, urging her to find a new pharmacy.

“I called 14 infusion pharmacies and haven’t been able to find anyone to take me,” said the Dallas 37-year-old. She suffers from weight loss and low blood sugar, and rationing her supplies raises dangers of seizures or coma, she said.

Trumble, 52, who started on PN 13 months ago because of colon cancer and severe intestinal issues, said she was grateful to the hospital and gets excellent care there, but missed her mother, son, and 8-year-old grandson, Jordan — and her cats — during her 17-day hospitalization.

What’s worse, Trumble said, her mother and son, who get Medicaid payments to care for her, weren’t paid while she was away.

But without IV nutrition at home, she said, “I’d starve.”

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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“When the ride is an hour or an hour and a half of mostly freeway driving, people tend to tell you what they’re going through,” she said.

Drivers such as Carr have become a critical part of the medical transportation system in Georgia, as well as in Washington, D.C., Mississippi, Arizona, and elsewhere. While some patients use transportation companies solely dedicated to medical rides or nonemergency ambulance rides to get to their appointments, the San Francisco-based ride-hailing companies Uber and Lyft are also ferrying people to emergency rooms, kidney dialysis, cancer care, physical therapy, and other medical visits.

But Georgia ride-hail drivers aren’t only serving patients living in Atlanta or its sprawling suburbs. When rural Georgians are too sick to drive themselves, Uber or Lyft is often one of the only ways to reach medical care in the state capital.

Rural hospital closures in Georgia have meant people battling cancer and other serious illnesses must now commute two or more hours to treatment facilities in Atlanta, said Bryan Miller, director of psychosocial support services at the Atlanta Cancer Care Foundation, a medical practice offshoot that seeks to alleviate financial burdens for cancer patients and their families.

From April 2022 to April 2024, Lyft drivers completed thousands of rides that were greater than 50 miles each way and that began or ended at Atlanta-area medical treatment centers, including the Winship Cancer Institute of Emory University and Emory University Hospital Midtown, according to Lyft.

While 75% of those trips were under 100 miles, the company said, 21% of them were between 100 and 200 miles and 4% were over 200, showing that even Georgians who live hours away from metro Atlanta rely on the ride-hail platform to reach medical care there.

Uber Health global head Zachary Clark declined to provide comparable ridership data. Uber Health is a division of Uber that organizes medical transportation for some Medicaid and Medicare recipients, health care workers, prescription drug delivery, and others seeking reimbursement for medical-related Uber rides, according to Uber’s website.

Lyft also has a health care division, offering programs such as Lyft Assisted and Lyft Concierge to coordinate rides for patients.

Nationwide, some insurance companies and cancer treatment centers, plus Medicare Advantage and state Medicaid plans, pay for such ride-hailing services, often with the goal of reducing missed appointments, according to Krisda Chaiyachati, an adjunct assistant professor at the University of Pennsylvania medical school.

In 2024, 36% of individual Medicare Advantage plans and 88% of special needs plans offered transportation services, said Jeannie Fuglesten Biniek, associate director of Medicare policy at KFF, the health policy research, polling, and news organization that includes KFF Health News. A special needs plan provides extra benefits to Medicare recipients who have severe and chronic diseases or certain other health care needs, or who also have Medicaid.

And Medicaid — the federal-state government safety net insurance plan for those with low incomes or disabilities — paid for up to 4 million beneficiaries to use nonemergency medical transportation services annually from 2018 through 2021, according to a Department of Health and Human Services report. Patients residing in rural areas used ride-hailing and other nonemergency transportation providers at the highest rates, the report said.

The estimated total federal and state investment in nonemergency medical transportation was approximately $5 billion in 2019, according to a study by the Texas A&M University Transportation Institute.

Even with some insurance covering trips or charities offering ride credits, social workers say, many ailing patients are still left without a ride. Nationwide, 21% of adults without access to a vehicle or public transit went without needed medical care in 2022, according to a study by the Robert Wood Johnson Foundation. People who lacked access to a vehicle but had access to public transit were less likely to skip needed care.

The data analytics company Geotab ranked Atlanta as tied for second worst in the nation when it comes to the accessibility of its public transportation network.

“The ability to get to a doctor’s appointment can be a barrier to care,” said Rochelle Schube, a cancer support group facilitator in Atlanta. “If I give a patient $250 in Uber cards and they live far away, that gets spent quickly.”

The fact that Uber and Lyft are harder to come by in rural America compounds the lack of medical access in those areas. “When you move to rural areas — which you could argue have a higher need — you see fewer services,” Chaiyachati said.

Finding drivers who are able and willing to provide medical transportation can be a challenge. The Atlanta-based start-up MedTrans Go connects patients and health care providers with vetted drivers, many offering wheelchair or stretcher rides, in Georgia and 16 other states. Many of its drivers have medical training, walk patients to and from medical facilities or their homes, and can handle complex situations for vulnerable patients, said Dana Weeks, the company’s co-founder and CEO.

The company’s app can also dispatch directly to Uber or Lyft for patients who do not need specialized assistance, she said.

Uber and Lyft trips can save patients and insurers money, costing a fraction of the typical fee for an ambulance ride, said David Slusky, an economics professor at the University of Kansas who has studied the impact of ride-hailing services on medicine.

But instead of all of that, argued Timothy Crimmins, a history professor emeritus at Georgia State University and a former director of the school’s neighborhood-studies center, the best solution would be for Georgia to expand Medicaid, so more rural hospitals would be able to remain open and Georgians could seek medical care close to home.

The decision by Georgia lawmakers to not accept a federally funded expansion of Medicaid has left more than 1.4 million Georgians without health insurance, according to KFF — and that hurts rural hospitals when those patients use the medical facilities and cannot pay their bills. In Georgia, 10 rural hospitals have either closed or ceased their inpatient care operations since 2010, according to a 2024 report from health care consultant Chartis, and 18 more are in danger of shuttering.

Until more patients are insured, Crimmins said, the state should subsidize Uber and Lyft trips for less prosperous Georgians who need help reaching medical care in Atlanta. “We might be talking about $100 to $150 round-trip,” he said. “That can be subsidized.”

Still, ferrying around patients is not for every ride-hail driver. Damian Durand said his Chevrolet Equinox SUV is large enough to accommodate a medical passenger requiring a wheelchair, but he isn’t paid extra to transport those with medical needs. He said some of his recent passengers in Atlanta have been Medicaid recipients with mental health conditions or disabilities.

“It can be stressful,” he said. “I do feel like Uber and Lyft are trying to catch me off guard. When I can see that the ride is going to the hospital, I try to avoid or cancel the ride.”

While Durand’s experience with medical transport has been mostly negative, Carr loves the work and appreciates being able to help older Georgians, who she said often tip her well. For her, ride-hail work remains a good option even when it entails medical calls.

“It’s not stressful for me,” she said. “I worked a good 20 years in customer service. For me, human connection is important. I tried to work from home, and I really didn’t like it. I prefer this because I can connect with people.”

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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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.”

The clinic, called the UniMóvil, is part of the Healthy Mujeres program at the University of Texas Rio Grande Valley School of Medicine.

The U.S. has about 3,000 mobile health programs. But Saul Rivas, an OB-GYN, said he wasn’t aware of any that shared the specific mission of Healthy Mujeres when he helped launch the initiative in 2017. “Mujeres” means “women” in Spanish.

It’s now part of a small but growing number of mobile programs aimed at increasing rural access to women’s health services, including long-acting reversible contraception.

There are two kinds of these highly effective methods: intrauterine devices, known as IUDs, and hormonal implants inserted into the upper arm. These birth control options can be especially difficult to obtain — or have removed — in rural areas.

“Women who want to prevent an unintended pregnancy should have whatever works best for them,” said Kelly Conroy, senior director of mobile and maternal health programs at the University of Arkansas for Medical Sciences.

The school is launching a mobile women’s health and contraception program in rural parts of the state this month.

Rural areas have disproportionately fewer doctors, including OB-GYNs, than urban areas. And rural providers may not be able to afford to stock long-acting birth control devices or may not be trained in administering them, program leaders say.

Mobile clinics help shrink that gap in rural care, but they can be challenging to operate, said Elizabeth Jones, a senior director at the National Family Planning & Reproductive Health Association.

Money is the greatest obstacle, Jones said. The Texas program costs up to $400,000 a year. A 2020 study of 173 mobile clinics found they cost an average of more than $630,000 a year. Mobile dental programs were the most expensive, averaging more than $1 million.

While many programs launch with the help of grants, they can be difficult to sustain, especially with over a decade of decreased or stagnant funding to Title X, a federal money stream that helps low-income people receive family planning services.

For example, a mobile contraception program serving rural Pennsylvania lasted less than three years before closing in 2023. It shut down after losing federal funding, said a spokesperson for the clinic that ran it.

Rural mobile programs aren’t as efficient or profitable as brick-and-mortar clinics. That’s because staff members may have to make hours-long trips to reach towns where they’ll probably see fewer patients than they would at a traditional site, Jones said.

She said organizations that can’t afford mobile programs can consider setting up “pop-up clinics” at existing health and community sites in rural areas.

Maria Briones is a patient who has benefited from the Healthy Mujeres program in southern Texas. The 41-year-old day care worker was concerned because she wasn’t getting her menstrual period with her IUD.

She considered going to Mexico to have the device removed because few doctors take her insurance on the U.S. side of the Rio Grande Valley.

But Briones learned that the UniMóvil was visiting a small Texas city about 20 minutes from her home. She told the staff there that she doesn’t want more kids but was worried about the IUD.

Briones decided to keep the device after learning it’s safe and normal not to have periods while using an IUD. She won’t get billed for her appointment with the mobile clinic, even though the university health system doesn’t take her insurance.

“They have a lot of patience, and they answered all the questions that I had,” Briones said.

IUDs and hormonal implants are highly effective and can last up to 10 years. But they’re also expensive — devices can cost more than $1,000 without insurance — and inserting an IUD can be painful.

Patient-rights advocates are also concerned that some providers pressure people to use these devices.

They say ethical birth control programs aim to empower patients to choose the contraceptive method — if any — that is best for them, instead of promoting long-acting methods in an attempt to lower birth and poverty rates. They point to the history of eugenics-inspired sterilization and even more recent incidents.

For example, an investigation by Time magazine found doctors are more likely to push Black, Latina, young, and low-income women than other patients to use long-acting birth control — and to refuse to remove the devices.

Rivas said Healthy Mujeres staffers are trained on this issue.

“Our goal isn’t necessarily to place IUDs and implants,” he said. It’s to “provide education and help patients make the best decisions for themselves.”

David Wise, a spokesperson for the University of Arkansas for Medical Sciences, said staff members with the university’s mobile program will ask patients if they want to get pregnant in the next year, and will support their choice. The Arkansas and Texas programs also remove IUDs and hormonal arm implants if patients aren’t happy with them.

The Arkansas initiative will visit 14 rural counties with four vehicles the size of food trucks that were used in previous mobile health efforts. Staffing and equipment will be covered by a two-year, $431,000 grant from an anonymous donor, Wise said.

In addition to contraception, faculty and medical residents staffing the vehicles will offer women’s health screenings, vaccinations, prenatal care, and testing and treatment for sexually transmitted infections.

Rivas said the Texas program was inspired by a study that found that, six months after giving birth, 34% of surveyed Texas mothers said long-acting contraception is their preferred birth control option — but only 13% were using that method.

“We started thinking about ways to address that gap,” Rivas said.

Healthy Mujeres, which is funded through multiple grants, started with a focus on contraception. It later expanded to services such as pregnancy ultrasounds, cervical cancer screenings, and testing for sexually transmitted infections.

While the Texas and Arkansas programs can bill insurance, they also have funding to help uninsured and underinsured patients afford their services. Both use community health workers — called promotoras in largely Spanish-speaking communities like the Rio Grande Valley — to connect patients with food, transportation, additional medical services, and other needs.

They partner with organizations that locals trust, such as food pantries and community colleges, which let the mobile units set up in their parking lots. And to further increase the availability of long-acting contraception in rural areas, the universities are training their students and local providers on how to insert, remove, and get reimbursed for the devices.

One difference between the programs is dictated by state laws. The Arkansas program can provide birth control to minors without a parent or guardian’s consent. But in Texas, most minors need consent before receiving health care, including contraception.

Advocates say these initiatives might help lower the rates of unintended and teen pregnancies in both states, which are higher than the national average.

Rivas and Conroy said their programs haven’t received much pushback. But Rivas said some churches that had asked the UniMóvil to visit their congregations changed their minds after learning the services included birth control.

Catherine Phillips, director of the Respect Life Office at Arkansas’ Catholic diocese, said the diocese supports efforts to achieve health care equity and she’s personally interested in mobile programs that visit rural areas such as where she lives.

But Phillips said the Arkansas program’s focus on birth control, especially long-acting methods, violates the teachings of the Catholic Church. Offering these services to minors without parental consent “makes it more egregious,” she said.

Jones said that, while these programs have hefty costs and other challenges, they also have benefits that can’t be measured in numbers.

“Building community trust and making an impact in the communities most impacted by health inequities — that’s invaluable,” she said.

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

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And they see the vice president and Democratic nominee as the best hope for preserving Americans’ access to health insurance. Comprehensive coverage that limits patients’ out-of-pocket costs offers the best defense against going into debt, experts say.

The Biden administration has expanded financial protections for patients, including a landmark proposal by the Consumer Financial Protection Bureau to remove medical debt from consumer credit reports.

In 2022, President Joe Biden also signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35-a-month cap on insulin. And in statehouses across the country, Democrats and Republicans have been quietly working together to enact laws to rein in debt collectors.

But advocates say the federal government could do more to address a problem that burdens 100 million Americans, forcing many to take on extra work, give up their homes, and cut spending on food and other essentials.

“Biden and Harris have done more to tackle the medical debt crisis in this country than any other administration,” said Mona Shah, senior director of policy and strategy at Community Catalyst, a nonprofit that has led national efforts to strengthen protections against medical debt. “But there is more that needs to be done and should be a top priority for the next Congress and administration.”

At the same time, patient advocates fear that if former President Donald Trump wins a second term, he will weaken insurance protections by allowing states to cut their Medicaid programs or by scaling back federal aid to help Americans buy health insurance. That would put millions of people at greater risk of sinking into debt if they get sick.

In his first term, Trump and congressional Republicans in 2017 tried to repeal the Affordable Care Act, a move that independent analysts concluded would have stripped health coverage from millions of Americans and driven up costs for people with preexisting medical conditions, such as diabetes and cancer.

Trump and his GOP allies continue to attack the ACA, and the former president has said he wants to roll back the Inflation Reduction Act, which also includes aid to help low- and middle-income Americans buy health insurance.

“People will face a wave of medical debt from paying premiums and prescription drug prices,” said Anthony Wright, executive director of Families USA, a consumer group that has backed federal health protections. “Patients and the public should be concerned.”

The Trump campaign did not respond to inquiries about its health care agenda. And the former president doesn’t typically discuss health care or medical debt on the campaign trail, though he said at last month’s debate he had “concepts of a plan” to improve the ACA. Trump hasn’t offered specifics.

Harris has repeatedly pledged to protect the ACA and renew expanded subsidies for monthly insurance premiums created by the Inflation Reduction Act. That aid is slated to expire next year.

The vice president has also voiced support for more government spending to buy and retire old medical debts for patients. In recent years, a number of states and cities have purchased medical debt on behalf of their residents.

These efforts have relieved debt for hundreds of thousands of people, though many patient and consumer advocates say retiring old debt is at best a short-term solution, as patients will continue to run up bills they cannot pay without more substantive action.

“It’s a boat with a hole in it,” said Katie Berge, a lobbyist for the Leukemia & Lymphoma Society. The patient group was among more than 50 organizations that last year sent letters to the Biden administration urging federal agencies to take more aggressive steps to protect Americans from medical debt.

“Medical debt is no longer a niche issue,” said Kirsten Sloan, who works on federal policy for the American Cancer Society’s Cancer Action Network. “It is key to the economic well-being of millions of Americans.”

The Consumer Financial Protection Bureau is developing regulations that would bar medical bills from consumer credit reports, which would boost credit scores and make it easier for millions of Americans to rent an apartment, get a job, or secure a car loan.

Harris, who has called medical debt “critical to the financial health and well-being of millions of Americans,” enthusiastically backed the proposed rule. “No one should be denied access to economic opportunity simply because they experienced a medical emergency,” she said in June.

Harris’ running mate, Minnesota Gov. Tim Walz, who has said his own family struggled with medical debt when he was young, signed a state law in June cracking down on debt collection.

CFPB officials said the regulations would be finalized early next year. Trump hasn’t indicated if he’d follow through on the medical debt protections. In his first term, the CFPB did little to address medical debt, and congressional Republicans have long criticized the regulatory agency.

If Harris prevails, many consumer groups want the CFPB to crack down even further, including tightening oversight of medical credit cards and other financial products that hospitals and other medical providers have started pushing on patients. These loans lock people into interest payments on top of their medical debt.

“We are seeing a variety of new medical financial products,” said April Kuehnhoff, a senior attorney at the National Consumer Law Center. “These can raise new concerns about consumer protections, and it is critical for the CFPB and other regulators to monitor these companies.”

Some advocates want other federal agencies to get involved, as well.

This includes the mammoth Health and Human Services department, which controls hundreds of billions of dollars through the Medicare and Medicaid programs. That money gives the federal government enormous leverage over hospitals and other medical providers.

Thus far, the Biden administration hasn’t used that leverage to tackle medical debt.

But in a potential preview of future actions, state leaders in North Carolina recently won federal approval for a medical debt initiative that will make hospitals take steps to alleviate patient debts in exchange for government aid. Harris praised the initiative.

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April 18

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It seemed clear they had some type of cognitive impairment. Yet they were living alone.

Portacolone, an associate professor at the University of California-San Francisco, wondered how common this was. Had anyone examined this group? How were they managing?

When she reviewed the research literature more than a decade ago, there was little there. “I realized this is a largely invisible population,” she said.

Portacolone got to work and now leads the Living Alone With Cognitive Impairment Project at UCSF. The project estimates that that at least 4.3 million people 55 or older who have cognitive impairment or dementia live alone in the United States.

About half have trouble with daily activities such as bathing, eating, cooking, shopping, taking medications, and managing money, according to their research. But only 1 in 3 received help with at least one such activity.

Compared with other older adults who live by themselves, people living alone with cognitive impairment are older, more likely to be women, and disproportionately Black or Latino, with lower levels of education, wealth, and homeownership. Yet only 21% qualify for publicly funded programs such as Medicaid that pay for aides to provide services in the home.

In a health care system that assumes older adults have family caregivers to help them, “we realized this population is destined to fall through the cracks,” Portacolone said.

Imagine what this means. As memory and thinking problems accelerate, these seniors can lose track of bills, have their electricity shut off, or be threatened with eviction. They might stop shopping (it’s too overwhelming) or cooking (it’s too hard to follow recipes). Or they might be unable to communicate clearly or navigate automated phone systems.

A variety of other problems can ensue, including social isolation, malnutrition, self-neglect, and susceptibility to scams. Without someone to watch over them, older adults on their own may experience worsening health without anyone noticing or struggle with dementia without ever being diagnosed.

Should vulnerable seniors live this way?

For years, Portacolone and her collaborators nationwide have followed nearly 100 older adults with cognitive impairment who live alone. She listed some concerns people told researchers they worried most about: “Who do I trust? When is the next time I’m going to forget? If I think I need more help, where do I find it? How do I hide my forgetfulness?”

Jane Lowers, an assistant professor at the Emory University School of Medicine, has been studying “kinless” adults in the early stages of dementia — those without a live-in partner or children nearby. Their top priority, she told me, is “remaining independent for as long as possible.”

Seeking to learn more about these seniors’ experiences, I contacted the National Council of Dementia Minds. The organization last year started a biweekly online group for people living alone with dementia. Its staffers arranged a Zoom conversation with five people, all with early-to-moderate dementia.

One was Kathleen Healy, 60, who has significant memory problems and lives alone in Fresno, California.

“One of the biggest challenges is that people don’t really see what’s going on with you,” she said. “Let’s say my house is a mess or I’m sick or I’m losing track of my bills. If I can get myself together, I can walk out the door and nobody knows what’s going on.”

An administrator with the city of Fresno for 28 years, Healy said she had to retire in 2019 “because my brain stopped working.” With her pension, she’s able to cover her expenses, but she doesn’t have significant savings or assets.

Healy said she can’t rely on family members who have troubles of their own. (Her 83-year-old mother has dementia and lives with Healy’s sister.) The person who checks on her most frequently is an ex-boyfriend.

“I don’t really have anybody,” she said, choking up.

David West, 62, is a divorced former social worker with Lewy body dementia, which can impair thinking and concentration and cause hallucinations. He lives alone in an apartment in downtown Fort Worth, Texas.

“I will not survive this in the end — I know that — but I’m going to meet this with resilience,” he said when I spoke with him by phone in June.

Since his diagnosis nearly three years ago, West has filled his life with exercise and joined three dementia support groups. He spends up to 20 hours a week volunteering, at a restaurant, a food bank, a museum, and Dementia Friendly Fort Worth.

Still, West knows that his illness will progress and that this period of relative independence is limited. What will he do then? Although he has three adult children, he said, he can’t expect them to take him in and become dementia caregivers — an extraordinarily stressful, time-intensive, financially draining commitment.

“I don’t know how it’s going to work out,” he said.

Denise Baker, 80, a former CIA analyst, lives in a 100-year-old house in Asheville, North Carolina, with her dog, Yolo. She has cognitive problems related to a stroke 28 years ago, Alzheimer’s disease, and serious vision impairment that prevents her from driving. Her adult daughters live in Massachusetts and Colorado.

“I’m a very independent person, and I find that I want to do everything I possibly can for myself,” Baker told me, months before Asheville was ravaged by severe flooding. “It makes me feel better about myself.”

She was lucky in the aftermath of Hurricane Helene: Baker lives on a hill in West Asheville that was untouched by floodwaters. In the week immediately after the storm, she filled water jugs every day at an old well near her house and brought them back in a wheelbarrow.  Though her power was out, she had plenty of food and neighbors looked in on her. 

“I’m absolutely fine,” she told me on the phone in early October after a member of Dementia Friendly Western North Carolina drove to Baker’s house to check in on her, upon my request. Baker is on the steering committee of that organization.

Baker once found it hard to ask for assistance, but these days she relies routinely on friends and hired help. A few examples: Elaine takes her grocery shopping every Monday. Roberta comes once a month to help with her mail and finances. Jack mows her lawn. Helen offers care management advice. Tom, a cab driver she connected with through Buncombe County’s transportation program for seniors, is her go-to guy for errands.

Her daughter Karen in Boston has the authority to make legal and health care decisions when Baker can no longer do so. When that day comes — and Baker knows it will — she expects her long-term care insurance policy to pay for home aides or memory care. Until then, “I plan to do as much as I can in the state I’m in,” she said.

Much can be done to better assist older adults with dementia who are on their own, said Elizabeth Gould, co-director of the National Alzheimer’s and Dementia Resource Center at RTI International, a nonprofit research institute. “If health care providers would just ask ‘Who do you live with?’” she said, “that could open the door to identifying who might need more help.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.