The monopoly can now be considered a 'clear and convincing' benefit to the public with performance that would earn a 'D' on most A-to-F grading scales.

This article was published on Tuesday, June 3, 2025 in KFF Health News.

By Brett Kelman

Despite years of patient complaints and quality-of-care concerns, Ballad Health — the nation's largest state-sanctioned hospital monopoly — will now be held to a lower standard by the Tennessee government, and state data that holds the monopoly accountable will be kept from the public for two years.

Ballad is the only option for hospital care for most of the approximately 1.1 million people in a 29-county swath of Appalachia. Such a monopoly would normally be prohibited by federal law. But under deals negotiated with Tennessee and Virginia years ago, the monopoly is permitted if both states affirm each year that it is an overall benefit to the public.

However, according to a newly renegotiated agreement between Ballad and Tennessee, the monopoly can now be considered a "clear and convincing" benefit to the public with performance that would earn a "D" on most A-to-F grading scales.

And the monopoly can be allowed to continue even with a score that most would consider an "F."

"It's an extreme disservice to the people of northeast Tennessee and southwest Virginia," said Dani Cook, who has organized protests against Ballad's monopoly for years. "We shouldn't have lowered the bar. We should be raising the bar."

The Ballad monopoly, which encompasses 20 hospitals and straddles the border of Tennessee and Virginia, was created in 2018 after lawmakers in both states, in an effort to prevent hospital closures, waived federal antitrust laws so two rival health systems could merge. Although Ballad has largely succeeded at keeping its hospitals open, staffing shortages and patient complaints have left some residents wary, afraid, or unwilling to seek care at Ballad hospitals, according to an investigation by KFF Health News published last year.

In Tennessee, the Ballad monopoly is regulated through a 10-year Certificate of Public Advantage agreement, or COPA — now in its seventh year — that establishes the state's goals and a scoring rubric for hospital performance. Tennessee Department of Health documents show Ballad has fallen short of about three-fourths of the state's quality-of-care goals over the past four fiscal years. But the monopoly has been allowed to continue, at least in part, because the scoring rubric doesn't prioritize quality of care, according to the documents.

Angie Odom, a county commissioner in Tennessee's Carter County, where leaders have clashed with Ballad, said she has driven her 12-year-old daughter more than 100 miles to Knoxville to avoid surgery at a Ballad hospital.

After years of disappointment in Tennessee's oversight of the monopoly, Odom said she was "not surprised" by Ballad's new grading scale.

"They've made a way that they can fail and still pass," she said.

Virginia regulates Ballad with a different agreement and scoring method, and its reviews generally track about one or two years behind Tennessee's. Both states have found Ballad to be an overall benefit in every year they've released a decision.

Neither Ballad Health nor the Tennessee Department of Health, which has the most direct oversight of the monopoly, answered questions submitted in writing about the renegotiated agreement. In an emailed statement, Molly Luton, a Ballad spokesperson, said the company's quality of care has steadily improved in recent years, and she raised repeated complaints from the hospital system about KFF Health News' reporting. The news organization has reviewed every complaint from Ballad and has never found a correction or clarification to be warranted in the coverage.

Tennessee Health Commissioner Ralph Alvarado, who has more than once described the regulation of Ballad Health as a matter of national importance, has declined or not responded to more than a dozen interview requests from KFF Health News to discuss the monopoly.

"Our effort and progress serve as a model for health care in Tennessee, the Appalachia Region, and the entire nation," Alvarado said in a May news release about the monopoly, adding, "We do not take our role lightly as we remain committed to transparency in our COPA oversight."

Tennessee's revised agreement was negotiated behind closed doors for more than a year and announced to the public in early May. As part of that announcement, Tennessee said it wouldn't score Ballad next year, to give the company time to adjust to the new scoring process.

Under that process, the minimum score Ballad needs to meet to show a "clear and convincing" public benefit has been lowered from 85 out of 100 to 70 out of 100. The new agreement also awards Ballad up to 20 points for providing Tennessee with data and records — for example, a report on patient satisfaction — regardless of the level of performance documented. The state can also raise or lower Ballad's overall score by up to 5 points in light of "reputable information" that is not spelled out in the scoring rubric.

Therefore, Ballad can score as low as 65 out of 100, with nearly a third of that score awarded for merely giving information to the state, and still be found to be a "clear and convincing" benefit to the public, which is the highest finding Tennessee can bestow, according to the agreement. And Ballad could score as low as 55 out of 100 without the monopoly facing a risk of being broken up, according to the new agreement.

The agreement also increases how much of Ballad's annual score is directly attributed to the quality of care provided in its hospitals, from 5% to 32%. But the agreement obscures how this will be measured.

Tennessee sets "baseline" goals for Ballad across dozens of quality-of-care issues — like infection rates and speed of emergency room care — and then tracks whether Ballad meets the goals. The new agreement resets these baselines to values that were not made public, leaving it unclear how much the goals for Ballad have changed. Health department spokesperson Dean Flener said the new baselines would not be disclosed until 2027.

Cook, the longtime leader of protests against Ballad, said she believes Tennessee is attempting to silence data-supported criticism until the final year of the 10-year COPA agreement, which ends in 2028.

By then, any outrage would be largely moot, she said.

"If you are going to wait until the last year to tell us the new measurements, why bother?" Cook said. "It is clear, without a shadow of a doubt, that the Tennessee Department of Health is putting the needs and concerns of a corporation above the health and well-being of people."

Brett Kelman: bkelman@kff.org, @BrettKelman

The number of U.S. doctors taking 'the first step' to being licensed in Canada has increased more than 750%.

This article was published on Friday, May 30, 2025 in KFF Health News.

By Brett Kelman

Earlier this year, as President Donald Trump was beginning to reshape the American government, Michael, an emergency room doctor who was born, raised, and trained in the United States, packed up his family and got out.

Michael now works in a small-town hospital in Canada. KFF Health News and NPR granted him anonymity because of fears he might face reprisal from the Trump administration if he returns to the U.S. He said he feels some guilt that he did not stay to resist the Trump agenda but is assured in his decision to leave. Too much of America has simply grown too comfortable with violence and cruelty, he said.

"Part of being a physician is being kind to people who are in their weakest place," Michael said. "And I feel like our country is devolving to really step on people who are weak and vulnerable."

Michael is among a new wave of doctors who are leaving the United States to escape the Trump administration. In the months since Trump was reelected and returned to the White House, American doctors have shown skyrocketing interest in becoming licensed in Canada, where dozens more than normal have already been cleared to practice, according to Canadian licensing officials and recruiting businesses.

The Medical Council of Canada said in an email statement that the number of American doctors creating accounts on physiciansapply.ca, which is "typically the first step" to being licensed in Canada, has increased more than 750% over the past seven months compared with the same time period last year — from 71 applicants to 615. Separately, medical licensing organizations in Canada's most populous provinces reported a rise in Americans either applying for or receiving Canadian licenses, with at least some doctors disclosing they were moving specifically because of Trump.

"The doctors that we are talking to are embarrassed to say they're Americans," said John Philpott, CEO of CanAm Physician Recruiting, which recruits doctors into Canada. "They state that right out of the gate: 'I have to leave this country. It is not what it used to be.'"

Canada, which has universal publicly funded health care, has long been an option for U.S.-trained doctors seeking an alternative to the American health care system. While it was once more difficult for American doctors to practice in Canada due to discrepancies in medical education standards, Canadian provinces have relaxed some licensing regulations in recent years, and some are expediting licensing for U.S.-trained physicians.

In mere months, the Trump administration has jeopardized the economy with tariffs, ignored court orders and due process, and threatened the sovereignty of U.S. allies, including Canada. The administration has also taken steps that may unnerve doctors specifically, including appointing Robert F. Kennedy Jr. to lead federal health agencies, shifting money away from pandemic preparedness, discouraging gender-affirming care, demonizing fluoride, and supporting deep cuts to Medicaid.

The Trump administration did not provide any comment for this article. When asked to respond to doctors' leaving the U.S. for Canada, White House spokesperson Kush Desai asked whether KFF Health News knew the precise number of doctors and their "citizenship status," then provided no further comment. KFF Health News did not have or provide this information.

Philpott, who founded CanAm Physician Recruiting in the 1990s, said the cross-border movement of American and Canadian doctors has for decades ebbed and flowed in reaction to political and economic fluctuations, but that the pull toward Canada has never been as strong as now.

Philpott said CanAm had seen a 65% increase in American doctors looking for Canadian jobs from January to April, and that the company has been contacted by as many as 15 American doctors a day.

Rohini Patel, a CanAm recruiter and doctor, said some consider pay cuts to move quickly.

"They're ready to move to Canada tomorrow," she said. "They are not concerned about what their income is."

The College of Physicians and Surgeons of Ontario, which handles licensing in Canada's most populous province, said in a statement that it registered 116 U.S.-trained doctors in the first quarter of 2025 — an increase of at least 50% over the prior two quarters. Ontario also received license applications from about 260 U.S.-trained doctors in the first quarter of this year, the organization said.

British Columbia, another populous province, saw a surge of licensure applications from U.S.-trained doctors after Election Day, according to an email statement from the College of Physicians and Surgeons of British Columbia. The statement also said the organization licensed 28 such doctors in the fiscal year that ended in February — triple the total of the prior year.

Quebec's College of Physicians said applications from U.S.-trained doctors have increased, along with the number of Canadian doctors returning from America to practice within the province, but it did not provide specifics. In a statement, the organization said some applicants were trying to get permitted to practice in Canada "specifically because of the actual presidential administration."

Michael, the physician who moved to Canada this year, said he had long been wary of what he described as escalating right-ring political rhetoric and unchecked gun violence in the United States, the latter of which he witnessed firsthand during a decade working in American emergency rooms.

Michael said he began considering the move as Trump was running for reelection in 2020. His breaking point came on Jan. 6, 2021, when a violent mob of Trump supporters besieged the U.S. Capitol in an attempt to stop the certification of the election of Joe Biden as president.

"Civil discourse was falling apart," he said. "I had a conversation with my family about how Biden was going to be a one-term president and we were still headed in a direction of being increasingly radicalized toward the right and an acceptance of vigilantism."

It then took about a year for Michael to become licensed in Canada, then longer for him to finalize his job and move, he said. While the licensing process was "not difficult," he said, it did require him to obtain certified documents from his medical school and residency program.

"The process wasn't any harder than getting your first license in the United States, which is also very bureaucratic," Michael said. "The difference is, I think most people practicing in the U.S. have got so much administrative fatigue that they don't want to go through that process again."

Michael said he now receives near-daily emails or texts from American doctors who are seeking advice about moving to Canada.

This desire to leave has also been striking to Hippocratic Adventures, a small business that helps American doctors practice medicine in other countries.

The company was co-founded by Ashwini Bapat, a Yale-educated doctor who moved to Portugal in 2020 in part because she was "terrified that Trump would win again." For years, Hippocratic Adventures catered to physicians with wanderlust, guiding them through the bureaucracy of getting licensed in foreign nations or conducting telemedicine from afar, Bapat said.

But after Trump was reelected, customers were no longer seeking grand travels across the globe, Bapat said. Now they were searching for the nearest emergency exit, she said.

"Previously it had been about adventure," Bapat said. "But the biggest spike that we saw, for sure, hands down, was when Trump won reelection in November. And then Inauguration Day. And basically every single day since then."

At least one Canadian province is actively marketing itself to American doctors.

Doctors Manitoba, which represents physicians in the rural province that struggles with one of Canada's worst doctor shortages, launched a recruiting campaign after the election to capitalize on Trump and the rise of far-right politics in the U.S.

The campaign focuses on Florida and North and South Dakota and advertises "zero political interference in physician patient relationship" as a selling point.

Alison Carleton, a family medicine doctor who moved from Iowa to Manitoba in 2017, said she left to escape the daily grind of America's for-profit healthcare system and because she was appalled that Trump was elected the first time.

Carleton said she now runs a small-town clinic with low stress, less paperwork, and no fear of burying her patients in medical debt.

She dropped her American citizenship last year.

"People I know have said, 'You left just in time,'" Carleton said. "I tell people, 'I know. When are you going to move?'"

Brett Kelman: bkelman@kff.org, @BrettKelman

Oona Zenda: ozenda@kff.org

Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. 

This article was published on Thursday, May 29, 2025 in KFF Health News.

By Vanessa G. Sánchez and Jazmin Orozco Rodriguez

SAN FRANCISCO — Health nonprofits and medical interpreters warn that federal cuts have eliminated dozens of positions in California for community workers who help non-English speakers sign up for insurance coverage and navigate the healthcare system.

At the same time, people with limited English proficiency have scaled back their requests for language services, which healthcare advocates attribute in part to President Donald Trump's immigration crackdown and his executive order declaring English as the national language.

Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. "People are going to have a hard time accessing benefits they're entitled to and need to live independently," said Carol Wong, a senior rights attorney for Justice in Aging, a national advocacy group.

Nearly 69 million people in the U.S. speak a language other than English, and 26 million of them speak English less than "very well," according to the most recent U.S. Census data available, from 2023. A KFF-Los Angeles Times survey from that year found that immigrants with limited English proficiency reported more barriers accessing healthcare and worse health than English-proficient immigrants.

Health advocates fear that, without adequate support, millions of people in the U.S. with limited English proficiency will be more likely to experience medical errors, misdiagnosis, neglect, and other adverse outcomes. During the start of the pandemic in 2020, ProPublica reported that a woman with coronavirus symptoms died in Brooklyn after missing out on timely treatment because emergency room staffers could not communicate with her in Hungarian. And, at the height of the crisis, The Virginian-Pilot first reported that a Spanish translation on a state website erroneously stated that the covid-19 vaccine was not necessary.

In 2000, President Bill Clinton signed an executive order aimed at improving access to federal services for people with limited English proficiency. Research shows language assistance results in higher patient satisfaction, as well as fewer medical errors, misdiagnoses, and adverse health outcomes. Language services also save the healthcare system money by reducing hospital stays and readmissions.

Trump's order repealed Clinton's directive and left it up to each federal agency to decide whether to maintain or adopt a new language policy. Some have already scaled back: The Department of Homeland Security and the Social Security Administration reportedly reduced language services, and the Justice Department says it is reviewing guidance materials. A link to its language plan is broken.

It's unclear what the Department of Health and Human Services intends to do. HHS did not respond to questions from KFF Health News.

An HHS plan implemented under President Joe Biden, including guidance during public health emergencies and disasters, has been archived, meaning it may not reflect current policies. However, HHS's Office for Civil Rights still informs patients of their right to language assistance services when they pick up a prescription, apply for a health insurance plan, or visit a doctor.

And the office added protections in July that prohibit health providers from using untrained staff, family members, or children to provide interpretation during medical visits. It also required that translation of sensitive information using artificial intelligence be reviewed by a qualified human translator for accuracy.

Those safeguards could be undone by the Trump administration, said Mara Youdelman, a managing director at the National Health Law Program, a national legal and health policy advocacy organization. "There's a process that needs to be followed," she said, about making changes with public input. "I would strongly urge them to consider the dire consequences when people don't have effective communication."

Even if the federal government ultimately doesn't offer language services for the public, Youdelman said, hospitals and health providers are required to provide language assistance at no charge to patients.

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race or national origin, protections that extend to language. And the 2010 Affordable Care Act, which expanded health coverage for millions of Americans and adopted numerous consumer protections, requires health providers receiving federal funds to make language services, including translation and interpretation, available. 

"English can be the official language and people still have a right to get language services when they go to access healthcare," Youdelman said. "Nothing in the executive order changed the actual law."

Insurers still need to include multi-language taglines in their correspondence to enrollees explaining how they can access language services. And health facilities must post visible notices informing patients about language assistance services and guarantee certified and qualified interpreters.

State and local governments could broaden their own language access requirements. A few states have taken such actions in recent years, and California state lawmakers are considering a bill that would establish a language access director, mandate human review of AI translations, and improve surveys assessing language needs.

"With increasing uncertainty at the federal level, state and local access laws and policies are even more consequential," said Jake Hofstetter, policy analyst at the Migration Policy Institute.

The Los Angeles Department of Public Health and San Francisco's Office of Civic Engagement and Immigrants Affairs said their language services have not been affected by Trump's executive order or federal funding cuts.

Demand, however, has dropped. Aurora Pedro of Comunidades Indígenas en Liderazgo, one of the few medical interpreters in Los Angeles who speaks Akatek and Qʼanjobʼal, Mayan languages from Guatemala, said she has received fewer calls for her services since Trump took office.  

And other pockets of California have reduced language services because of the federal funding cuts. 

Hernán Treviño, a spokesperson for the Fresno County Department of Public Health, said the county cut the number of community health workers by more than half, from 49 to 20 positions. That reduced the availability of on-the-ground navigators who speak Spanish, Hmong, or Indigenous languages from Latin America and help immigrants enroll in health plans and schedule routine screenings.

Treviño said staffers are still available to support residents in Spanish, Hmong, Lao, and Punjabi at county offices. A free phone line is also available to help residents access services in their preferred language.

Mary Anne Foo, executive director of the Orange County Asian and Pacific Islander Community Alliance, said the federal Substance Abuse and Mental Health Services Administration froze $394,000 left in a two-year contract to improve mental health services. As a result, the alliance is planning to let go 27 of its 62 bilingual therapists, psychiatrists, and case managers. The organization serves more than 80,000 patients who speak over 20 languages.

"We can only keep them through June 30," Foo said. "We're still trying to figure it out — if we can cover people."

Orozco Rodriguez reported from Elko, Nevada.

Vanessa G. Sánchez: vsanchez@kff.org, @vanesanchez_g

Jazmin Orozco Rodriguez: jorozco@kff.org, @jazmin1orozco

Evaluated alongside the administration's actions so far, the early proposal hints at Trump's priorities. 

This article was published on Wednesday, May 21, 2025 in KFF Health News.

By Aneri Pattani

Since President Donald Trump released his 2026 budget blueprint in early May, calling for $163 billion in federal spending cuts, much of the attention has focused on his slashing of foreign aid and boosting of border security. But the proposal also holds important clues — amid some mixed messages — about the administration's approach to two pressing public health issues: mental health and addiction.

There are about 80,000 overdose deaths in the United States each year, recent data shows, and nearly 50,000 deaths by suicide. Trump's proposal includes heavy cuts, totaling more than $22.6 billion, to three federal agencies that address these issues and suggests eliminating programs aimed at suicide and overdose prevention. The administration says this will streamline its efforts, but advocates, researchers, and public health practitioners worry this could make the death toll even worse.

Of course, a proposal is far from a final budget.

And this isn't even a full budget proposal. It's what people on Capitol Hill call a "skinny budget." It covers only discretionary spending that Congress authorizes each year, not larger entitlement programs like Medicare, Medicaid, and Social Security. Those big-ticket items and many other details will be addressed in the administration's full budget, expected in the coming months.

Still, evaluated alongside the administration's actions so far — including slashing the federal health workforce and disupting grants to addiction recovery programs — the early proposal hints at Trump's priorities.

"You don't have it in enough detail to be able to really make assessments" about specific policies, said Rodney Whitlock, a vice president at the McDermott+ consulting firm and a longtime Republican Senate staffer. But "even in a skinny budget, you have to take it seriously and think that, 'Oh yeah, they're going to try to accomplish this.'"

About two weeks before Trump released his skinny budget, a preliminary budget document for the Department of Health and Human Services was leaked, showing deep funding cuts and lists of programs slated for elimination.

Discrepancies between those two documents — the official, skinny budget and the more detailed leaked one — have muddled the budget process even more than usual.

Here are three things that millions of Americans experiencing mental illness or addiction, and their loved ones, should watch as the process continues.

1. There is considerable confusion about the future of suicide prevention programs, including the nation's mental health crisis hotline, 988.

Trump plans to propose spending $520 million on the 988 system next year — the same amount as in the current fiscal year, said Rachel Cauley, a spokesperson for the White House Office of Management and Budget. She told KFF Health News that the president's budget will include an additional $95 million for other suicide prevention programs.

But that's far from clear when looking through the only official budget document released so far.

Trump's skinny proposal calls for more than $1 billion in cuts to the Substance Abuse and Mental Health Services Administration, the government's lead agency on all things related to mental health and addiction. The proposal says much of that comes from "eliminating inefficient funding" for SAMHSA's Programs of Regional and National Significance.

This bucket of spending includes a variety of grant programs, in areas including children's mental health and homelessness prevention. Budget documents from the current fiscal year show some of the costliest programs under this title focus on suicide prevention, including 988 grants to ensure state and regional call centers have the capacity to handle the millions of calls and texts the crisis line receives, Garrett Lee Smith grants focused on preventing youth suicide, and Zero Suicide grants that help health systems develop comprehensive suicide screening and response protocols.

Many people consider these programs vital given the country's ongoing suicide crisis. From 2000 to 2018, the national suicide rate increased 35%. Although there was a slight dip the following two years, the rate returned to its peak in 2022.

The 988 system, since launching in 2022 under the Biden administration, has fielded more than 9.8 million calls and 2.5 million texts.

"Cutting this funding is going to be disastrous," said Paul Nestadt, a psychiatrist and an associate professor at Johns Hopkins University. "A lot of suicide prevention does take place at the state or even local level, but it's funded by federal programs."

The skinny budget proposal says, "These programs either duplicate other Federal spending or are too small to have a national impact."

Cauley did not respond to questions about where she got the 988 and suicide prevention funding numbers she cited or why they differ from what's noted in the skinny budget.

Although it's fairly common to see discrepancies among an administration's various budget documents, attention to these documents — and concerns about differences — are heightened this year amid the Trump team's efforts to radically downsize the government and federal spending.

"It's very confusing," said Laurel Stine, chief advocacy and policy officer with the American Foundation for Suicide Prevention. "We want to ensure that the 988 lifeline is safeguarded," but the only officially released budget document "doesn't speak to it at all."

Another point of confusion: The skinny budget suggests that states can accomplish the work supported by the eliminated funding through separate block grants they receive from the federal government to address mental health and addiction.

However, those grants are specifically aimed at caring for people with serious mental illness and cannot be spent on suicide prevention for the general public.

2. The administration wants to cut certain tools used for preventing drug overdoses.

In the skinny budget, the Trump administration says it is "committed to combatting the scourge of deadly drugs that have ravaged American communities."

It goes on to propose eliminating the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control, which has overseen a lot of overdose prevention work, and consolidating the infectious disease and opioids program with three other programs, effectively reducing its budget and capacity.

Some advocates, clinicians, and researchers worry such actions could reverse the recent progress made on overdose deaths.

"President Trump says that he wants to protect Americans from fentanyl," said Hanna Sharif-Kazemi, who works on federal affairs for the Drug Policy Alliance, an advocacy organization for people who use drugs. "But the plan that he has outlined in his budget proposal really doesn't match those words."

The proposal refers to "harm reduction" efforts, including providing sterile syringes to people using drugs, as "dangerous activities" and suggests federal funds should not support them.

But syringe service programs are among the most studied interventions and are proven to reduce the transmission of infectious diseases, such as HIV and hepatitis, without increasing crime or drug use.

They also "do so much more than just give syringes," Sharif-Kazemi said, adding that they typically distribute naloxone, which can reverse opioid overdoses, and connect people to resources for food, housing, and treatment, which help keep them alive.

Without these programs, infectious diseases are more likely to spread and affect the broader community, said Nestadt, the Johns Hopkins professor. "Eliminating those programs is going to have terrible effects on the population of the United States, regardless of whether they're using opiates or not."

3. Research cuts aimed at 'DEI' could worsen disparities in suicide and overdose rates.

The Trump proposal takes an axe to the National Institutes of Health, wiping out nearly $18 billion of the research agency's budget and eliminating several centers within it, including the National Institute on Minority and Health Disparities.

These actions align with Trump's ongoing attacks on "diversity, equity, and inclusion" programs, which he calls "woke" ideology.

Researchers say the proposed cuts, if enacted, could hamper efforts to address racial disparities in mental health and addiction that have become increasingly prominent.

Although national overdose deaths dropped last year, rates have increased in many Black and Native American communities.

Suicide rates have been rising faster for Black Americans than for their white counterparts. Early in the covid-19 pandemic, when suicide rates decreased for white Americans, they trended in the opposite direction for Black Americans and other communities of color.

"It might seem to the layperson that suicide is suicide, overdose is overdose," Nestadt said. But the data shows that trends are different for different groups. That means the factors that drive them to suicide — and the interventions that could save their lives — may be different.

"If I want to reach people with suicidal thoughts that are a highly educated, affluent population that has access to health care, I'm going to go to primary care doctors and pediatricians" to implement interventions, Nestadt said. But when trying to reach urban Black teens who have limited access to health care, "maybe it's a church" or barbershop, he said.

Nestadt is currently working on a CDC-funded study in which he interviews the family and friends of Black youths who died by suicide to understand what led to that point and how it could be prevented. He worries his funding could be cut any day.

What happens next?

Nothing in any Trump budget proposal is final. Lawmakers hold the power to determine federal spending.

Although some advocates worry that congressional Republicans will simply accede to Trump's demands, Whitlock, the McDermott+ consultant, said, "Congress is always going to want to express its will, and this will be no different."

Susan Collins, the Republican chair of the Senate Appropriations Committee, which oversees the budget, has stated that she has "serious objections" to some of the proposed cuts.

And when Health and Human Services Secretary Robert F. Kennedy Jr. appeared before House and Senate committees on May 14, some lawmakers pushed back on the administration's plans. Rep. Madeleine Dean (D-Pa.) held up a packet of naloxone and said the government should amplify what works to decrease overdose deaths instead of shuttering SAMHSA.

"Help us save more lives," she said. "Don't shift it and shaft it."

Aneri Pattani: apattani@kff.org, @aneripattani