patient

In recent months, federal agents camped out in the lobby of a Southern California hospital, guarded detained patients — sometimes shackled — in hospital rooms, and chased an immigrant landscaper into a surgical center.

U.S. Immigration and Customs Enforcement agents also have shown up at community clinics. Health providers say officers tried to enter a parking lot hosting a mobile clinic, waved a machine gun in the faces of clinicians serving the homeless, and hauled a passerby into an unmarked car outside a community health center.

In response to such immigration enforcement activity in and around clinics and hospitals, Gov. Gavin Newsom last month signed SB 81, which prohibits medical establishments from allowing federal agents without a valid search warrant or court order into private areas, including places where patients receive treatment or discuss health matters.

But while the bill received broad support from medical groups, health care workers and immigrant rights advocates, legal experts say California can’t stop federal authorities from carrying out duties in public places like hospital lobbies and general waiting areas, parking lots and surrounding neighborhoods — places where recent ICE activities sparked outrage and fear. Previous federal restrictions on immigration enforcement in or near sensitive areas, including health care establishments, were rescinded by the Trump administration in January.

“The issue that states encounter is the supremacy clause,” said Sophia Genovese, a supervising attorney and clinical teaching fellow at Georgetown Law. She said the federal government has the right to conduct enforcement activities, and there are limits to what the state can do to stop them.

California’s law designates a patient’s immigration status and birthplace as protected information, which like medical records cannot be disclosed to law enforcement without a warrant or court order. And it requires health care facilities to have clear procedures for handling requests from immigration authorities, including training staff to immediately notify a designated administrator or legal counsel if agents ask to enter a private area or review patient records.

Several other Democratic-led states also have taken up legislation to protect patients at hospitals and health centers. In May, Colorado Gov. Jared Polis signed the Protect Civil Rights Immigration Status bill, which penalizes hospitals for unauthorized sharing of information about people in the country illegally and bars ICE agents from entering private areas of health care facilities without a judicial warrant. In Maryland, a law requiring the attorney general to create guidance on keeping ICE out of health care facilities went into effect in June. New Mexico instituted new patient data protections, and Rhode Island prohibited health care facilities from asking patients about their immigration status.

Republican-led states have aligned with federal efforts to prevent health care spending on immigrants without legal authorization. Such immigrants are not eligible for comprehensive Medicaid coverage, but states do bill the federal government for emergency care in certain cases. Under a law that took effect in 2023, Florida requires hospitals that accept Medicaid to ask about a patient’s legal status. In Texas, hospitals now have to report how much they spend on care for immigrants without legal authorization.

“Texans should not have to shoulder the burden of financially supporting medical care for illegal immigrants,” Gov. Greg Abbott said in issuing his executive order last year.

California’s efforts to rein in federal enforcement come as the state, where more than a quarter of residents are foreign-born, has become a target of President Trump’s immigration crackdown. Newsom signed SB 81 as part of a bill package prohibiting immigration agents from entering schools without a warrant, requiring law enforcement officers to identify themselves, and banning officers from wearing masks. SB 81 was passed on a party-line vote with no formal opposition.

“We’re not North Korea,” Newsom said during a September bill-signing ceremony. “We’re pushing back against these authoritarian tendencies and actions of this administration.”

Some supporters of the bill and legal experts said California’s law can prevent ICE from violating existing patient privacy rights. Those include the Fourth Amendment, which prohibits searches without a warrant in places where people have a reasonable expectation of privacy. Valid warrants must be issued by a court and signed by a judge. But ICE agents frequently use administrative warrants to try to gain access to private areas they don’t have the authority to enter, Genovese said.

“People don’t always understand the difference between an administrative warrant, which is a meaningless piece of paper, versus a judicial warrant that is enforceable,” Genovese said. Judicial warrants are rarely issued in immigration cases, she added.

The Department of Homeland Security said it won’t abide by California’s mask ban or identification requirements for law enforcement officers, slamming them as unconstitutional. The department did not respond to a request for comment on the state’s new rules for health care facilities, which went into immediate effect.

Tanya Broder, a senior counsel with the National Immigration Law Center, said immigration arrests at health care facilities appear to be relatively rare. But the federal decision to rescind protections around sensitive areas, she said, “has generated fear and uncertainty across the country.” Many of the most high-profile news reports of immigration agents at health care facilities have been in California, largely involving detained patients brought in for care.

The California Nurses Assn., the state’s largest nurses union, was a co-sponsor of the bill and raised concerns about the treatment of Milagro Solis-Portillo, a 36-year-old Salvadoran woman who was under round-the-clock ICE surveillance at Glendale Memorial Hospital over the summer.

Nurses say immigration agents brought a patient to California Hospital Medical Center in Los Angeles and stayed in the patient’s room for almost a week.

(Mel Melcon/Los Angeles Times)

Union leaders also condemned the presence of agents at California Hospital Medical Center south of downtown Los Angeles. According to Anne Caputo-Pearl, a labor and delivery nurse and the chief union representative at the hospital, agents brought in a patient on Oct. 21 and remained in the patient’s room for almost a week. The Los Angeles Times reported that a TikTok streamer, Carlitos Ricardo Parias, was taken to the hospital that day after he was wounded during an immigration enforcement operation in South Los Angeles.

The presence of ICE was intimidating for nurses and patients, Caputo-Pearl said, and prompted visitor restrictions at the hospital. “We want better clarification,” she said. “Why is it that these agents are allowed to be in the room?”

Hospital and clinic representatives, however, said they already are following the law’s requirements, which largely reinforce extensive guidance put out by state Attorney General Rob Bonta in December.

Community clinics throughout Los Angeles County, which serve more than 2 million patients a year, including a large portion of immigrants, have been implementing the attorney general’s guidelines for months, said Louise McCarthy, president and chief executive of the Community Clinic Assn. of Los Angeles County. She said the law should help ensure uniform standards across health facilities that clinics refer out to and reassure patients that procedures are in place to protect them.

Still, it can’t prevent immigration raids from happening in the broader community, which have made some patients and even health workers afraid to venture outside, McCarthy said. Some incidents have occurred near clinics, including an arrest of a passerby outside a clinic in East Los Angeles, which a security guard caught on video, she said.

“We’ve had clinic staff say, ‘Is it safe for me to go out?’” she said.

At St. John’s Community Health, a network of 24 community health centers and five mobile clinics in South Los Angeles and the Inland Empire, chief executive Jim Mangia agreed the new law can’t prevent all immigration enforcement activity, but said it gives clinics a tool to push back with if agents show up, something his staff has had to do.

Mangia said St. John’s staff had two encounters with immigration agents over the summer. In one, he said, staff stopped armed officers from entering a gated parking lot at a drug and alcohol recovery center where doctors and nurses were seeing patients at a mobile health clinic.

Another occurred in July, when immigration agents descended upon MacArthur Park on horses and in armored vehicles, in a show of force by the Trump administration. Mangia said masked officers in full tactical gear surrounded a street medicine tent where St. John’s providers were tending to homeless patients, screamed at staff to get out and pointed a gun at them. The providers were so shaken by the episode, Mangia said, that he had to bring in mental health professionals to help them feel safe going back out on the street.

A DHS spokesperson told CalMatters that in the rare instance when agents enter certain sensitive locations, officers would need “secondary supervisor approval.”

Since then, St. John’s doubled down on providing support and training to staff and offered patients afraid to go out the option of home medical visits and grocery deliveries. Patient fears and ICE activity have decreased since the summer, Mangia said, but with DHS planning to hire an additional 10,000 ICE agents, he doubts that will last.

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 — the independent source for health policy research, polling, and journalism.

Pregnancy centers in the U.S. that discourage women from getting abortions have been adding more medical services — and could be poised to expand further.

The expansion — including testing and treatment for sexually transmitted infections (STIs) and even providing primary medical care — has been unfolding for years. It gained steam after the Supreme Court overturned Roe vs. Wade three years ago, clearing the way for states to ban abortion.

The push could get more momentum with Planned Parenthood closing some clinics and considering shutting others after changes to Medicaid. Planned Parenthood is not just the nation’s largest abortion provider, but also offers cancer screenings, sexually transmitted infection testing and treatment, and other reproductive health services.

“We ultimately want to replace Planned Parenthood with the services we offer,” said Heather Lawless, founder and director of Reliance Center in Lewiston, Idaho. She said about 40% of patients at the antiabortion center are there for reasons unrelated to pregnancy, including some who use the nurse practitioner as a primary caregiver.

The changes have frustrated abortion rights groups, who, in addition to opposing the centers’ antiabortion messaging, say they lack accountability; refuse to provide birth control; and offer only limited ultrasounds that cannot be used for diagnosing fetal anomalies because the people conducting them don’t have that training. A growing number also offer unproven abortion-pill reversal treatments.

Because most of the centers don’t accept insurance, the federal law restricting release of medical information doesn’t apply to them, though some say they follow it anyway. They also don’t have to follow standards required by Medicaid or private insurers, though those offering certain services generally must have medical directors who comply with state licensing requirements.

“There are really bedrock questions about whether this industry has the clinical infrastructure to provide the medical services it’s currently advertising,” said Jennifer McKenna, a senior advisor for Reproductive Health and Freedom Watch, a project funded by liberal policy organizations that researches the pregnancy centers.

Post-Roe world opened new opportunities

Perhaps best known as “crisis pregnancy centers,” these mostly privately funded and religiously affiliated centers were expanding services such as diaper banks ahead of the Supreme Court’s 2022 Dobbs vs. Jackson Women’s Health Organization ruling, which overturned Roe.

As abortion bans kicked in, the centers expanded medical, educational and other programs, said Moira Gaul, a scholar at the Charlotte Lozier Institute, the research arm of SBA Pro-Life America. “They are prepared to serve their communities for the long term,” she said in a statement.

In Sacramento, for instance, Alternatives Pregnancy Center in the last two years has added family practice doctors, a radiologist and a specialist in high-risk pregnancies, along with nurses and medical assistants. Alternatives — an affiliate of Heartbeat International, one of the largest associations of pregnancy centers in the U.S. — is some patients’ only health provider.

When the Associated Press asked to interview a patient who had received only non-pregnancy services, the clinic provided Jessica Rose, a 31-year-old woman who took the rare step of detransitioning after spending seven years living as a man, during which she received hormone therapy and a double mastectomy.

For the last two years, she’s received all her medical care at Alternatives, which has an OB-GYN who specializes in hormone therapy. Few, if any, pregnancy centers advertise that they provide help with detransitioning. Alternatives has treated four similar patients over the last year, though that’s not its main mission, director Heidi Matzke said.

“APC provided me a space that aligned with my beliefs as well as seeing me as a woman,” Rose said. She said other clinics “were trying to make me think that detransitioning wasn’t what I wanted to do.”

Pregnancy centers expand as health clinics decline

As of 2024, more than 2,600 antiabortion pregnancy centers operated in the U.S., up 87 from 2023, according to the Crisis Pregnancy Center Map, a project led by University of Georgia public health researchers who are concerned about aspects of the centers. According to the Guttmacher Institute, 765 clinics offered abortions last year, down more than 40 from 2023.

Over the years, pregnancy centers have received a boost in taxpayer funds. Nearly 20 states, largely Republican-led, now funnel millions of public dollars to these organizations. Texas alone sent $70 million to pregnancy centers this fiscal year, while Florida dedicated more than $29 million for its “Pregnancy Support Services Program.”

This boost in resources is unfolding as Republicans have barred Planned Parenthood from receiving Medicaid funds under the tax and spending law President Trump signed in July. While federal law already blocked the use of taxpayer funds for most abortions, Medicaid reimbursements for other health services were a big part of Planned Parenthood’s revenue.

Planned Parenthood said its affiliates could be forced to close up to 200 clinics.

Some already had closed or reorganized. They have cut abortion in Wisconsin and eliminated Medicaid services in Arizona. An independent group of clinics in Maine stopped primary care for the same reason. The uncertainty is compounded by pending Medicaid changes expected to result in more uninsured Americans.

Some abortion rights advocates worry that will mean more healthcare “deserts” where the pregnancy centers are the only option for more women.

Kaitlyn Joshua, a founder of abortion rights group Abortion in America, lives in Louisiana, where Planned Parenthood closed its clinics in September.

She’s concerned that women seeking health services at pregnancy centers as a result of those closures won’t get what they need. “Those centers should be regulated,” she said. “They should be providing information which is accurate, rather than just getting a sermon that they didn’t ask for.”

Thomas Glessner, founder and president of the National Institute of Family and Life Advocates, a network of 1,800 centers, said the centers do have government oversight through their medical directors. “Their criticism,” he said, “comes from a political agenda.”

In recent years, five Democratic state attorneys general have issued warnings that the centers, which advertise to people seeking abortions, don’t provide them and don’t refer patients to clinics that do. And the Supreme Court has agreed to consider whether a state investigation of an organization that runs centers in New Jersey stifles its free speech.

Different services than Planned Parenthood

Choices Medical Services in Joplin, Mo., where the Planned Parenthood clinic closed last year, moved from focusing solely on discouraging abortion to a broader sexual health mission about 20 years ago when it began offering STI treatment, said its executive director, Karolyn Schrage.

The center, funded by donors, works with law enforcement in places where authorities may find pregnant adults, according to Schrage and Arkansas State Police.

Schrage estimates that more than two-thirds of its work isn’t related to pregnancy.

Hayley Kelly first encountered Choices volunteers in 2019 at a regular weekly dinner they brought to dancers at the strip club where she worked. Over the years, she went to the center for STI testing. Then in 2023, when she was uninsured and struggling with drugs, she wanted to confirm a pregnancy.

She anticipated the staff wouldn’t like that she was leaning toward an abortion, but she says they just answered questions. She ended up having that baby and, later, another.

“It’s amazing place,” Kelly said. “I tell everybody I know, ‘You can go there.’”

The center, like others, does not provide contraceptives — standard offerings at sexual health clinics that experts say are best practices for public health.

“Our focus is on sexual risk elimination,” Schrage said, “not just reduction.”

Mulvihill and Kruesi write for the Associated Press.

Barring new cases, the patient’s recovery kicks off a 42-day countdown to declaring the country’s 16th outbreak over.

The last Ebola patient in the Democratic Republic of the Congo (DRC) has been released from a treatment centre in Kasai province, according to the United Nations health agency.

The patient is the 19th to recover out of 64 total cases recorded since the outbreak was declared in September, the World Health Organization (WHO) said in a statement on Sunday.

If no new cases are discovered in the next 42 days, the outbreak will be declared over.

Mohamed Janabi, the WHO’s director for Africa, said the recovery was a “remarkable achievement”, given the outbreak began just six weeks ago.

“The country’s robust response, with support from WHO and partners, was pivotal to this achievement,” he added in a social media post.

In a video alongside the post on X, health workers were seen celebrating as the final patient exited the treatment centre in Bulape.

Today, the last #Ebola patient in Bulape, #DRC was discharged from the treatment centre.

The country’s robust response, with support from WHO and partners, was pivotal to this achievement. A 42-day countdown to declare the outbreak over has now begun.

Until then, @WHO and… pic.twitter.com/YTEpGzYwPW

— Prof. Mohamed Janabi (@ProfJanabi) October 19, 2025

The outbreak, which is the DRC’s 16th to date, was declared on September 4 as Ebola cases appeared in the Bulape and Mweka areas of the Kasai province in the country’s southwest.

Since then, the WHO has tallied 53 confirmed and 11 probable cases, with patients showing typical Ebola symptoms such as fever, vomiting, diarrhoea and haemorrhaging. Forty-five people have died.

The remote Kasai province has proven challenging to reach, even as it may have helped to prevent the spread of the virus, health officials have said.

Still, the WHO deployed response teams and set up a 32-bed treatment centre for the first time “outside a simulation exercise” in the region, the organisation said. More than 35,000 people have received vaccinations in the Bulape area.

No new cases have been identified since September 25.

Ebola was first identified in 1976 after an outbreak in what is now the DRC. Without treatment, up to 90 percent of cases are fatal, according to the US Centers for Disease Control and Prevention.

The largest outbreak occurred from 2014 to 2016 in West Africa, ultimately infecting 28,600 and killing 11,325 people, with the disease also spreading to Europe and the United States.

The DRC’s most recent outbreak occurred in 2022 and involved just one recorded case of the virus.

This is an uncertain world and there are very few sure things. As Ben Franklin once observed, “nothing is certain except death and taxes.” But I think investors can almost add a third thing to that item — the trusty real estate dividend stock Realty Income (O 1.10%) and its ability to keep paying investors, no matter what the market looks like.

Realty Income is perhaps the most reliable dividend stock you can find. And it’s a well-deserved mantle. Realty Income just declared its 664th consecutive monthly dividend since the company was founded in 1969 — a streak that goes back more than 55 years. The company has also increased its dividend 132 times in that period, giving Realty Income shareholders a rare blend of growth and income.

This California-based real estate investment trust (REIT), is a no-brainer dividend stock to buy, and is a perfect investment for anyone looking to build their dividend portfolio over a long period of time.

About Realty Income

Realty Income is based in California, but it has a massive presence. The company has 15,600 commercial properties, located in every U.S. state and much of Europe. Realty Income’s customers represent 91 separate industries and include more than 1,600 clients.

And most importantly, the company’s portfolio has an occupancy rate of 98.5% — meaning that Realty Income is assured of a consistent revenue stream. That’s how it can afford to pay a consistent, reliable monthly dividend. Industries the company leases property to include grocery stores, convenience stores, home improvement stores, dollar stores, restaurants, drug stores, health and fitness centers, and more.

The company also diversifies its portfolio, which means a catastrophic failure in an industry or by a single business won’t hurt its operations. Convenience store chain 7-Eleven is the biggest tenant  for Realty Income, and even then it’s only a 3.4% weighting.

Data source: Realty Income. Data as of June 30, 2025. 

Realty Income stock performance

Unsurprisingly, real estate stocks haven’t done well for much of the year. The S&P 500 real estate sector as a whole is up only 4%, thanks to the weak housing market and high interest rates that make borrowing more expensive. But Realty Income has been able to shake off those pressures. The stock is up 11% on the year, and when you calculate the total return of reinvesting dividend payments, the return is more than 15%.

O data by YCharts

The company recorded $1.41 billion in revenue in the second quarter, up from $1.34 billion a year ago. Income was down, however, thanks to borrowing costs — the company recorded $196.9 million and $0.22 per share versus $256.8 million and $0.29 per share a year ago.

Realty Income lowered its full-year guidance, with net income now expected to be $1.29 to $1.33 per share, from previous guidance of $1.40 to $1.46 per share.

Image source: Getty Images.

The case for Realty Income

There’s nothing flashy about this stock. But that’s fine — not everything in your portfolio needs to be a shiny new toy. Realty Income’s strength comes with its consistency and long-term growth window.

An investment 10 years ago in Realty Income would give you $20,270 today, assuming that you reinvested all those dividends back into your stock. Had you pocketed the money, you’d still have $12,880 — which all goes to show the power of compound interest.

O data by YCharts

And remember, because Realty Income is a REIT, it’s required by law to disburse 90% of its profits back to shareholders (the current yield is 5.4%). Because it’s a monthly payout instead of a quarterly check, investors get the proceeds quicker, and those funds can work for them rather than working for Realty Income.

If you are an income investor, you really can’t beat Realty Income for its business plan, diversification, and combination of growth and income. If you are a patient investor with a long-term view, Realty Income is a perfect dividend stock.

California Gov. Gavin Newsom this week signed a suite of privacy protection bills for transgender patients amid continuing threats by the Trump administration.

But there was one glaring omission that LGBTQ+ advocates and political strategists say is part of an increasingly complex dance the Democrat faces as he curates a more centrist profile for a potential presidential bid.

Newsom vetoed a bill that would have required insurers to cover, and pharmacists to dispense, 12 months of hormone therapy at one time to transgender patients and others. The proposal was a top priority for trans rights leaders, who said it was crucial to preserve care as clinics close or limit gender-affirming services under White House pressure.

Political experts say Newsom’s veto highlights how charged trans care has become for Democrats nationally and, in particular, for Newsom, who as San Francisco mayor engaged in civil disobedience by allowing gay couples to marry at City Hall. The veto, along with his lukewarm response to anti-trans rhetoric, they argue, is part of an alarming pattern that could damage his credibility with key voters in his base.

“Even if there were no political motivations whatsoever under Newsom’s decision, there are certainly political ramifications of which he is very aware,” said Dan Schnur, a former GOP political strategist who is now a politics lecturer at the University of California-Berkeley. “He is smart enough to know that this is an issue that’s going to anger his base, but in return, may make him more acceptable to large numbers of swing voters.”

Earlier this year on Newsom’s podcast, the governor told the late conservative activist Charlie Kirk that trans athletes competing in women’s sports was “deeply unfair,” triggering a backlash among his party’s base and LGBTQ+ leaders. And he has described trans issues as a “major problem for the Democratic Party,” saying Donald Trump’s trans-focused campaign ads were “devastating” for his party in 2024.

Still, in a conversation with YouTube streamer ConnorEatsPants this month, Newsom defended himself “as a guy who’s literally put my political life on the line for the community for decades, has been a champion and a leader.”

“He doesn’t want to face the criticism as someone who, I’m sure, is trying to line himself up for the presidency, when the current anti-trans rhetoric is so loud,” said Ariela Cuellar, a spokesperson for the California LGBTQ Health and Human Services Network.

Caroline Menjivar, the state senator who introduced the measure, described her bill as “the most tangible and effective” measure this year to help trans people at a time when they are being singled out for what she described as “targeted discrimination.”

In a legislature in which Democrats hold supermajorities in both houses, lawmakers sent the bill to Newsom on a party-line vote. Earlier this year, Washington became the first to enact a state law extending hormone therapy coverage to a 12-month supply.

In a veto message on the California bill, Newsom cited its potential to drive up health care costs, impacts that an independent analysis found would be negligible.

“At a time when individuals are facing double-digit rate increases in their health care premiums across the nation, we must take great care to not enact policies that further drive up the cost of health care, no matter how well-intended,” Newsom wrote.

Under the Trump administration, federal agencies have been directed to limit access to gender-affirming care for children, which Trump has referred to as “chemical and surgical mutilation,” and demanded documents from or threatened investigations of institutions that provide it.

In recent months, Stanford Medicine, Children’s Hospital Los Angeles, and Kaiser Permanente have reduced or eliminated gender-affirming care for patients under 19, a sign of the chilling effect Trump’s executive orders have had on health care, even in one of the nation’s most progressive states.

California already mandates wide coverage of gender-affirming health care, including hormone therapy, but pharmacists can currently dispense only a 90-day supply. Menjivar’s bill would have allowed 12-month supplies, modeled after a 2016 law that allowed women to receive an annual supply of birth control.

Luke Healy, who told legislators at an April hearing that he was “a 24-year-old detransitioner” and no longer believed he was a woman, criticized the attempt to increase coverage of services he thought were “irreversibly harmful” to him.

“I believe that bills like this are forcing doctors to turn healthy bodies into perpetual medical problems in the name of an ideology,” Healy testified.

The California Association of Health Plans opposed the bill over provisions that would limit the use of certain practices such as prior authorization and step therapy, which require insurer approval before care is provided and force patients and doctors to try other therapies first.

“These safeguards are essential for applying evidence-based prescribing standards and responsibly managing costs — ensuring patients receive appropriate care while keeping premiums in check,” said spokesperson Mary Ellen Grant.

An analysis by the California Health Benefits Review Program, which independently reviews bills relating to health insurance, concluded that annual premium increases resulting from the bill’s implementation would be negligible and that “no long-term impacts on utilization or cost” were expected.

Shannon Minter, legal director for the National Center for LGBTQ Rights, said Newsom’s economic argument was “not plausible.” Although he said he considers Newsom a strong ally of the transgender community, Minter noted he was “deeply disappointed” to see the governor’s veto.

“I understand he’s trying to respond to this political moment, and I wish he would respond to it by modeling language and policies that can genuinely bring people along.”

Newsom’s press office declined to comment further.

Following the podcast interview with Kirk, Cuellar said, advocacy groups backing SB 418 grew concerned about a potential veto and made a point to highlight voices of other patients who would benefit, including menopausal women and cancer patients. It was a starkly different strategy than what they might have done before Trump took office.

“Had we run this bill in 2022-2023, the messaging would have been totally different,” said another proponent who requested anonymity because they were not authorized to speak publicly on the issue.

“We could have been very loud and proud. In 2023, we might have gotten a signing ceremony.”

Advocates for trans rights were so wary of the current political climate that some also felt the need to steer clear of promoting a separate bill that would have expanded coverage of hormone therapy and other treatments for menopause and perimenopause. That bill, authored by Assembly member Rebecca Bauer-Kahan, who has spoken movingly about her struggles with health care for perimenopause, was also vetoed.

In the meantime, said Jovan Wolf, a trans man and military veteran, patients like him will be left to suffer. Wolf, who had taken testosterone for more than 15 years, tried to restart hormone therapy in March, following a two-year hiatus in which he contemplated having children.

Doctors at the Department of Veterans Affairs told him it was too late. Days earlier, the Trump administration had announced it would phase out hormone therapy and other treatments for gender dysphoria.

“Having estrogen pumping through my body, it’s just not a good feeling for me, physically, mentally. And when I’m on testosterone, I feel balanced,” said Wolf, who eventually received care elsewhere. “It should be my decision and my decision only.”

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 — the independent source for health policy research, polling, and journalism.

A California woman is suing Dignity Health, alleging two hospitals denied her emergency abortion services due to their Catholic directives, violating state law and putting her life in danger.

During two separate pregnancies, Rachel Harrison’s water broke at just 17 weeks — a condition that can cause deadly complications. An abortion is typically the course of action recommended by doctors, but on both occasions staff members at Dignity Health hospitals refused to act because they detected a fetal heartbeat, the lawsuit alleges.

The second time it happened, Harrison experienced life-threatening sepsis and had to travel to a hospital outside her insurance network to receive a blood transfusion, the complaint states.

Harrison, 30, and her partner Marcell Johnson filed a lawsuit against Dignity Health in San Francisco Superior Court on Friday. The claim, first reported by Courthouse News Service, alleges that subsidiaries Mercy San Juan Medical Center and Mercy General Hospital refused to provide her emergency abortion care for religious reasons.

The 24 Catholic hospitals within the Dignity Health network follow a set of “Ethical and Religious Directives for Catholic Health Services,” which caused Harrison to be turned away from an emergency room during the loss of a high-risk pregnancy, the complaint alleges.

“While publicly touting their hospitals’ qualifications as reliable emergency services centers, Dignity Health prioritized its own religious directives over the best interests of Rachel’s health and well-being,” the lawsuit alleges.

Last September the state filed a similar lawsuit against a Catholic hospital in Eureka after a woman whose water broke at 15 weeks was denied an emergency abortion. That hospital then agreed to provide emergency abortions in cases where a woman’s health is at risk.

A spokesperson for Dignity Health did not comment on the specific allegations contained in Harrison’s lawsuit.

“When a pregnant woman’s health is at risk, appropriate emergency care is provided,” the spokesperson said in a statement. “The well-being of our patients is the central mission for our dedicated caregivers.”

On Sept. 13, 2024, according to Harrison‘s lawsuit, she experienced a condition called previable preterm premature rupture of the membranes, or previable PPROM, when her water broke at just 17 weeks of pregnancy.

This condition is fatal for the fetus and dangerous for the mother.

According to the American College of Obstetricians and Gynecologists, the standard of care is to inform the patient that the pregnancy is not viable and recommend termination as the safest option to reduce maternal risk. Miscarrying the fetus naturally comes with higher risk of infection and blood loss, both of which can lead to permanent loss of reproductive function or even death.

Last September, Harrison traveled to Mercy San Juan Medical Center in Carmichael for emergency care, but doctors did not recommend an abortion, the complaint alleges.

“Instead, Rachel was told that because of the hospital’s Catholic affiliation, there was nothing more the hospital could do for her,” the complaint states. “Confused and distressed, Rachel was discharged and left to complete a high-risk miscarriage of a fetus ‘the size of an avocado’ — as she was told by the physician’s assistant — at home, on her own, and without medical supervision.”

She went to a Kaiser hospital the following morning and received emergency care, the lawsuit says.

Last December, Harrison was thrilled to learn that she was pregnant again, but then “her worst nightmare” repeated itself. At 17 weeks pregnant, she once again experienced previable PPROM, the complaint states.

Her insurance only covers OB/GYN care within the Dignity Health network, so she went to Mercy General Hospital in Sacramento.

In a repeat of her past experience, her lawsuit alleges, staff members told her they could not provide the care she sought due to the fetal heartbeat. She was able to access care at another hospital, her complaint says, but experienced sepsis and heavy blood loss in the process.

The lawsuit alleges that the denials violated California’s Emergency Services Law, which requires hospitals operating a licensed emergency room to treat patients suffering from emergency medical conditions, including previable PPROM.

Harrison also alleges that Dignity Health violated the Unruh Civil Rights Act, California Unlawful Competition Law and her right to privacy under the California Constitution.

Harrison and her partner are seeking an order requiring Dignity Health hospitals to provide emergency abortions in a manner compliant with state law, as well as compensatory and punitive damages.

WASHINGTON — A day after conservative activist Laura Loomer, an advisor to President Trump, posted videos on social media of children from Gaza arriving in the U.S. for medical treatment and questioning how they got visas, the State Department said it was halting all visitor visas for people from Gaza pending a review.

The State Department said Saturday the visas would be stopped while it looks into how “a small number of temporary medical-humanitarian visas” were issued in recent days. Secretary of State Marco Rubio on Sunday told “Face the Nation” on CBS that the action came after ”outreach from multiple congressional offices asking questions about it.”

Rubio said that there were “just a small number” of the visas issued to children in need of medical aid but that they were accompanied by adults. The congressional offices reached out with evidence that “some of the organizations bragging about and involved in acquiring these visas have strong links to terrorist groups like Hamas,” he asserted, without providing evidence or naming those organizations.

As a result, he said, “we are going to pause this program and reevaluate how those visas are being vetted and what relationship, if any, has there been by these organizations to the process of acquiring those visas.”

Loomer on Friday posted videos on X of children from Gaza arriving this month in San Francisco and Houston for medical treatment with the aid of an organization called Heal Palestine. “Despite the US saying we are not accepting Palestinian ‘refugees’ into the United States under the Trump administration,” these people from Gaza were able to travel to the U.S., she said.

She called it a “national security threat” and asked who signed off on the visas, calling for the person to be fired. She tagged Rubio, Trump, Vice President JD Vance, Texas Gov. Greg Abbott and California Gov. Gavin Newsom.

Trump has downplayed Loomer’s influence on his administration, but several officials swiftly left or were removed shortly after she publicly criticized them.

The State Department on Sunday declined to comment on how many of the visas had been granted and whether the decision to halt visas to people from Gaza had anything to do with Loomer’s posts.

Heal Palestine said in a statement Sunday that it was “distressed” by the State Department decision to stop halt visitor visas from Gaza. The group said it is “an American humanitarian nonprofit organization delivering urgent aid and medical care to children in Palestine.”

A post on the organization’s Facebook page Thursday shows a photo of a boy from the Gaza Strip leaving Egypt and headed to St. Louis for treatment and said he is “our 15th evacuated child arriving in the U.S. in the last two weeks.”

The organization brings “severely injured children” to the U.S. on temporary visas for treatment they can’t get at home, the statement said. After treatment, the children and any family members who accompanied them return to the Middle East, the statement said.

“This is a medical treatment program, not a refugee resettlement program,” it said.

The World Health Organization has repeatedly called for more medical evacuations from Gaza, where Israel’s 22-month war against Hamas has heavily destroyed or damaged much of the territory’s health system.

“More than 14,800 patients still need lifesaving medical care that is not available in Gaza,” WHO Director-General Tedros Adhanom Ghebreyesus said Wednesday on social media, and called on more countries to offer support.

A WHO description of the medical evacuation process from Gaza published last year explained that the organization submits lists of patients to Israeli authorities for security clearance. It noted that before the war in Gaza began, 50 to 100 patients were leaving the territory daily for medical treatment, and it called for a higher rate of approvals from Israeli authorities.

The United Nations and partners say medicines and basic healthcare supplies are low in Gaza after Israel cut off all aid to the territory of over 2 million people for more than 10 weeks earlier this year.

“Ceasefire! Peace is the best medicine,” Tedros added Wednesday.

State lawmakers are considering a bill meant to protect access to HIV prevention drugs for insured Californians as threats from the federal government continue.

Assembly Bill 554 would require health plans and insurers to cover all antiretroviral drugs used for PrEP and PEP regimens. The drugs just have to be approved by the Food and Drug Administration, and would not require prior authorization. The bill would also prevent health plans from forcing patients to first try a less expensive drug before choosing a more expensive, specialty option.

The bill requires insurance providers to cover these drugs without cost-sharing with patients, and it limits the ability of insurers and employers to review treatments to determine medical necessity. To streamline reimbursements and expand the range of PrEP medications doctors can pick for their patients, the legislation allows providers to directly bill insured patients’ pharmaceutical benefit plans.

LGBTQ+ public health advocates worry that the Trump administration’s recent attempt to slash $1.5 billion in HIV prevention funding from the federal budget — along with its decisions to stop offering suicide-prevention counseling for LGBTQ+ individuals through the national 988 lifeline and to restrict gender-affirming care for transgender Americans — amounts to an assault on the queer community.

The state bill would act “as a shield against this administration’s cruelty,” said California Assemblymember Mark González (D-Los Angeles) who co-sponsored AB 554 with Assemblymember Matt Haney (D-San Francisco).

A recent cause for alarm among LGBTQ+ health advocates, first reported in the Wall Street Journal, is news that Health and Human Services Secretary Robert F. Kennedy Jr. plans to replace the entire U.S. Preventive Services Task Force because its 16 appointed members are too “woke,” according to unnamed individuals cited by the Journal.

At a news conference Monday, Kennedy confirmed that he is reviewing the makeup of the panel, adding that he hasn’t made a final decision.

The bill was introduced earlier in the year out of fear that Kennedy’s skepticism about vaccines might spill over into HIV/PrEP drug coverage and because of worries that President Trump would dismantle the task force, González said.

The task force wields immense influence, making recommendations about which cancer screenings, tests for chronic diseases and preventive medications are beneficial for Americans and therefore should be covered by insurers — including drugs for HIV/AIDS prevention.

Drugs prescribed in a PrEP regimen — short for pre-exposure prophylaxis — block the virus that causes AIDS from multiplying in a person’s body. They can be taken in either pill or injection form on an ongoing basis. PEP refers to post-exposure prophylaxis and involves taking medication within 72 hours of potential exposure and for a short period of time, in order to prevent infection and transmission of the virus. Both regimens are recommended by the Centers for Disease Control and Prevention as effective ways to reduce the spread of HIV/AIDS when used correctly.

The U.S. Preventive Services Task Force was created in 1984 by congressional authorization to issue evidence-based advice to physicians on which screenings and preventive medicines are worth considering for their healthy patients. The panel’s recommendations are closely watched by professional societies when adopting guidelines for their clinician members. In many cases, when insurers are on the fence about whether to cover a given screening or diagnostic test, they’ll turn to the panel’s recommendations.

The panel, made up of doctors, nurses, health psychologists, epidemiologists and statisticians who are experts in primary care and preventive medicine and who serve four-year terms on a voluntary basis, is meant to be free from conflicts of interest and outside influences.

Some of its past recommendations, however, such as its advice on prostate cancer screenings, have been met with criticism.

When it comes to HIV prevention, the U.S. Supreme Court appeared to back up the task force with its July 11 ruling in Kennedy vs. Braidwood Management, which upheld a key mandate in the Affordable Care Act requiring insurers to cover preventive care, including for HIV.

However, in the same ruling, the court also declared that the Secretary of Health and Human Services has the power to review decisions made by the task force, and to remove members at his or her discretion.

Kennedy abruptly postponed the task force’s July meeting, sparking concern among public health advocates and Democratic leaders.

“The task force has done very little over the past five years,” Kennedy said at Monday’s news conference. “We want to make sure that it is performing, that it is approving interventions that are actually going to prevent the health decline of the American public.”

González said he worries that the Supreme Court gave the administration a new way to meddle in the healthcare decisions of LGBTQ+ people.

“The Braidwood decision was both a relief and a wake-up call,” González said. “While it upheld the Preventive Services Task Force’s existing recommendations — keeping protections for PrEP, cancer screenings, and vaccines intact — it handed unprecedented authority to RFK Jr. to reshape that very task force and place existing protections under direct threat once again.”

González described AB 554 as “a measure to protect LGBTQ+ Californians and ensure we never return to the neglect and devastation of the HIV/AIDS crisis.” The state Senate Appropriations Committee is expected to vote on whether to advance the bill on Aug. 29.

“These attacks aren’t isolated,” the lawmaker said. “They are coordinated, deliberate, and aimed squarely at our most vulnerable communities.”

Los Angeles County’s health system, which is responsible for the care of the region’s poorest, is careening toward a financial crisis because of cuts from a presidential administration and Republican-led Congress looking to drastically slash the size of government.

President Trump’s “Big Beautiful Bill,” which passed earlier this month, is expected to soon claw $750 million per year from the county Department of Health Services, which oversees four public hospitals and roughly two dozen clinics. In an all-staff email Friday, the agency called the bill a “big, devastating blow to our health system” and said a hiring freeze had gone into effect, immediately.

And the Trump administration’s budget for the next fiscal year will likely result in a $200-million cut to the county Department of Public Health, whose responsibilities include monitoring disease outbreaks, inspecting food and providing substance use treatment.

“I’m not going to sugarcoat it. I’m not going to say we survive this,” said Barbara Ferrer, head of the public health department, in an interview. “We can’t survive this big a cut.”

Both Ferrer and Department of Health Services head Christina Ghaly warned that the federal cuts will devastate their agencies — and the patients they serve — for years to come. Employee layoffs are likely.

In April, the White House announced it was ending infectious disease grants worth billions of dollars, including $45 million that L.A. County was supposed to use to combat the spread of measles and bird flu. California has joined other states in a lawsuit fighting the cuts, and the court has issued a preliminary injunction suspending the cuts.

A protest earlier this month in Anaheim, co-led by the California Nurses Assn., called on Rep. Young Kim (R-Anaheim Hills) to vote against President Trump’s spending bill.

(Allen J. Schaben/Los Angeles Times)

This month, the county public health department lost another $16 million after Trump’s bill cut funding for a program educating food stamp recipients about how to buy healthy meals.

And there’s more to come. The Trump administration’s proposed budget for 2026 will be the biggest blow yet, Ferrer warned, yanking $200 million from her department — a 12% cut.

“I’m old. I’ve been around for a long time,” said Ferrer, whose work in public health dates back to the Reagan administration. “I’ve never actually seen this much disdain for public health.”

Ferrer said the cuts mean she no longer has enough money for the county’s bioterrorism watch program, which monitors for outbreaks that might signal a biological attack. Soon, she said, county officials may have to stop testing ocean water for toxins year round, cutting back to just half the year.

“Like, you want to swim? You want to know that the water is safe where you swim, then oppose these kinds of cuts,” she said. “That affects everybody who goes to the beach.”

L.A. County Public Health Director Barbara Ferrer said she is bracing for $200 million in cuts to her budget.

(Al Seib/Los Angeles Times)

Layoffs are likely, said Ferrer. About 1,500 public health staffers are supported through federal grants. More than half the federal money the department receives is funneled to outside organizations, which would likely need to make cuts to stay afloat.

A similarly grim cost analysis is underway at the county Department of Health Services, where executives said they expect to lose $280 million this fiscal year because of the bill.

“I can’t make a promise that we will be able to avoid layoffs because of the magnitude of the challenges,” said Ghaly.

Ghaly said the bill slashed the extra Medicaid money the county typically gets to cover care for low-income patients. They expect many patients might be kicked off Medicaid because of new eligibility and work requirements. The federal government is pulling back on payments for emergency services for undocumented people, meaning the county will have to foot more of the bill.

The White House did not respond to a request for comment.

Department of Health Services officials said they expect to lose $750 million per year by 2028. By then, the agency’s budget deficit is projected to have ballooned to $1.85 billion.

In an attempt to pump more cash into the system, L.A. County supervisors voted on Tuesday to increase a parcel tax first approved by voters in 2002, which is expected to raise an additional $87 million for the county’s trauma care network.

After a long debate Tuesday, Supervisors Holly Mitchell and Lindsey Horvath worked to direct $9 million of the parcel tax money to Martin Luther King Jr. Community Hospital, a private hospital that serves as a critical safety net for South Los Angeles residents who would otherwise find themselves in a medical desert.

Without that cash infusion from the county, the cuts in Trump’s bill would have put the hospital at risk of closing, since the majority of patients in its emergency room are on Medicaid, said Elaine Batchlor, Martin Luther King’s chief executive officer.

“If they’ve lost their Medicaid coverage, we simply won’t get paid for those patients,” she said.

Dr. Elaine Batchlor, chief executive of MLK Community Healthcare, said her hospital was hanging by a thread financially. Then came more cuts.

(Francine Orr/Los Angeles Times)

Martin Luther King replaced a county hospital that closed after losing national accreditation in 2005 because of serious medical malpractice, landing it the nickname “Killer King.”

“The fact that that hospital closed in the first place I think is criminal, and I intend to do all I can to protect the integrity of the services,” said Mitchell, whose district includes the hospital and who pushed for it to get a cut of money from the parcel tax increase.

Local health providers said that changes at the state level have created additional uncertainty. The state budget for this fiscal year freezes enrollment in Medi-Cal, California’s version of Medicaid, for undocumented immigrants ages 19 and older starting in January. Medi-Cal recipients ages 19 to 59 will have to pay a $30 monthly premium beginning July 1, 2027.

“Most families [we serve] are making about $2,400 to $2,600 a month. They’re going to have to choose between paying their Medi-Cal fees for a family of four — that’s $120 a month — or paying rent or paying for food,” said Jim Mangia, head of St. John’s Community Health, who said the cuts will disrupt care for tens of thousands of low-income residents.

The St. John’s clinic, which gets most of its revenue from Medi-Cal reimbursements, serves more than 120,000 patients a year, most of whom live below the federal poverty line.

If the clinic doesn’t find a way to replace the lost revenue, Mangia warned, services will have to be reduced. The clinic recently started treating immigrant patients in their homes after realizing they had been skipping appointments because they feared being arrested by federal immigration agents.

“Then what we’re looking at is closing several health centers,” said Mangia. “We’re looking at laying off hundreds of staff.”

At Venice Family Clinic, a community health center that serves nearly 45,000 patients annually, 80% of patients rely on Medi-Cal. Roughly half the clinic’s revenue comes from Medi-Cal reimbursements.

Dr. Mitesh Popat, a family physician and head of the clinic, said that federal policy changes — especially more frequent paperwork and added work requirements — will likely push eligible patients off of Medi-Cal. He said the clinic is exploring ways to expand support for patients to navigate the paperwork and keep their coverage.

“This puts a bunch of barriers in the way of people who already have enough challenges in life,” Popat said. “They’re trying to make it, trying to survive, trying to put food on the table.”

SACRAMENTO — For nearly 20 years, Maria would call her sister — a nurse in Mexico — for advice on how to manage her asthma and control her husband’s diabetes instead of going to the doctor in California.

She didn’t have legal status, so she couldn’t get health insurance and skipped routine exams, relying instead on home remedies and, at times, getting inhalers from Mexico. She insisted on using only her first name for fear of deportation.

Things changed for Maria and many others in recent years when some Democratic-led states opened up their health insurance programs to low-income immigrants regardless of their legal status. Maria and her husband signed up the day the program began last year.

“It changed immensely, like from Earth to the heavens,” Maria said in Spanish of Medi-Cal, California’s Medicaid program. “Having the peace of mind of getting insurance leads me to getting sick less.”

At least seven states and the District of Columbia have offered coverage for immigrants, mostly since 2020. But three of them have done an about-face, ending or limiting coverage for hundreds of thousands of immigrants who aren’t in the U.S. legally — California, Illinois and Minnesota.

The programs cost much more than officials had projected at a time when the states are facing multibillion-dollar deficits now and in the future. In Illinois, adult immigrants ages 42 to 64 without legal status have lost their healthcare to save an estimated $404 million. All adult immigrants in Minnesota no longer have access to the state program, saving nearly $57 million. In California, no one will automatically lose coverage, but new enrollments for adults will stop in 2026 to save more than $3 billion over several years.

Cuts in all three states were backed by Democratic governors who once championed expanding health coverage to immigrants.

The Trump administration this week shared the home addresses, ethnicities and personal data of all Medicaid recipients with U.S. Immigration and Customs Enforcement officials. Twenty states, including California, Illinois and Minnesota, have sued.

Healthcare providers told the Associated Press that all of those factors, especially the fear of being arrested or deported, are having a chilling effect on people seeking care. And states may have to spend more money down the road because immigrants will avoid preventive healthcare and end up needing to go to safety-net hospitals.

“I feel like they continue to squeeze you more and more to the point where you’ll burst,” Maria said, referencing all the uncertainties for people who are in the U.S. without legal permission.

‘People are going to die’

People who run free and community health clinics in California and Minnesota said patients who got on state Medicaid programs received knee replacements and heart procedures and were diagnosed for serious conditions like late-stage cancer.

CommunityHealth is one of the nation’s largest free clinics, serving many uninsured and underinsured immigrants in the Chicago area who have no other options for treatment. That includes the people who lost coverage July 1 when Illinois ended its Health Benefits for Immigrants Adults Program, which served about 31,500 people ages 42 to 64.

One of CommunityHealth’s community outreach workers and care coordinator said Eastern European patients she works with started coming in with questions about what the change meant for them. She said many of the patients also don’t speak English and don’t have transportation to get to clinics that can treat them. The worker spoke to the AP on condition of anonymity to protect patients’ privacy.

Health Finders Collective in Minnesota’s rural Rice and Steele counties south of Minneapolis serves low-income and underinsured patients, including large populations of Latino immigrants and Somali refugees. Executive director Charlie Mandile said his clinics are seeing patients rushing to squeeze in appointments and procedures before 19,000 people age 18 and older are kicked off insurance at the end of the year.

Free and community health clinics in all three states say they will keep serving patients regardless of insurance coverage — but that might get harder after the U.S. Department of Health and Human Services decided this month to restrict federally qualified health centers from treating people without legal status.

CommunityHealth Chief Executive Stephanie Willding said she always worried about the stability of the program because it was fully state funded, “but truthfully, we thought that day was much, much further away.”

“People are going to die. Some people are going to go untreated,” Alicia Hardy, chief executive officer of CommuniCARE+OLE clinics in California, said of the state’s Medicaid changes. “It’s hard to see the humanity in the decision-making that’s happening right now.”

A spokesperson for the Minnesota Department of Health said ending the state’s program will decrease MinnesotaCare spending in the short term, but she acknowledged healthcare costs would rise elsewhere, including uncompensated care at hospitals.

Minnesota House Speaker Lisa Demuth, a Republican, said the state’s program was not sustainable.

“It wasn’t about trying to be non-compassionate or not caring about people,” she said. “When we looked at the state budget, the dollars were not there to support what was passed and what was being spent.”

Demuth also noted that children will still have coverage, and adults lacking permanent legal status can buy private health insurance.

Healthcare providers also are worried that preventable conditions will go unmanaged, and people will avoid care until they end up in emergency rooms — where care will be available under federal law.

One of those safety-net public hospitals, Cook County Health in Chicago, treated about 8,000 patients from Illinois’ program last year. Dr. Erik Mikaitis, the health system’s CEO, said doing so brought in $111 million in revenue.

But he anticipated other providers who billed through the program could close, he said. “Things can become unstable very quickly,” he said.

Monthly fees, federal policies create barriers

State lawmakers said California’s Medi-Cal changes stem from budget issues — a $12-billion deficit this year, with larger ones projected ahead. Democratic state leaders last month agreed to stop new enrollment starting in 2026 for all low-income adults without legal status. Those under 60 remaining on the program will have to pay a $30 monthly fee in 2027.

States are also bracing for impact from federal policies. Cuts to Medicaid and other programs in President Trump’s massive tax and spending bill include a 10% cut to the federal share of Medicaid expansion costs to states that offer health benefits to immigrants starting October 2027.

California health officials estimate roughly 200,000 people will lose coverage after the first full year of restricted enrollment, though Gov. Gavin Newsom maintains that even with the rollbacks, California provides the most expansive healthcare coverage for poor adults.

Every new bill requires a shift in Maria’s monthly calculations to make ends meet. She believes many people won’t be able to afford the $30-a-month premiums and will instead go back to self-medication or skip treatment altogether.

“It was a total triumph,” she said of Medi-Cal expansion. “But now that all of this is coming our way, we’re going backwards to a worse place.”

Fear and tension about immigration raids are changing patient behavior, too. Providers told the AP that, as immigration raids ramped up, their patients were requesting more virtual appointments, not showing up to routine doctor’s visits and not picking up prescriptions for their chronic conditions.

Maria has the option to keep her coverage. But she is weighing the health of her family against risking what they’ve built in the U.S.

“It’s going to be very difficult,” Maria said of her decision to remain on the program. “If it comes to the point where my husband gets sick and his life is at risk, well then, obviously, we have to choose his life.”

Nguyễn and Shastri write for the Associated Press and reported from Sacramento and Milwaukee, respectively. AP journalist Godofredo Vasquez in San Francisco contributed to this report.

Children’s Hospital Los Angeles is the preeminent center for pediatric medicine in Southern California. For three decades, it’s also been one of the world’s leading destinations for trans care for minors. Don’t take my word for it: CHLA boasts about its record of providing “high-quality, evidence-based, medically essential care for transgender and gender-diverse youth, young adults, and their families.”

Earlier this month, it abruptly ended all that, telling its staff in a meeting that the Center for Transyouth Health and Development would be shutting down. (My daughter was, until this announcement, a patient at the center.)

Did some new medical breakthrough, some unexpected research drive the decision to cut off care for roughly 2,500 patients with no warning? No. It came, the hospital said, after “a thorough legal and financial assessment of the increasingly severe impacts of recent administrative actions and proposed policies.”

In other words, the hospital caved. In advance.

CHLA made the move a week before the Supreme Court’s 6-3 decision in the United States vs. Skrmetti, which upheld a Tennessee law that bans most gender-affirming care for minors. More than 20 states have passed similar laws that prevent trans minors from accessing many different forms of medical care. The decision essentially shields those laws from future legal challenges.

But the Supreme Court ruling had nothing to do with CHLA’s decision. There is no such law in California.

Why, then, without any court order or law, did the center suddenly close, leaving so many young patients in need of doctors, medications and procedures? You can probably guess the answer.

Pressure from the Trump administration threatened the hospital with severe repercussions if it continued to serve these patients. One form of pressure arrived in a May 28 letter from the Centers for Medicare and Medicaid Services, signed by its administrator, the former TV host Dr. Mehmet Oz. He announced that his agency would seek financial records on a range of gender-affirming care procedures from several dozen hospitals.

Being faced with the choice of discontinuing care for an entire class of patients or battling the administration over access to financial records is not a dilemma any doctor wants to face. To be clear, this is not a debate over medical science or proper care for trans youth. CHLA followed the science — until it didn’t. This is a debate over ideology about who is deserving of medical care.

In the past few months, we have seen powerful law firms, large corporations and universities forced to contend with difficult bargains. Settle with an administration that has singled you out? Or take the battle to court?

In February, when Children’s Hospital announced that it would stop taking on new patients in its Transyouth Center, California Atty. Gen. Rob Bonta sternly reminded them that they had a legal obligation to continue to provide this care. The hospital quickly reversed course.

That’s why the recent choice of the CHLA board marks a huge shift that could potentially affect care for not just trans youth patients but so many others as well.

Because what the board of CHLA did was, in fact, a choice. Moreover, CHLA’s choice went against its own medical advice about the urgent need for such care. On its website, the hospital claims it was “immensely proud of this legacy of caring for young people on the path to achieving their authentic selves.”

When confronted with threats, the board chose to sacrifice the care of one group of patients in the hope that it could continue to care for others. Perhaps the board concluded that it was following a crude, utilitarian logic: denying the medical needs of some would allow it to provide for many more.

That’s not how I see it. In caving to blackmail, they have endorsed the administration’s bigotry. They have demonstrated that trans youth are expendable. The board has made it clear that this group of patients is not as deserving of care as others. When CHLA faced actual pressure, its own record of providing “high-quality, evidence-based, medically essential care” simply became too inconvenient.

This time, it was trans youth. Who will it be next time? Disabled children? Children born outside the U.S.? CHLA agreed to play the game rather than call it out for what it is.

As a journalist, I occasionally grant anonymity to a source. It’s not an action I take lightly. The decision means that if pressured, even when threatened with contempt of court, I will not reveal their identity. Thankfully, it’s never come to that for me, although other journalists have gone to jail to protect sources. If I were to break that pledge once, I could never in good conscience grant it again.

I now wonder how doctors at CHLA can ever look their young patients in the eye again and promise that, no matter what, they will fight for their care.

Gabriel Kahn is a professor of professional practice at the USC Annenberg School for Communication and Journalism.

Under mounting pressure from the Trump administration, Children’s Hospital Los Angeles will shutter its longstanding healthcare program for trans children and young adults this summer, according to emails reviewed by The Times.

The Center for Transyouth Health and Development began telling its nearly 3,000 patient families of the closure on Thursday, saying there was “no viable alternative” that would allow the safety-net hospital to continue specialized care.

“There is no doubt that this is a painful and significant change to our organization and a challenge to CHLA’s mission, vision, and values,” hospital executives wrote to staff in a Thursday morning email.

The email said the decision to close the center on July 22 “follows a lengthy and thorough assessment of the increasingly severe impacts of federal administrative actions and proposed policies” that have emerged since the hospital briefly paused the initiation of care for some patients this winter.

The note sent shock waves through the tight-knit patient community, members of which had recently breathed a sigh of relief after CHLA reversed its brief ban on some care for new patients in February.

“We’re just disappointed and scared and enraged” said Maxine, the mother of a current patient, who declined to give her last name for fear of attacks on her son. “The challenge is how we break news to this kid who has had such a positive experience with everybody at Children’s.”

In the email, executives said that continuing to operate the center would jeopardize the hospital’s ability to care for “hundreds of thousands” of other children, noting that federal agencies including the Department of Justice, Health and Human Services, and the Centers for Medicare and Medicaid Services had warned of dire consequences for doctors and hospitals providing care opposed by the administration — including threat of prosecutions for doctors.

“These threats are no longer theoretical,” the note said. “Taken together, the Attorney General memo, HHS review, and the recent solicitation of tips from the FBI to report hospitals and providers of GAC strongly signal this Administration’s intent to take swift and decisive action, both criminal and civil, against any entity it views as being in violation of the executive order.”

The hospital’s Transyouth center is among the oldest and largest programs in the country, and among the only facilities that provides puberty blockers, hormones and surgical procedures for trans youth on public insurance.

But the hospital is also significantly more reliant on public funding than any other pediatric medical center in California — a situation that leaves it particularly exposed to the Trump administration. Roughly 40% of pediatric beds in Los Angeles are at Children’s.

“CHLA has a responsibility to navigate this complex and uncertain regulatory environment in a way that allows us to remain open as much as possible for as many as possible,” executives wrote. “In the end, this painful and difficult decision was driven by the need to safeguard CHLA’s ability to operate amid significant external pressures beyond our control.”

Protests erupted in February after the hospital briefly paused hormone therapy for some patients under 19, in response to President Trump’s executive order.

That move was reversed a few weeks later, amid pressure from patient families, LGBTQ+ civil rights groups and the state Department of Justice.

“Let me be clear: California law has not changed, and hospitals and clinics have a legal obligation to provide equal access to healthcare services,” Atty. Gen. Rob Bonta wrote on Feb. 5, days into the pause.

The California Justice Department did not immediately respond to requests for comment.

Thursday’s internal email from Children’s leadership notes the pressure from the federal government has risen at the same time that support from the state has ebbed.

“Over the past several months, California’s deepening budget crisis, President Trump’s executive orders, proposed federal legislation and rulemaking, and growing economic uncertainty have made the situation even more dire,” the email said.

Activists say the closure sets a dangerous precedent.

“CHLA needs to be a leader in this and stand up to the Trump administration, because other hospitals are taking note of what they’re doing,” said Maebe Pudlow, a trans nonbinary activist and Silverlake Neighborhood Council member who helped lead the protests when care was paused this winter.

“It feels very conveniently timed when everybody’s focus is on ICE raids happening in Los Angeles,” the activist went on. “I think it’s despicable.”

Maxine, the mom, was more measured.

“We’re slowly going underground, underground, underground,” the mother said. “You put one thing in place, and then you have to prepare for when that gets taken away. We’re just trying to stay a couple of steps ahead, sticking together with other parents, knowing who our allies are.”

WASHINGTON — A Texas hospital that repeatedly sent a woman who was bleeding and in pain home without ending her nonviable, life-threatening pregnancy violated the law, according to a newly released federal investigation.

The government’s findings, which have not been previously reported, were a small victory for 36-year-old Kyleigh Thurman, who ultimately lost part of her reproductive system after being discharged without any help from her hometown emergency room for her dangerous ectopic pregnancy.

But a new policy the Trump administration announced on Tuesday has thrown into doubt the federal government’s oversight of hospitals that deny women emergency abortions, even when they are at risk for serious infection, organ loss or severe hemorrhaging.

Thurman had hoped the federal government’s investigation, which issued a report in April after concluding its inquiry last year, would send a clear message that ectopic pregnancies must be treated by hospitals in Texas, which has one of the nation’s strictest abortion bans.

“I didn’t want anyone else to have to go through this,” Thurman said in an interview with the Associated Press from her Texas home this week. “I put a lot of the responsibility on the state of Texas and policy makers and the legislators that set this chain of events off.”

Uncertainty regarding emergency abortion access

Women around the country have been denied emergency abortions for their life-threatening pregnancies after states swiftly enacted abortion restrictions in response to a 2022 ruling from the U.S. Supreme Court, which includes three appointees of President Trump.

The guidance issued by the Biden administration in 2022 was an effort to preserve access to emergency abortions for extreme cases in which women were experiencing medical emergencies. It directed hospitals — even ones in states with severe restrictions — to provide abortions in those emergency cases. If hospitals did not comply, they would be in violation of a federal law and risk losing some federal funds.

On Tuesday, the Centers for Medicare and Medicaid Services, the federal agency responsible for enforcing the law and inspecting hospitals, announced it would revoke the Biden-era guidance around emergency abortions.

The law, which requires doctors to provide stabilizing treatment, was one of the few ways that Thurman was able to hold the emergency room accountable after she didn’t receive any help from staff at Ascension Seton Williamson in Round Rock, Texas, in February 2023, a few months after Texas enacted its strict abortion ban.

An ectopic pregnancy left untreated

Emergency room staff observed that Thurman’s hormone levels had dropped, a pregnancy was not visible in her uterus and a structure was blocking her fallopian tube — all telltale signs of an ectopic pregnancy, when a fetus implants outside of the uterus and has no room to grow. If left untreated, ectopic pregnancies can rupture, causing organ damage, hemorrhage or even death.

Thurman, however, was sent home and given a pamphlet on miscarriage for her first pregnancy. She returned three days later, still bleeding, and was given an injected drug intended to end the pregnancy, but it was too late. Days later, she showed up again at the emergency room, bleeding out because the fertilized egg growing on Thurman’s fallopian tube ruptured it. She underwent an emergency surgery that removed part of her reproductive system.

CMS launched its investigation of how Ascension Seton Williamson handled Thurman’s case late last year, shortly after she filed a complaint. Investigators concluded the hospital failed to give her a proper medical screening exam, including an evaluation with an OB-GYN. The hospital violated the federal Emergency Medical Treatment and Labor Act, which requires emergency rooms to provide stabilizing treatment to all patients. Thurman was “at risk for deterioration of her health and wellbeing as a result of an untreated medical condition,” the investigation said in its report, which was publicly released last month.

Ascension, a vast hospital system that has facilities across multiple states, did not respond to questions about Thurman’s case, saying only that it “is committed to providing high-quality care to all who seek our services.”

Penalties for doctors, hospital staff

Doctors and legal experts have warned abortion restrictions like the one Texas enacted have discouraged emergency room staff from aborting dangerous and nonviable pregnancies, even when a woman’s life is imperiled. The stakes are especially high in Texas, where doctors face up to 99 years in prison if convicted of performing an illegal abortion. Lawmakers in the state are weighing a law that would remove criminal penalties for doctors who provide abortions in certain medical emergencies.

“We see patients with miscarriages being denied care, bleeding out in parking lots. We see patients with nonviable pregnancies being told to continue those to term,” said Molly Duane, an attorney at the Center for Reproductive Rights that represented Thurman. “This is not, maybe, what some people thought abortion bans would look like, but this is the reality.”

The Biden administration routinely warned hospitals that they need to provide abortions when a woman’s health was in jeopardy, even suing Idaho over its state law that initially prohibited nearly all abortions, unless a woman’s life was on the line.

Questions remain about hospital investigations

But CMS’ announcement on Tuesday raises questions about whether such investigations will continue if hospitals do not provide abortions for women in medical emergencies.

The agency said it will still enforce the law, “including for identified emergency medical conditions that place the health of a pregnant woman or her unborn child in serious jeopardy.”

While states like Texas have clarified that ectopic pregnancies can legally be treated with abortions, the laws do not provide for every complication that might arise during a pregnancy. Several women in Texas have sued the state for its law, which has prevented women from terminating pregnancies in cases where their fetuses had deadly fetal anomalies or they went into labor too early for the fetus to survive.

Thurman worries pregnant patients with serious complications still won’t be able to get the help they may need in Texas emergency rooms.

“You cannot predict the ways a pregnancy can go,” Thurman said. “It can happen to anyone, still. There’s still so many ways in which pregnancies that aren’t ectopic can be deadly.”

Seitz writes for the Associated Press.

Healthcare is changing fast. More and more often, patients are monitored not in hospital beds but in their own homes. What makes this possible? A combination of smart technology, secure networks, and thoughtful design — all bundled into what we call Remote Patient Monitoring (RPM).

The real engine behind this change is the Internet of Things (IoT). Tiny sensors, wearable devices, and connected platforms now let doctors see how their patients are doing in real time — even from hundreds of miles away. And that’s just scratching the surface.

Healthcare providers who partner with a reliable remote patient monitoring software development company can create systems that support personalized, proactive care — not just reactive treatments.

So, What Is IoT in Remote Patient Monitoring?

What Makes an IoT-Enabled RPM System Work?

1. The Devices Themselves

2. Reliable Data Transmission

3. A Secure Cloud Platform

4. Interfaces That Make Sense

The Value IoT Brings to Remote Monitoring

Timely Alerts and Earlier Interventions

Better Care Without Leaving Home

More Control for People with Chronic Illness

Cost and Time Savings

Where It’s Already Making a Difference

After Surgery

Supporting Aging in Place

Monitoring Pregnancies Remotely

Building Secure, Compliant, Scalable Systems

Looking Ahead: What’s Next for IoT and RPM?

Conclusion – Smart Devices, Smarter Care

Across Los Angeles, the Inland Empire and the Coachella Valley, one community health center is extending its services to immigrant patients in their homes after realizing that people were skipping critical medical appointments because they’ve become too afraid to venture out.

St. John’s Community Health, one of the largest nonprofit community healthcare providers in Los Angeles County that caters to low-income and working-class residents, launched a home visitation program in March after learning that patients were missing routine and urgent care appointments because they feared being taken in by U.S. Immigration and Customs Enforcement agents.

St. John’s, which offers services through a network of clinics and mobile units across the region, estimates that at least 25,000 of its patients are undocumented, and about a third of them suffer from chronic conditions, including diabetes and hypertension, which require routine checkups. But these patients were missing tests to monitor their blood sugar and blood pressure, as well as appointments to pick up prescription refills.

Earlier this year, the health center began surveying patients and found that hundreds were canceling appointments “solely due to fear of being apprehended by ICE.”

President Trump came into his second term promising the largest deportation effort in U.S. history, initially focusing his rhetoric on undocumented immigrants who had committed violent crimes. But shortly after he took office, his administration said they considered anyone in the country without authorization to be a criminal.

In the months since, the new administration has used a variety of tactics to sow fear in immigrant communities. The Department of Homeland Security has launched an ad campaign urging people in the country without authorization to leave or risk being rounded up and deported. Immigration agents are showing up at Home Depots and inside courtrooms, in search of people in the U.S. without authorization. Increasingly, immigrants who are detained are being whisked away and deported to their home countries — or, in some cases, nations where they have no ties — without time for packing or family goodbyes.

The Trump administration in January rescinded a policy that once shielded sensitive locations such as hospitals, churches and schools from immigration-related arrests.

In response to the survey results, St. John’s launched the Health Care Without Fear program in an effort to reach patients who are afraid to leave their homes. Jim Mangia, chief executive and president of St. John’s, said in a statement that healthcare providers should implement policies to ensure all patients, regardless of immigration status, have access to care.

“Healthcare is a human right — we will not allow fear to stand in the way of that,” he said.

Bukola Olusanya, a nurse practitioner and the regional medical director at St. John’s, said one woman reported not having left her home in three months. She said she knows of other patients with chronic conditions who aren’t leaving their house to exercise, which could exacerbate their illness. Even some immigrants in the U.S. legally are expressing reservations, given news stories about the government accusing people of crimes and deporting them without due process.

Olusanya said waiting for people to come back in for medical care on their own felt like too great a risk, given how quickly their conditions could deteriorate. “It could be a complication that’s going to make them get a disability that’s going to last a lifetime, and they become so much more dependent, or they have to use more resources,” she said. “So why not prevent that?”

On a recent Thursday at St. John’s Avalon Clinic in South L.A., Olusanya prepared to head to the home of a patient who lived about 30 minutes away. The Avalon Clinic serves a large population of homeless patients and has a street team that frequently uses a van filled with medical equipment. The van is proving useful for home visits.

Olusanya spent about 30 minutes preparing for the 3 p.m. appointment, assembling equipment to draw blood, collect a urine sample and check the patient’s vitals and glucose levels. She said she has conducted physical exams in bedrooms and living rooms, depending on the patient’s housing situation and privacy.

She recalled a similar drop in patient visits during Trump’s first administration when he also vowed mass deportations. Back then, she said, the staff at St. John’s held drills to prepare for potential federal raids, linking arms in a human chain to block the clinic entrance.

But this time around, she said, the fear is more palpable. “You feel it; it’s very thick,” she said.

While telehealth is an option for some patients, many need in-person care. St. John’s sends a team of three or four staff members to make the house calls, she said, and are generally welcomed with a mix of relief and gratitude that makes it worthwhile.

“They’re very happy like, ‘Oh, my God, St. John’s can do this. I’m so grateful,’ ” she said. “So it means a lot.”

A growing coalition of HIV prevention organizations, health experts and Democrats in Congress are sounding the alarm over sweeping Trump administration cuts to HIV/AIDS prevention and surveillance programs nationally, warning they will reverse years of progress combating the disease and cause spikes in new cases — especially in California and among the LGBTQ+ community.

In a letter addressed Friday to Health and Human Services Secretary Robert F. Kennedy Jr., Rep. Laura Friedman (D-Glendale) and 22 of her House colleagues demanded the release of HIV funding allocated by Congress but withheld by the Trump administration. They cited estimates from the Foundation for AIDS Research, known as amfAR, that the cuts could lead to 143,000 additional HIV infections nationwide and 127,000 additional deaths from AIDS-related causes within five years.

Friedman said the effects would be felt in communities small and large across the country but that California would be hit the hardest. She said L.A. County — which stands to lose nearly $20 million in annual federal HIV prevention funding — is being forced to terminate contracts with 39 providers and could see as many as 650 new cases per year as a result.

According to amfAR, that would mark a huge increase, pushing the total number of new infections per year in the county to roughly 2,000.

“South L.A. and communities across California are already feeling the devastating impacts of these withheld HIV prevention funds. These cuts aren’t just numbers — they’re shuttered clinics, canceled programs, and lives lost,” Friedman said in a statement to The Times.

As one example, she said, the Los Angeles LGBT Center — which is headquartered in her district — would likely have to eliminate a range of services including HIV testing, STD screening, community education and assistance for patients using pre-exposure prophylaxis, or PrEP, a medicine taken by pill or shot that can greatly reduce a person’s risk of becoming infected from sex or injection drug use.

A list reviewed by The Times of L.A. County providers facing funding cuts included large and small organizations and medical institutions in a diverse set of communities, from major hospitals and nonprofits to small clinics. The list was provided by a source on the condition of anonymity in order to be candid about the funding of organizations that have not all publicly announced the cuts.

The affected organizations serve a host of communities that already struggle with relatively high rates of HIV infection, including low-income, Spanish speaking, Black and brown and LGBTQ+ communities.

According to L.A. County, the Trump administration’s budget blueprint eliminates or reduces a number of congressionally authorized public health programs, including funding cuts to the domestic HIV prevention program and the Ryan White program, which supports critical care and treatment services for uninsured and underinsured people living with HIV.

The county said the cuts would have “an immediate and long-lasting impact” on community health.

Dozens of organizations and hospitals, such as Children’s Hospital of Los Angeles, are bracing for the disruption and potential vacuum of preventative services they’ve been providing to the community since the 1980s, according to Claudia Borzutzky, the hospital’s Chief of Adolescent and Young Adult Medicine.

Borzutzky said without the funding, programs that provide screening, education, patient navigation and community outreach — especially for at-risk adolescents and young adults — will evaporate. So, too, will free services that help patients enroll in insurance and access HIV prevention medications.

Patients who “face a variety of health barriers” and are often stigmatized will bear the brunt, she said, losing the “role models [and] peer educators that they can relate to and help [them] build confidence to come into a doctor’s office and seek testing and treatment.”

“We are having to sunset these programs really, really quickly, which impacts our patients and staff in really dramatic ways,” she said.

Answers to queries sent to other southern California health departments suggested they are trying to figure out how to cope with budget shortfalls, too. Health officials from Kern, San Bernardino and Riverside counties all said the situation is uncertain, and that they don’t yet know how they will respond.

Friedman and her colleagues — including fellow California representatives Nancy Pelosi, Judy Chu, Gilbert Cisneros Jr., Robert Garcia, Sam Liccardo, Kevin Mullin, Mark Takano, Derek Tran and George Whitesides — said they were concerned not only about funding for programs nationwide being cut, but also about the wholesale dismantling or defunding of important divisions working on HIV prevention within the federal government.

They questioned in their letter staffing cuts to the National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention at the U.S. Centers for Disease Control and Prevention, as well as “the reported elimination” of the Division of HIV Prevention within that center.

In addition to demanding the release of funds already allocated by Congress, the representatives called on Kennedy — and Dr. Debra Houry, deputy director of the CDC — to better communicate the status of ongoing grant funding, and to release “a list of personnel within CDC who can provide timely responses” when those groups to whom Congress had already allocated funding have questions moving forward.

“Although Congress has appropriated funding for HIV prevention in Fiscal Year 2025, several grant recipients have failed to receive adequate communication from CDC regarding the status of their awards,” Friedman and her colleagues wrote. “This ambiguity has caused health departments across the country to pre-emptively terminate HIV and STD prevention contracts with local organizations due to an anticipated lack of funding.”

The letter is just the latest challenge to the Trump administration’s sweeping cuts to federal agencies and to federal funding allocated by Congress to organizations around the country.

Through a series of executive orders and with the help of his billionaire adviser Elon Musk’s “Department of Government Efficiency” and other agency heads, Trump in the first months of his second term has radically altered the federal government’s footprint, laying off thousands of federal workers and attempting to claw back trillions of dollars in federal spending — to be reallocated to projects more aligned with his political agenda, or used to pay for tax cuts that Democrats and independent reviewers have said will disproportionately help wealthy Americans.

California Atty. Gen. Rob Bonta’s office has repeatedly sued the Trump administration over such moves, including cuts and layoffs within Health and Human Services broadly and cuts to grants intended to make states more resistant to infectious disease specifically — calling them unwise, legally unjustifiable and a threat to the health of average Americans.

LGBTQ+ organizations also have sued the Trump administration over orders to preclude health and other organizations from spending federal funding on diversity, equity and inclusion programs geared toward LGBTQ+ populations, including programs designed to decrease new HIV infections and increase healthy management of the disease among transgender people and other vulnerable groups.

“The orders seek to erase transgender people from public life; dismantle diversity, equity, inclusion, and accessibility initiatives; and strip funding from nonprofits providing life-saving health care, housing, and support services,” said Jose Abrigo, the HIV Project Director of Lambda Legal, in a statement. The legal group has filed a number of lawsuits challenging the Trump administration cuts, including one on behalf of the San Francisco AIDS Foundation and other nonprofits.

Trump has defended his cuts to the federal government as necessary to implement his agenda. He and his agency leaders have consistently said that the cuts target waste, fraud and abuse in the government, and that average Americans will be better served following the reshuffling.

Kennedy has consistently defended the changes within Health and Human Services, as well. Agency spokespeople have said the substantial cuts would help it focus on Kennedy’s priorities of “ending America’s epidemic of chronic illness by focusing on safe, wholesome food, clean water, and the elimination of environmental toxins.”

“We aren’t just reducing bureaucratic sprawl. We are realigning the organization with its core mission and our new priorities in reversing the chronic disease epidemic,” Kennedy has said. “This Department will do more — a lot more — at a lower cost to the taxpayer.”

Kennedy has repeatedly spread misinformation about HIV and AIDS in the past, including by giving credence to the false claim that HIV does not cause AIDS.

As recently as June 2023, Kennedy told a reporter for New York Magazine that there “are much better candidates than H.I.V. for what causes AIDS,” and he has previously suggested that environmental toxins and “poppers” — an inhalant drug popular in the gay community — could be causes of AIDS instead.

None of that is supported by science or medicine. Studies from around the world have proven the link between HIV and AIDS, and found it — not drug use or sexual behavior — to be the only common factor in AIDS cases.

Officials in L.A. County said they remained hopeful that the Trump administration would reverse course after considering the effects of the cuts — and the “detrimental impacts on the health and well-being of residents and workers across” the county if they are allowed to stand.