“I’ve got a surgeon that’s willing to do it. My facility isn’t big enough,” Stansbury said. “And urgent services like obstetrics I can’t do in my hospital, because my facility won’t meet code.”

Besides securing additional revenue for the hospital, such an expansion could keep locals from having to drive the 100 miles to Denver for orthopedic surgeries or to deliver babies.

Rural hospitals throughout the nation are facing a similar conundrum. An increase in costs amid lower payments from insurance plans makes it harder for small hospitals to fund large capital improvement projects. And high inflation and rising interest rates coming out of the pandemic are making it tougher for aging facilities to qualify for loans or other types of financing to upgrade their facilities to meet the ever-changing standards of medical care.

“Most of us are operating at very low margins, if any margin at all,” Stansbury said. “So, we’re struggling to find the money.”

Aging hospital infrastructure, particularly in rural areas, is a growing concern. Data on the age of hospitals is hard to come by, because hospitals expand, upgrade, and refurbish different parts of their facilities over time. A 2017 analysis by the American Society for Health Care Engineering, a part of the American Hospital Association, found that the average age of hospitals in the U.S. increased from 8.6 years in 1994 to 11.5 years in 2015. That number has likely grown, industry insiders say, as many hospitals delayed capital improvement projects, particularly during the pandemic.

Research published in 2021 by the capital planning firm Facility Health Inc., now called Brightly, found that U.S. health care facilities had deferred about 41% of their maintenance and would need $243 billion to complete the backlog.

Rural hospitals don’t have the resources of larger hospitals, particularly those in hospital chains, to fund billion-dollar expansions.

Most of today’s rural hospitals were opened with funding from the Hill-Burton Act, passed by Congress in 1946. That program was rolled into the Public Health Service Act in the 1970s and, by 1997, had funded the construction of nearly 7,000 hospitals and clinics. Now, many of those buildings, particularly those in rural areas, are in dire need of improvements.

Stansbury, who is also board chair of the Colorado Hospital Association, said at least a half-dozen rural hospitals in the state need significant capital investment.

Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a think tank in Pittsburgh, said the major problem for small rural hospitals is that private insurance is no longer covering the full cost of providing care. Medicare Advantage, a program under which Medicare pays private plans to provide coverage for seniors and people with disabilities, is a major contributor to the problem, he said.

“You’re basically taking patients away from what may be the best payer that the small hospital has, and pushing those patients onto a private insurance plan, which doesn’t pay the same way that traditional Medicare pays and ends up also using a variety of techniques to deny claims,” Miller said.

Rural hospitals also must staff their emergency rooms with physicians round-the-clock, but the hospitals get paid only if someone comes in.

Meanwhile, labor costs coming out of the pandemic have increased, and inflation has driven up the cost of supplies. Those financial headwinds will likely push more rural hospitals out of business. Hospital closures dropped during the pandemic, from a record 18 closures in 2020 to a combined eight closures in 2021 and 2022, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill, as emergency relief funds kept them open. But that life support has ended, and at least nine more closed in 2023. Miller said closures are reverting to pre-pandemic rates.

That raises concerns that some hospitals might invest in new facilities and end up shutting down anyway. Miller said only a small portion of rural hospitals might be able to make a meaningful difference to their bottom lines by adding new services.

Lawmakers have tried to help. California, for example, has loan programs charging low to no interest that rural hospitals can participate in, and hospital representatives are urging Colorado legislators to approve similar support.

At the federal level, Rep. Yadira Caraveo, a Colorado Democrat, has introduced the bipartisan Rural Health Care Facilities Revitalization Act, which would help rural hospitals get more funding for capital projects through the U.S. Department of Agriculture. The USDA has been one of the largest funders of rural development through its Community Facilities Programs, providing over $3 billion in loans a year. In 2019, half of the more than $10 billion in outstanding loans through the program helped health care facilities.

“Otherwise, facilities would have to go to private lenders,” said Carrie Cochran-McClain, chief policy officer for the National Rural Health Association.

Rural hospitals might not be very attractive to private lenders because of their financial constraints, and thus may have to pay higher interest rates or meet additional requirements to get those loans, she said.

Caraveo’s bill would also allow hospitals that already have loans to refinance at lower interest rates, and would cover more categories of medical equipment, such as devices and technology used for telehealth.

“We need to keep these places open, even not just for emergencies, but to deliver babies, to have your cardiology appointment,” said Caraveo, who is also a pediatrician. “You shouldn’t have to drive two, three hours to get it.”

Kristin Juliar, a capital resources consultant for the National Organization of State Offices of Rural Health, has been studying the challenges rural hospitals face in borrowing money and planning big projects.

“They’re trying to do this while they’re doing their regular jobs running a hospital,” Juliar said. “A lot of times when there are funding opportunities, for example, the timing may be just too tight for them to put together a project.”

Some funding is contingent on the hospital raising matching funds, which may be difficult in distressed rural communities. And most projects require hospitals to cobble together funding from multiple sources, adding complexity. And since these projects often take a long time to put together, rural hospital CEOs or board members sometimes leave before they come to fruition.

“You get going at something and then key people disappear, and then you feel like you’re starting all over again,” she said.

The hospital in Hugo opened in 1959 after soldiers coming back from World War II decided that Lincoln County on the eastern Colorado plains needed a hospital. They donated money, materials, land, and labor to build it. The hospital has added four family practice clinics, an attached skilled nursing facility, and an off-site assisted living center. It brings in specialists from Denver and Colorado Springs.

Stansbury would like to build a new hospital roughly double the size of the current 45,000-square-foot facility. With inflation easing and interest rates likely to go down this year, Stansbury hopes to get financing lined up in 2024 and to break ground in 2025.

“The problem is, every day I wake up, it gets more expensive,” Stansbury said.

When hospital officials first contemplated building a new hospital three years ago, they estimated a total project cost of about $65 million. But inflation skyrocketed and now interest rates have gone up, pushing the total cost to $75 million.

“If we have to wait another couple of years, we may be pushing up closer to $80 million,” Stansbury said. “But we’ve got to do it. I can’t wait five years and think the costs of construction are going to go down.”

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“I was just trying to make a living,” said Brady, 56, a dealer and supervisor at Borgata in that New Jersey resort city. “You don’t think, you know, that you’re going to get sick at your job.”

Some casinos continue to allow indoor smoking even as the share of Americans who smoke fell from about 21% in 2005 to 12% in 2021 and smoking is banned in at least some public spaces in 35 states, the District of Columbia, and U.S. territories. Still, 13 of the 22 states and territories that allow casino gambling permit smoking in at least part of their facilities.

Brady is among the casino employees, anti-smoking advocates, and public health experts who argue it is long past time to snuff out casino exemptions from smoking bans, given the dangers of secondhand smoke. But they’ve faced stiff pushback from some gambling industry leaders, including in Missouri, Louisiana, Kentucky, and New Jersey, who argue that smoking bans drive gamblers away — especially in places where patrons can go instead to a casino in a nearby jurisdiction that allows them to light up.

The covid-19 pandemic renewed this fight and sharpened the arguments on both sides — on the dangers of particulate matter for the anti-smoking side and the vulnerability of revenues for the casino industry, even as the American Gaming Association reported record-breaking revenues in 2022 for in-person casino gambling beyond the growth of sports betting and online gambling.

Casinos were shut down for several months in spring 2020 as part of the nationwide effort to mitigate the spread of the coronavirus. Rules governing reopening, including masking and physical distancing requirements and bans on smoking, varied by state and, in some cases, by casino operator and community.

After suffering pandemic-era losses, some casino executives, and at least one union representing workers, leaned into a 2021 report commissioned by the Casino Association of New Jersey to combat efforts to ban or restrict smoking at their properties. Using data from 2019, the report suggests that as many as 2,500 Atlantic City casino workers could lose their jobs and tax revenue could fall by as much as $44 million in the first year if smoking is banned in New Jersey but not in neighboring Pennsylvania. Both states considered prohibitions on casino smoking in 2023; New Jersey lawmakers didn’t pass their bill and Pennsylvania’s remains in limbo.

Brian Christopher, a social media influencer specializing in casinos and gambling, said he has heard the arguments about lost business before — and is unconvinced. “People are not driving or flying to a casino to have a cigarette,” he said.

Still, officials in some places are persuaded by arguments about depressed tax revenue. Last spring, Shreveport, Louisiana, officials repealed a 2020 ban on smoking in casinos. Those pushing the repeal said local gambling taxes fell when gamblers left for nearby casinos where they could smoke. The new ordinance allows smoking on 75% of the casino floor.

And Churchill Downs Inc. announced in June it was moving a gambling facility planned for empty mall space in Owensboro, Kentucky, to a location outside the city limits. Though the company declined to comment for this article, the city’s mayor told the Messenger-Inquirer newspaper that a primary reason for the move was the city’s long-standing voter-approved smoking restrictions, which do not exempt casinos.

Kanika Cunningham, director of the St. Louis County Department of Public Health in Missouri, was part of an effort last year to end a casino loophole in her county’s 2011 indoor smoking ban. But after pushback from the gambling company Penn Entertainment, a compromise was reached allowing smoking on 50% of a casino’s floor.

“It’s a balance and one that we feel the marketplace should determine, particularly in such a competitive environment with other gaming facilities nearby and in neighboring states,” said Jeff Morris, Penn Entertainment’s vice president of public affairs and government relations.

Penn Entertainment employs “state of the art ventilation systems, extremely high ceilings,” and “adequate separation of smoking and non-smoking areas,” he wrote in an email to KFF Health News.

The problem, Cunningham said, is that secondhand smoke cannot be contained to a single location in a big room.

“There’s no safe amount, and trying to restrict it to a certain area isn’t going to work,” she said.

Filtration systems can remove much of the visible smoke, as well as the odor, from indoor spaces even when lots of people are smoking, creating the impression of clean air. But existing technology does not eliminate the dangerous particulates in cigarette smoke, according to a 2023 report from the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE.

A study published in 2023 for the National Institutes of Health evaluated particulate matter at eight Las Vegas casinos that allowed smoking and one that did not. In casinos where smoking is allowed, particulate levels were significantly higher — even in areas designated as nonsmoking — than at the nonsmoking casino.

And in ventilated casinos where indoor smoking is allowed, one study showed, workers can have nicotine levels as much as 600% higher than employees exposed to smoking in other workplaces.

Secondhand smoke can cause coronary heart disease, stroke, lung cancer, and other diseases. Some studies have shown a link to breast cancer, although more research is needed, according to the National Cancer Institute.

The pandemic raised awareness of the dangers of airborne particulates, giving smoking bans fresh momentum, said Andrew Klebanow, co-founder of the independent industry consulting group C3 Gaming, which produced a report in 2022 largely refuting the economic risk of casinos going smoke-free.

Indeed, more than 1,000 U.S. casinos and other gambling properties now ban smoking, including more than 140 tribal casinos, according to Americans Nonsmokers’ Rights Foundation.

New Mexico’s tribal leaders collectively agreed to maintain smoking bans when pandemic restrictions were lifted, said Denis Floge, chief executive of Acoma Business Enterprises and Sky City Casino in North Acomita Village. Employee health has improved, he said, qualifying the casino for rebates on its insurance premium. Cleaning and replacement costs for carpets and equipment fell, he said, and the tribes “haven’t missed a beat” on revenues.

Some guests have grumbled about having to go outside to smoke, Floge said, but that’s about it. “We don’t have anybody who jumps up and down, or throws a fit and says, ‘I’m leaving and never coming back!’” he said.

Casino executives who oppose smoking restrictions overlook people who want to enjoy the “great food and the great entertainment, but won’t step foot in a casino because they get hit by a blast of smoke as soon as they step in,” said Pete Naccarelli, a Borgata dealer and one of three co-founders of the advocacy organization Casino Employees Against Smoking’s Effects.

He said they founded the group, which has chapters in New Jersey, Kansas, Pennsylvania, Rhode Island, and Virginia, after his casino put out ashtrays at 12:01 a.m. the day the pandemic-related smoking ban officially ended. Borgata did not answer requests for comment.

The industry-commissioned report on New Jersey suggests that while more nonsmokers might frequent casinos once smoking is banned, they probably would not make up for the revenue lost if smokers choose other venues or when smokers take breaks from gambling to light up.

But Brady, now cancer-free after chemotherapy and a full mastectomy, believes that if policymakers spent some time breathing the same air she and her co-workers do they’d act more quickly to ban smoking in casinos, rather than prioritize tax revenues. “Our lives are more important,” she said.

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Several organizations waiting for contracts to be approved and funding to arrive said that more than 200 private and public contractors across the state government were affected at one point. Montana Department of Public Health and Human Services officials acknowledged the delays but would not confirm the total number of contracts affected.

“I’ve never seen it this dysfunctional,” said Jim Hajny, executive director of Montana’s Peer Network, a state contractor affected by the delays. “Something just completely broke down, but there is nothing coming out. Not even a letter to say, ‘Hey, sorry, we’re not going to get the contracts out.’”

The state health department contracts with more than 4,000 organizations, including crisis mental health care and other critical local services. Contractors have reported going months without pay; one said it had been nine months. Some have laid off employees, scaled back services, or stalled programs.

By January, the health department had 31 contracts left to finalize out of more than 700 due for review from June through December, spokesperson Jon Ebelt said.

Ebelt blamed the delays, in part, on a higher-than-usual contract load, staff turnover, and new legislative mandates.

The department also has increased the scrutiny of contracts during the state’s legal review process. That is due to a new emphasis by the state Department of Administration on “the importance of legal review of agency contracts,” Ebelt said.

The bureaucratic snafu comes amid an ongoing initiative by Republican Gov. Greg Gianforte to cut bureaucratic red tape and strengthen the state’s mental health system, which has long been shaky.

Health department officials wouldn’t disclose how much money is owed to organizations with outstanding or finalized contracts. The health and administration departments “have worked collaboratively and constructively to address delayed contracts,” health department spokesperson Holly Matkin told KFF Health News by email. “We have no further comment.”

Both agencies assigned additional staffers to finalize the remaining contracts.

Marvin Colman, who runs a substance use disorder facility in Helena, Colman Community Services, said he hasn’t received any of the $330,000 grant it was awarded last April. The federal grant, managed through the state health department, was supposed to cover people who can’t afford insurance or don’t qualify for Medicaid.

Colman hired staff and opened a second clinic in anticipation of the funding. Colman said he went into debt to stay open nine months, during which time about half of his employees resigned and he closed the new clinic. Now, due to the unpredictable funding, Colman said, they can no longer treat uninsured people.

“We discharged 20 clients this last week, not because they didn’t need services, but because we can’t afford to do it anymore,” Colman said.

In Ronan, on the Flathead Indian Reservation, a drop-in center for people in addiction recovery run by Never Alone Recovery Support Services is reducing hours. Executive Director Don Roberts said staffers, including himself, had to take part-time jobs after the company dwindled its reserve funds waiting months for a finalized contract.

“I’m worried about keeping people alive,” said Roberts, a licensed addiction counselor. “If a person is like, ‘I need help right now,’ and they show up at the recovery home and we’re not here, what happens to that person? They go and relapse.”

He worries those who survive a crisis won’t come back the next time they need help.

After three months without state funding that covers payroll, Roberts still doesn’t understand what caused the delay. He said state employees trying to finalize the contract are helpful, but even they seem confused about the cause of the holdup.

Once the money comes in, the inconsistent hours will remain for the foreseeable future due to workers’ new part-time jobs, Roberts said.

Montana’s Peer Network, which trains mental health workers statewide, delayed holding its courses and laid off employees in October due to a lapse in multiple state contracts, Hajny said. Neither the health nor administration department explained why there was a delay or when to expect payment as of early January, he said.

One of the legislative mandates Ebelt cited as a factor in the delays is a new state law requiring state contractors to verify in writing that they won’t discriminate against companies that make, distribute, or sell guns, or firearm associations.

Hajny shared emails with KFF Health News that showed his organization waited at least a month for a state official to sign off on its firearm nondiscrimination declaration.

Although some of the company’s contracts were finalized in December, he’s still waiting for backdated pay. In the meantime, one employee found a new job, and Hajny said he’s gotten calls from agencies with new hires who need training.

“How can I bring my employees who were laid off back on if I haven’t been paid for three months?” Hajny said. “It’s because the department can’t get a contract out.”

The impact of the delayed funding varies based on how large an organization is and how much cash it has on hand.

Gallatin County Commissioner Zach Brown said the state hasn’t paid the county for its mobile crisis response services for six months. Officials found temporary funding to fill the gap, something smaller governments likely can’t afford to do.

Brown said he trusts the state will eventually pay up, but he doesn’t know how much the county will be reimbursed for what it’s spending now. He also worries that the unpredictability risks scaring off contractors that helped launch its mobile crisis team.

“It’s a big deal for our community to sort of organize its crisis system around having this service available,” Brown said. “It’s not like we’ve got other folks champing at the bit to try and stand something like this up. It’s not a moneymaker. It’s really a difficult service to provide.”

Matt Furlong is a board member of the Montana Mental Health Central Service Area Authority, which advocates for and supports mental health services. The health department historically runs a little late in paying contracts, Furlong said. But this time, the gap has lasted long enough to risk contractors’ operations.

He said organizations are hesitant to speak publicly for fear the state will withhold future contracts. Living in uncertainty can create lasting trust issues between already stretched-thin health workers and the state.

“It just breaks everybody down,” Furlong said.

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Her commitment to becoming a maternal health care provider was sparked early on when she witnessed the discrimination and judgment leveled against her older sister, who became a mother as a teen. When the Supreme Court overturned Roe v. Wade in 2022, Peacock was already in her residency program in California, and her thoughts turned back to women like her sister.

“I knew that the people — my people, my community back home — was going to be affected in a dramatic way, because they’re in the South and because they’re Black,” she said.

But even though Peacock attended the Medical College of Georgia, she’s doing her obstetrics and gynecology residency at the University of California-San Francisco, where she has gotten comprehensive training in abortion care.

“I knew as a trainee that’s what I needed,” said Peacock, who plans to return to her home state after her residency.

Ever since the Supreme Court decision, California has worked to become a sanctuary for people from states where abortion is restricted. In doing so, it joins 14 other states, including Colorado, New Mexico, and Massachusetts. Now, it’s addressing the fraught issue of abortion training for medical residents, which most doctors believe is crucial to comprehensive OB-GYN training.

A law enacted in September makes it easier for out-of-state trainees to get up to 90 days of in-person training under the supervision of a California-licensed doctor. The law eliminated the requirement for a training license and also permitted training at programs such as Planned Parenthood that are affiliated with accredited medical schools.

“By allowing physician residents to come to California, where there are more opportunities for abortion training, and by allowing them to be reimbursed for this work, we’re sending a message that abortion care is health care and an essential part of physician training,” said Lisa Folberg, CEO of the California Academy of Family Physicians, which supported the bill.

The question of how to provide complete OB-GYN training promises to become more urgent as the effects of abortion bans on medical education become clear: 18 states restrict or ban abortion to the point of effectively stripping 20% of OB-GYN medical residents of the opportunity to get abortion training, according to the Ryan Residency Training Program in Abortion and Family Planning. That’s 1,354 residents this year out of 5,962 OB-GYN residents nationwide.

The restrictions in some cases aim to reach beyond state borders, spooking medical students and residents who fear hostility from anti-abortion groups and right-wing legislators.

One OB-GYN resident in a state with abortion restrictions, who asked to remain anonymous for fear of reprisals, said she’s keen on getting comprehensive abortion care training in California — but can’t.

“My program will not allow us to perform abortions in other states,” she said.

She said administrators worry that doing so would subject residents to litigation because the program is state-funded.

“That is how my program is interpreting the law,” she said. “They’re being very conservative in order to protect us.”

Pamela Merritt, executive director of Medical Students for Choice, pointed to a Kansas law that requires repayment of state medical school scholarships — with 15% interest — if residents perform abortions or work in clinics that perform them, except in cases of rape, incest, or a medical emergency.

Doctors point out that abortion training is not just about ending pregnancies. Peacock recalled a patient who started hemorrhaging badly shortly after a healthy delivery. Peacock and her team at UCSF performed a dilation and curettage — a procedure commonly used to terminate pregnancy.

“If we did not have that skill set, and the patient continued to bleed, it could have been life-taking,” said Peacock, chief OB-GYN resident at UCSF.

It’s not yet clear how many spots will be available in California to train out-of-state medical residents as demand ratchets up. “Many sites were already at their training maximums and are unable to expand opportunities to others,” said Michael Belmonte, a fellow with the American College of Obstetricians and Gynecologists.

Between June 2022, when Roe was overturned, and the end of June 2023, 125 out-of-state doctors did residencies in programs that use the Ryan Residency Training Program model, according to Kristin Simonson, director of programs and operations. Ryan helps OB-GYN residency programs integrate comprehensive abortion care training.

Even when opportunities to learn abortion care are available, those seeking training are proceeding with caution. “Residents arranging to travel for abortion training, like patients who travel for abortion care, are making arrangements quietly so they do not draw unwanted attention or repercussions,” said Janet Jacobson, medical director and senior vice president of clinical services at Planned Parenthood of Orange and San Bernardino Counties, which just trained its first resident from a state with an abortion ban.

Statistics on harassment and attacks against abortion providers or disruption of their work back up such concerns, even in states where abortions are allowed. From 2021 to 2022, for example, there were upticks in stalking of personnel, bomb threats, assault and battery, and obstruction, according to the latest data from the National Abortion Federation.

Jessica Mecklosky, a pediatric resident at UCSF, said she hopes to focus on adolescent medicine, including reproductive health, where she can offer young patients choices about their futures. Her medical school experience in Louisiana, she said, is a prime example of why abortion training in California and other states is so crucial.

She initially wanted to specialize in obstetrics and gynecology but switched to pediatrics, which also would involve reproductive health care. Although she knew Louisiana had abortion restrictions, she didn’t realize how much those restrictions would interfere with her ability to learn: There were just three abortion clinics in the entire state, and as she soon found out, none were available for her training.

“I was actually not going to be able to see any elective abortion procedures throughout medical school, because we don’t rotate through any abortion clinics,” she said. There was an opportunity for a day’s training in her third year, “but, unfortunately, Roe fell before I was able to do that.”

Through Medical Students for Choice, a group that provides stipends of up to $1,200, Mecklosky got an abortion care rotation at Montefiore Medical Center in New York during her summer break.

Mecklosky is torn about where she’ll land after her residency. She may return to Louisiana and advocate for legislative changes in reproductive health while attending to patients and making forays to other states to provide abortions.

She recounts an experience in New Orleans when the Dobbs v. Jackson Women’s Health Organization decision, which undid Roe, was imminent that is etched into her memory. “I had actually seen a few patients who were minors, were pregnant, and wanted to terminate their pregnancies,” she said, noting that they could not afford to travel for an abortion. “And I just remember having this sense of dread, just knowing that if we couldn’t get them into an appointment in the next 24 or 48 hours, it was possible that they would not be able to do it.”

Peacock, for her part, is adamant about returning to Georgia, where abortions are banned after six weeks. “I’m still going to provide abortions, whether that’s in Georgia or I need to fly to a different state and work in abortion clinics for a week out of the month,” she said. “It would definitely be a big part of my work.”

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

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The added services would provide care to patients who live in largely rural eastern Iowa, including some of the hundreds previously treated at a University of Iowa clinic, saving them half-day drives to clinics in larger cities like Chicago and Minneapolis.

By June, The Project of the Quad Cities, as the Illinois clinic is called, had hired a provider who specializes in transgender health care. So, Andy Rowe, The Project’s health care operations director, called the clinic’s insurance broker to see about getting the new provider added to the nonprofit’s malpractice policy.

“I didn’t anticipate that it was going to be a big deal,” Rowe said. Then the insurance carriers’ quotes came. The first one specifically excluded gender-affirming care for minors. The next response was the same. And the one after that. By early November, more than a dozen malpractice insurers had declined to offer the clinic a policy.

Rowe didn’t know it at the time, but he wasn’t alone in his frustrating quest.

Nearly half the states have banned medication or surgical treatment for transgender youth. Independent clinics and medical practices located in states where such care is either allowed or protected have moved to fill that void for patients commuting or relocating across state lines. But as the risk of litigation rises for clinics, obtaining malpractice insurance on the commercial marketplace has become a quiet barrier to offering care, even in states with legal protections for health care for trans people. In extreme cases, lawmakers have deployed malpractice insurance regulations against gender-affirming care in states where courts have slowed or blocked anti-trans legislation.

Five months after starting his search for malpractice insurance, Rowe said, he received a quote for a policy that would allow The Project to treat trans youth. That’s when he realized finding a policy was only the first hurdle. He expected the coverage to cost $8,000 to $10,000 a year, but he was quoted $50,000.

Rowe said he hadn’t experienced anything like it in his 20 years working in health care administration.

Insurance industry advocates argue that higher premiums are justified because the rise in legislation surrounding gender-affirming care for minors means clinics are at increased risk of being sued.

“If state laws increase the risk of civil liability for health professionals, premiums will be adjusted accordingly and appropriately to reflect the level of financial risk incurred by the insured,” Mike Stinson, vice president of public policy and legal affairs at the Medical Professional Liability Association, an insurance trade association, said in an emailed statement. If state laws make an activity illegal, then insurance will not cover it at all, he said.

Only a few states have passed laws preventing malpractice insurers from treating gender-affirming care differently than other care. Massachusetts was the first, when lawmakers there passed legislation that says insurers could not increase rates for health care providers for offering services that are illegal in other states.

Since then, five other states have passed laws requiring malpractice insurers to treat gender-affirming health care as they do any other legally protected health activity: Colorado, Vermont, New York, Oregon, and California (similar legislation is pending in Hawaii).

“This was a preventative measure, and it was met with full acceptance by both the insured and the insurers,” said Vermont state Sen. Virginia “Ginny” Lyons, a Democrat who co-sponsored the state’s law. She said lawmakers consulted with both physicians and malpractice insurance companies to make sure the language was accurate. Insurers just wanted to be able to clearly assess the risk, she said.

Lyons said she hadn’t heard of any providers in Vermont who had trouble with their malpractice insurance before the law was enacted, but she was concerned politics might get in the way of doctors’ ability to offer care. In March 2022, The Texas Tribune reported that one Texas doctor had stopped offering care because his malpractice provider had stopped covering hormone therapy for minors.

Lawmakers in some states have gone further and revised malpractice provisions to restrict access to gender-affirming care, often while bans on offering that care to trans youth are stalled in court. In 2021, Arkansas became the first state to ban gender-affirming care for trans children. When that ban was held up in court last year, the governor signed a new law allowing anyone who received gender-affirming care as a minor to file a malpractice lawsuit up to 15 years after they turn 18.

Similar laws followed in Tennessee, Florida, and Missouri, all extending the statute of limitations on filing a malpractice claim anywhere from 15 to 30 years. (Another was introduced but not passed in Texas that would have stretched the statute of limitations to the length of the patient’s life.) Typically, malpractice suits must be filed within one to three years of injury.

The civil liability that those laws created has forced at least one clinic to stop offering some treatments. The Washington University Transgender Center in Missouri said the law subjected the clinic to “unacceptable level of liability.”

Alejandra Caraballo, a civil rights attorney and clinical instructor at the Harvard Law School Cyberlaw Clinic, said there has been “a concerted effort on the part of anti-trans activists to utilize malpractice insurance as a means of eliminating care.”

She likens the strategy to laws that have long targeted abortion providers by increasing “legal liability to chill a certain type of conduct.”

Anti-trans activists have drawn attention to a small number of “detransitioners,” who have filed lawsuits against the doctors who provided them with gender-affirming care, she said. She believes those lawsuits, filed in such states as California, Nebraska, and North Carolina, will be used to lobby for longer statutes of limitations and to create the perception that liability for providers is increasing.

For independent clinics, like The Project in the Quad Cities, and small medical practices that purchase their malpractice insurance on the commercial marketplace, those tactics are restricting their ability to offer care. Many providers of gender-affirming care are protected from rising premiums such as health centers that receive federal funding, which are covered under the Federal Tort Claims Act, or academic medical centers and Planned Parenthood clinics, which are self-insured. But a small number of independent clinics have been priced out.

In Albuquerque, New Mexico, a state that, like Illinois, has protected access to gender-affirming care, family medicine physician Anjali Taneja said the clinic where she works is running into the same trouble getting coverage.

Casa de Salud, where Taneja is the executive director, has provided gender-affirming care to adults for years, but when the clinic decided to start offering that care to younger patients, insurers wouldn’t issue a malpractice policy. The clinic was quoted “double what we paid a few years ago,” just to cover the gender-affirming care it offers to adults, Taneja said.

The red tape both Casa de Salud and The Project are encountering has prevented treatment for patients. When Iowa’s ban on gender-affirming care took effect Sept. 1, officials at The Project had hoped to offer services to the transgender youth who previously sought care an hour west at the University of Iowa’s LGBTQ Clinic. Instead, Rowe said, patients are making the difficult decision between going without treatment or commuting four hours to Chicago or Minneapolis.

After months of fundraising, The Project has almost enough money to pay for the $50,000 malpractice policy. But, Rowe said, “it’s a tough swallow.”

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An infusion of reliable federal funding, advocates say, could allow these nonprofits to expand their reach to more residents most at risk of being shot — or of shooting someone.

So far, California, Colorado, Connecticut, Illinois, Maryland, New York, and Oregon have passed laws approving the use of Medicaid money for gun violence prevention, said Kyle Fischer, policy and advocacy director for The Health Alliance for Violence Intervention, which has lobbied for the federal and state Medicaid policy changes allowing this spending. More states are expected to follow.

“These are concrete things that we can do that avoid the debates around the Second Amendment,” Fischer said.

With gun control legislation stalled in Congress, the Biden administration has opened up federal Medicaid dollars to violence prevention as one of the ways states and cities can combat firearm violence. President Joe Biden announced the novel approach in April 2021, and now the money is starting to flow to interested states.

But the process to unlock the funding has been lengthy, and it’s unclear how much money will ultimately be spent on these programs. Because Medicaid, which provides health care for low-income and disabled residents, is a state-federal program, states must also approve spending the money on violence prevention.

In Illinois, which two years ago became one of the first states to approve Medicaid spending for violence prevention, Chicago CRED hopes to get approval for its program this spring. Arne Duncan, the former U.S. education secretary who leads the violence prevention group, said getting paid by Medicaid will be worth the wait and that he hopes his state’s experience will make it more expeditious for others.

“We’re trying to build a public health infrastructure to combat gun violence,” Duncan said. “Having Medicaid start to be a player in this space and create those opportunities could be a game changer.”

In 2020, many cities around the country confronted a rise in shootings and homicides after officials responding to the pandemic shut down schools, businesses, and critical social services. That same year, police murdered George Floyd, a Black man, in Minneapolis, sparking nationwide protests and calls to cut police funding. Americans, already armed to the hilt, rushed to buy more guns.

While the pandemic has receded and homicide rates have dropped nationally, homicides haven’t gone down in some cities. The number of gun purchases is historically high in the United States, which is estimated to have more guns than people. Programs that worked a few years ago in places like Oakland, Calif. — which had won acclaim for slashing its gun violence — can’t keep up. Memphis in November broke its record for homicides in a year.

“We have a uniquely high prevalence of firearm ownership in the United States,” said Garen Wintemute, a professor of emergency medicine and chair in violence prevention at the University of California-Davis. “We have more guns in civilian hands than we have civilians, with something on the order of 400 million guns in the United States.”

“Guns are tools, and you put a tool in somebody’s hands, they’re going to use it,” he added.

Gun violence also brings a hefty price tag. Studies from the Government Accountability Office and Harvard Medical School have shown that the cost of caring for gunshot survivors ranges from $1 billion in initial treatments to $2.5 billion over the 12 months post-injury. And it’s not only gunshot victims who need medical help.

“The patients that we see, there’s a lot of grief. Parents losing their children, grandparents losing their grandchildren. That impacts people’s health tremendously,” said Noha Aboelata, founding CEO of Roots Community Health Center in Oakland. “Entire neighborhoods have ongoing stress and trauma.”

Despite the long and often bureaucratic process, Medicaid dollars are incredibly attractive for community organizations that have historically relied on philanthropic donations and grants, which can vary year to year.

“Medicaid is reliable,” Fischer said. “If you’re doing the work, you’re qualified for it, and you are taking care of patients, you get reimbursed for the work that you do.”

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

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The survey sheds light on why millions of beneficiaries nationwide were dropped from the federal-state health insurance program for “procedural reasons.” KFF Health News obtained the survey, which Utah’s Medicaid program paid more than $20,000 to conduct, through a public records request.

Like many states, Utah terminated Medicaid coverage for a large share of enrollees whose eligibility was reevaluated in 2023, following a three-year pause during the coronavirus pandemic. And, as in most states, an overwhelming number of those disenrollments were executed for procedural reasons such as missing paperwork, rather than determinations that people were no longer eligible for coverage.

Nationally, more than 13.3 million people were cut from Medicaid in 2023, according to KFF, and procedural issues were cited in just over 70% of cases. In Utah, such issues accounted for 94% of disenrollments — the second-highest rate among states.

It’s been unclear what led to those procedural terminations in Utah and other states. But the Utah survey of more than 1,000 disenrolled Medicaid beneficiaries, conducted in October, found that 57% of people who left the program in 2023 never tried to renew their coverage.

“It is frustrating to see that 57% of respondents did not attempt to renew and that over 50% of those former members reported paperwork or other challenges as the reason they did not attempt to renew coverage,” said Matt Slonaker, executive director of the Utah Health Policy Project, an advocacy group.

Many of them found insurance elsewhere — 39% through an employer and 15% through the Affordable Care Act marketplaces, according to the survey.

But 30% became uninsured, and many people reported obstacles in reapplying for Medicaid, which covers people with low incomes and disabilities.

Nineteen percent said they never received renewal documents from the Utah Medicaid enrollment agency, the Department of Workforce Services. Fourteen percent said they didn’t get around to the paperwork, 13% said it was too difficult, and 7% said they didn’t have the necessary documents to prove their eligibility.

The online survey, which had a margin of error of plus or minus 3%, found that many disenrolled people had trouble getting questions answered by the state Medicaid agency. While 39% of those polled said they were able to resolve their issue the same day or the next day, 12% waited more than two weeks, and 21% said they were still waiting for their question, complaint, or problem to be resolved.

About half of those disenrolled described the renewal process as difficult. Just a quarter found it to be easy.

“Too many people, overrepresented by children, will be newly uninsured as a result of the unwinding, and much needs to be done to develop and execute ‘chase’ strategies to find and assist these people with getting covered,” Slonaker said.

Jennifer Strohecker, Utah’s Medicaid director, said the state is using feedback from the survey to improve its consumer engagement. It’s renewing more beneficiaries using databases to verify their income and residency, she said, and is assisting with enrollment at laundromats and Department of Motor Vehicles offices.

The state’s strong economy and low unemployment rate may help explain the high percentage of people terminated from Medicaid, she said. And about 35% who were disenrolled are returning to the program, said Kevin Burt, a deputy director of the Utah Department of Workforce Services.

But health experts worry that any disruption of insurance coverage can leave people vulnerable to losing access to care or responsible for large medical bills.

In August 2023, the Centers for Medicare & Medicaid Services sent letters to states expressing concern over high procedural disenrollment rates. CMS said the procedural disenrollment rate was too high in more than half of states and urged them to reduce it.

The Biden administration has expressed alarm in particular about losses of coverage among children, who accounted for about 46% of enrollment in Medicaid and the related Children’s Health Insurance Program in August, according to KFF. Almost 90 million people were enrolled in the two programs that month — up about 20 million from before the covid-19 pandemic.

Medicaid beneficiaries typically must have their eligibility reviewed every year to renew their coverage. But in March 2020, after the pandemic hit, the federal government froze eligibility checks as part of the public health emergency. That prevented people from losing coverage.

Since last spring, when Congress ended the emergency, states began to once again review beneficiaries’ eligibility — and terminated coverage for millions. This “unwinding” is scheduled to continue through May, though some states have already completed their process.

Utah has dropped roughly 150,000 of about 500,000 Medicaid beneficiaries since April.

Utah officials confirmed this week that the state’s Medicaid unwinding is under audit by the Department of Health and Human Services’ Office of Inspector General, which can levy fines and other penalties on states that it finds broke the law.

Strohecker said she believes Utah is one of a handful of states facing such an examination. The state is also facing an audit by the HHS Office of Civil Rights, possibly due to the high proportion of Black, Hispanic, and Pacific Islander beneficiaries who lost coverage. That agency is also able to issue fines.

Lindsey Browning, a policy analyst for the National Association of Medicaid Directors, said she is aware of about a dozen states facing these audits, which she said are routine when there are big changes in Medicaid policy.

Both HHS agencies refused to confirm or comment on the audits.

UnidosUS, the nation’s largest Hispanic civil rights and advocacy group, has called on states to more aggressively protect eligible people from losing Medicaid coverage.

“People of all races and ethnicities are losing their health care, but Latinos and members of other historically marginalized communities are suffering disproportionate harm, as are children,” said Stan Dorn, health policy director of UnidosUS.

Stephanie Burdick, a Medicaid enrollee and consumer advocate on Utah’s Medicaid advisory board, said the survey points to serious shortcomings in the state’s unwinding.

“It’s a huge communication failure,” she said when asked why more than half of those dropped made no effort to renew their coverage. Many Medicaid enrollees, she said, didn’t know they had to reapply.

“A lot of people thought it was like the federal stimulus checks and was just a one-time benefit,” she said.

Utah fully expanded Medicaid in 2020 under the Affordable Care Act, raising eligibility to cover more working people with low incomes. As a result, tens of thousands of people who enrolled during the pandemic had never been through the process of renewing their coverage.

The Utah survey found that former Medicaid recipients rated the state’s program as 7 on a scale of 1 to 10. And nearly 80% said they would reenroll in the program if they could.

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A survey conducted for state officials in Utah, obtained by KFF Health News, holds some clues.

Like many states, Utah terminated Medicaid coverage for a large share of enrollees whose eligibility was reevaluated in 2023, following a three-year pause during the coronavirus pandemic. And like most states, an overwhelming share of those disenrollments were made for procedural reasons, such as missing paperwork.

More than 13.3 million people were disenrolled from Medicaid in 2023, according to KFF, and just over 70 percent of disenrollments were for procedural reasons.

It’s been unclear what led to those procedural terminations in Utah and other states. But the Utah survey of more than 1,000 disenrolled Medicaid beneficiaries, conducted in October, found that 57 percent of people who left the program in 2023 never tried to renew their coverage.

The good news is that many of them found insurance elsewhere — 39 percent through an employer, and 15 percent through the Affordable Care Act marketplaces, according to the survey.

The bad news is that 30 percent became uninsured, and many people reported obstacles in reapplying for Medicaid, which covers low-income and disabled people.

Nineteen percent said they never received renewal documents from the Utah Medicaid enrollment agency, the Department of Workforce Services. Fourteen percent said they didn’t get around to the paperwork, 13 percent said it was too difficult, and 7 percent said they didn’t have the necessary documents to prove their eligibility.

The survey found that many disenrolled people who asked why had trouble getting questions answered by the state Medicaid agency. While 39 percent polled said they were able to resolve their issue the same day or the next day, 12 percent waited over two weeks and 21 percent said their question or complaint was never resolved.

Half of those disenrolled described the renewal process as difficult. Just a quarter found it to be easy.

The online survey had a margin of error of plus-or-minus 3 percent. 

Medicaid beneficiaries typically must have their eligibility reviewed every year to renew their coverage. But in March 2020, after the pandemic hit, the federal government froze eligibility checks as part of the public health emergency. That kept anyone from being dropped.

Since the spring, when Congress ended the emergency, states have begun once again reviewing eligibility for Medicaid beneficiaries — and terminating coverage for millions. The “unwinding” is scheduled to continue through May of this year, though some states have already completed it.

Utah has dropped about 150,000 of about 500,000 Medicaid beneficiaries since April.

Stephanie Burdick, a Medicaid enrollee and consumer advocate on Utah’s Medicaid advisory board, said the state’s survey results point to serious shortcomings in Utah’s unwinding.

“It’s a huge communication failure,” she said when asked why more than half of those dropped made no effort to renew their coverage. Many Medicaid enrollees, she said, didn’t know they had to reapply. 

“A lot of people thought it was like the federal stimulus checks and was just a one-time benefit,” she said.

Jennifer Strohecker, Utah’s Medicaid director, said the state is using feedback from the survey to improve its consumer engagement. It’s renewing more beneficiaries using databases to verify their income and residency, she said, and is assisting with enrollment at laundromats and Department of Motor Vehicles offices.

The state’s strong economy and low unemployment rate may help explain the high percentage of people terminated from Medicaid, she said. And about 35 percent who were disenrolled are returning to the program, said Kevin Burt, deputy director of the Utah Department of Workforce Services.

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Determining a baby’s size during a 28-week obstetrical visit is routine. But Magloire, a family physician trained in obstetrics, knows that finding the mother’s uterus and, thus, checking the baby, can be tricky for inexperienced doctors.

“Sometimes it’s, like, off to the side,” Magloire said, showing a visiting medical student how to press down firmly and complete the hands-on exam. She moved her finger slightly to calculate the fetus’s height: “There she is, right here.”

Evans smiled and later said Magloire made her “comfortable.”

The 21-year-old had recently relocated from Louisiana to southeastern Georgia, two states where both maternal and infant mortality are persistently high. She moved in with her mother and grandfather near Cairo, an agricultural community where the hospital has a busy labor and delivery unit. Magloire and other doctors at the local clinic where she works deliver hundreds of babies there each year.

Scenes like the one between Evans and Magloire regularly play out in this rural corner of Georgia despite grim realities mothers and babies face nationwide. Maternal deaths keep rising, with Black and Indigenous mothers most at risk; the number of babies who died before their 1st birthday climbed last year; and more than half of all rural counties in the United States have no hospital services for delivering babies, increasing travel time for parents-to-be and causing declines in prenatal care.

There are many reasons labor and delivery units close, including high operating costs, declining populations, low Medicaid reimbursement rates, and staffing shortages. Family medicine physicians still provide the majority of labor and delivery care in rural America, but few new doctors recruited to less populated areas offer obstetrics care, partly because they don’t want to be on call 24/7. Now, with rural America hemorrhaging health care providers, the federal government is investing dollars and attention to increase the ranks.

“Obviously the crisis is here,” said Hana Hinkle, executive director of the Rural Training Track Collaborative, which works with more than 70 rural residency training programs. Federal grants have boosted training programs in recent years, Hinkle said.

In July, the Department of Health and Human Services announced a nearly $11 million investment in new rural programs, including family medicine residencies that focus on obstetrical training.

Nationwide, a declining number of primary care doctors — internal and family medicine — has made it difficult for patients to book appointments and, in some cases, find a doctor at all. In rural America, training family medicine doctors in obstetrics can be more daunting because of low government reimbursement and increasing medical liability costs, said Hinkle, who is also assistant dean of Rural Health Professions at the University of Illinois College of Medicine in Rockford.

In the 1980s, about 43% of general family physicians who completed their residencies were trained in obstetrics. In 2021, the American Academy of Family Physicians’ annual practice profile survey found that 15% of respondents had practiced obstetrics.

Yet family doctors, who also provide the full spectrum of primary care services, are “the backbone of rural deliveries,” said Julie Wood, a doctor and senior vice president of research, science, and health of the public at the AAFP.

In a survey of 216 rural hospitals in 10 states, family practice doctors delivered babies in 67% of the hospitals, and at 27% of the hospitals they were the only ones who delivered babies. The data counted babies delivered from 2013 to 2017. And, the authors found, if those family physicians hadn’t been there, many patients would have driven an average of 86 miles round-trip for care.

Mark Deutchman, the report’s lead author, said he was “on call for 12 years” when he worked in a town of 2,000 residents in rural Washington. Clarifying that he was exaggerating, Deutchman explained that he was one of just two local doctors who performed cesarean sections. He said the best way to ensure family physicians can bolster obstetric units is to make sure they work as part of a team to prevent burnout, rather than as solo do-it-all doctors of old.

There needs to be a core group of physicians, nurses, and a supportive hospital administration to share the workload “so that somebody isn’t on call 365 days a year,” said Deutchman, who is also associate dean for rural health at the University of Colorado Anschutz Medical Campus School of Medicine. The school’s College of Nursing received a $2 million federal grant this fall to train midwives to work in rural areas of Colorado.

Nationwide, teams of providers are ensuring rural obstetric units stay busy. In Lakin, Kansas, Drew Miller works with five other family physicians and a physician assistant who has done an obstetrical fellowship. Together, they deliver about 340 babies a year, up from just over 100 annually when Miller first moved there in 2010. Word-of-mouth and two nearby obstetric unit closures have increased their deliveries. Miller said he has seen friends and partners “from surrounding communities stop delivering just from sheer burnout.”

In Galesburg, Illinois, Annevay Conlee has watched four nearby obstetric units close since 2012, forcing some pregnant people to drive up to an hour and a half for care. Conlee is a practicing family medicine doctor and medical director overseeing four rural areas with a team of OB-GYNs, family physicians, and a nurse-midwife. “There’s no longer the ability to be on 24/7 call for your women to deliver,” Conlee said. “There needs to be a little more harmony when recruiting in to really support a team of physicians and midwives.”

In Cairo, Magloire said practicing obstetrics is “just essential care.” In fact, pregnancy care represents just a slice of her patient visits in this Georgia town of about 10,000 people. On a recent morning, Magloire’s patients included two pregnant people as well as a teen concerned about hip pain and an ecstatic 47-year-old who celebrated losing weight.

Cairo Medical Care, an independent clinic situated across the street from the 60-bed Archbold Grady hospital, is in a community best known for its peanut crops and as the birthplace of baseball legend Jackie Robinson. The historical downtown has brick-accented streets and the oldest movie theater in Georgia, and a corner of the library is dedicated to local history.

The clinic’s six doctors, who are a mix of family medicine practitioners, like Magloire, and obstetrician-gynecologists, pull in patients from the surrounding counties and together deliver nearly 300 babies at the hospital each year.

Deanna Buckins, a 36-year-old mother of four boys, said she was relieved when she found “Dr. Z” because she “completely changed our lives.”

“She actually listens to me and accepts my decisions instead of pushing things upon me,” said Buckins, as she held her 3-week-old son, whom Magloire had delivered. Years earlier, Magloire helped diagnose one of Buckins’ older children with autism and built trust with the family.

“Say I go in with one kid; before we leave, we’ve talked about every single kid on how they’re doing and, you know, getting caught up with life,” Buckins said.

Magloire grew up in Tallahassee, Florida, and did her residency in rural Kansas. The smallness of Cairo, she said, allows her to see patients as they grow — chatting up the kids when the mothers or siblings come for appointments.

“She’s very friendly,” Evans said of Magloire. Evans, whose first child was delivered by an OB-GYN, said she was nervous about finding the right doctor. The kind of specialist her doctor was didn’t matter as much as being with “someone who cares,” she said.

As a primary care doctor, Magloire can care for Evans and her children for years to come.

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Garfield County’s public health nurse, one of few public health officials serving the town and nearly 5,000 square miles that surround it, had quit because she had given birth to her second child and couldn’t find day care.

“My primary goal was to give families a safe place to take their children so they could work if they needed to,” said Murnion, 63. She started in 2015 with eight slots, the maximum she could cover herself, and slowly grew. Then, during the covid-19 pandemic, a surge in federal aid to child care programs helped her raise wages for her workers and expand to a second facility.

Today, her day care programs, the only ones in Jordan, can serve up to 30 children, ranging from 6 weeks old to school age. But after that pandemic-era funding support ended in September, Murnion began to wonder how long she could sustain her expanded capacity, or whether she’d need to raise prices or lower enrollment.

And she isn’t alone.

Data collected prior to the pandemic shows that more than half of Americans lived in neighborhoods classified as child care deserts, areas that have no child care providers or where there are more than three children in the community for every available licensed care slot. Other research shows parents and child care providers in rural areas face unique barriers. Access to quality child care programs and early education is linked to better educational and behavioral outcomes for kids and can also help link families and children to immunizations, health screenings, and greater food security by providing meals and snacks.

Policymakers and researchers now fear that inequitable child care access threatens the sustainability and longevity of rural communities.

“If we want to keep rural parts of this country alive and thriving, we need to address this,” said Linda Smith, director of the Early Childhood Initiative at the Bipartisan Policy Center, a Washington, D.C.-based think tank.

According to an October report that Smith co-authored, there is a 35% gap between the need for and availability of child care programs in rural areas, compared with 29% in urban areas, based on data from 35 states.

The report echoed concerns local, state, and national experts have raised for a number of years.

A report published last year by the National Advisory Committee on Rural Health and Human Services found that, per capita, more parents rely on family members or friends for child care in rural areas than in urban areas. This isn’t sustainable for parents, said Cara James, CEO and president of Grantmakers in Health, a nonprofit that helps guide health philanthropy.

“Right now, we have a system that’s very expensive for people who can afford it and for people who can access it, not necessarily available to all those who need it,” James said. “That’s leading us to rely on other workarounds that are not ideal or ones that are giving the children the best support that they need to grow into healthy adults.”

For example, according to a state report, Montana’s total child care capacity met 44% of estimated demand in 2021 and infant care capacity met only 34% of estimated demand. Garfield County had only 23% of potential demand for children under six. Nationally, the rural health advisory committee has found, child care deserts are most likely to be located in “low-income rural census tracts.”

The dearth of child care in many rural communities exacerbates workforce shortages by forcing parents, including those who work in health care locally, to stay home as full-time caregivers, and by preventing younger workers and families from putting down roots there.

Eighty-six percent of parents in rural areas who are not working or whose partner is not working said in a 2021 Bipartisan Policy Center survey that child care responsibilities were a reason why, while 45% said they or their spouse cared for at least their youngest child. Staying home to care for children is a responsibility that disproportionately falls on women, affecting their ability to participate in the workforce and make an independent living.

A report from the rural health advisory committee shows that when center-based care is readily available in a community, the percentage of mothers who use that type of care and are employed doubles from 11% to 22%.

According to the Biden administration, pandemic emergency funding increased maternal labor workforce participation, stabilized employment and increased wages for child care workers, tempered costs for families, and helped providers afford their facilities.

That funding included $52 billion in emergency aid allocated by Congress for child care program owners and low-income families. Murnion’s day care was one of an estimated 30,000 in rural counties that received federal grants.

She said the roughly $100,000 she received in federal aid allowed her to raise wages for her workers to $13 an hour and expand her facility space. She said she doesn’t take a paycheck from the business and instead relies on income from a family ranch and trucking business.

Now that the federal aid programs have expired, Murnion and other child care operators nationwide are wrestling with how to sustain those wages without hiking the cost of care for parents.

The Biden administration requested congressional approval of $16 billion to extend the pandemic-era child care stabilization program but doesn’t have enough support to continue the funding, despite nearly 80% of voters supporting increasing federal funding for states to expand their child care programs.

According to the administration, the funding would support more than 220,000 child care providers in the U.S. that collectively serve more than 10 million kids. Montana would receive an estimated additional $46 million if Congress approved the request.

Although federal aid helped Murnion get through the pandemic, she said she doesn’t want to rely on the government forever. She charges parents $30 a day for one child and $22 a day each for siblings. And she doesn’t charge parents for days their children don’t attend. If she does need to raise prices, Murnion said, she’ll increase the per-sibling cost.

The pandemic provided some meaningful lessons, said Smith of the Bipartisan Policy Center. “Those stabilization grants were, I think, a key to what we actually need to do with child care down the road.”

The number of child care programs has grown since before the pandemic in most states, but the employee count per facility has decreased. The federal cash infusion helped child care employment rebound after a 35% dip at the beginning of the pandemic. By November 2022, the number of workers in child care jobs had climbed to 92% of the pre-pandemic level.

In the best circumstances, Smith said, parents would pay more for child care, and the corresponding supply or availability of programs would increase. But because parents are struggling to keep up with the rising costs, which in some places can be more than in-state college tuition, supply is stagnant.

Smith said the end of federal aid programs kicked the issue back to state and local governments. “I think most people would agree that what we need is some type of funding that goes to the programs to keep it so that they can do what they need to do and not charge the parents for it,” she said.

Some state and local governments are doing so. In Alabama, lawmakers approved $42 million last year in the state budget for child care. The Missouri state legislature approved $160 million for child care. Voters in rural Warren, Minnesota, narrowly approved a half-percent sales tax to support a child care center that was struggling to stay open.

During last year’s legislative session, Montana lawmakers and Republican Gov. Greg Gianforte approved new laws to improve child care access, including removing state licensing requirements for small in-home day cares and expanding a program that helps lower-income families pay for child care.

“You can’t sit here in Washington, D.C., and figure out how you’re going to get child care out in eastern Montana,” Smith said. “It just doesn’t work.”

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