New Federal Loan Limits Will Worsen America’s Nursing Shortage And Leave Patients Waiting Longer For Care

Nursing students work in a simulation lab at the Florida A&M University Campus School of Nursing in Tallahassee in April 2023. Glenn Beil/Florida A&M University via Getty Images

BY KYBERLEE MONTGOMERY AND MARY ELLEN SMITH GLASGOW

There is growing need for nurses in the United States – but not enough nurses currently working, or students training to become nurses, to promptly see all of the patients who need medical care.

Tens of thousands of nurses have left practice since the pandemic, and many more plan to leave within a few years, according to the 2024 National Nursing Workforce Survey, which reviews the number of registered nurses working in the U.S.

Meanwhile, the U.S. Bureau of Labor Statistics projects that there will be an average of 189,100 openings for registered nurses each year through 2032. In addition, there will be a need for approximately 128,400 new nurse practitioners by 2034 – making it the fastest-growing occupation in the country.

The tax and spending package signed into law in July 2025 will take effect on July 1, 2026. Among other things, it will likely make it even harder for people to take out loans and help pay for a graduate nursing degree.

We are nurses and professors who oversee large nursing programs at universities. We believe that new restrictions on how nursing students can take out federal loans to pay for their education are likely to prevent people from pursuing advanced nursing roles.

These new regulations will cause the shortage of practicing nurses to intensify – in turn, worsening the quality of care patients receive.

Clinics may offer fewer appointments, hospitals may be forced to reduce services, and nursing programs may have to accept fewer students. As a result, some patients will wait longer, travel farther, or not see nurses altogether.

Paying for nursing education

Someone can become a registered nurse with an associate or bachelor’s degree. But a graduate-level degree is needed for other nursing roles – including nurse practitioners, nurse anesthetists and nurse midwives.

Nursing school costs vary greatly, depending on which degree students are seeking and whether they attend a public or private school. Roughly three-quarters of graduate nursing students rely on student loans and graduate with debt to pay for programs that can range from US$30,000 to $120,000 or more.

We have found that nursing students, unlike medical students, often work while enrolled in their programs, stretching their education over longer periods and accumulating additional costs.

The tax and spending law eliminates several federal grants and loan repayment programs for nurses and aspiring nurse educators – faculty members who teach nursing students in colleges and universities.

The law also sharply restricts how much money graduate nursing students can borrow through federal student loans.

Approximately 59% of 1,550 nurses surveyed in December 2025 said that they are now less likely to pursue a graduate degree with the new borrowing limit changes.

A fractured system

Nurse practitioners provide the majority of primary care in the U.S. – particularly in rural areas and communities with few physicians.

In addition, certified registered nurse anesthetists administer anesthesia for surgeries and procedures in many areas. Meanwhile, certified nurse-midwives deliver babies and provide prenatal and postpartum care, especially in areas where there are few obstetricians.

Long waits for new patient appointments are now common across the country, with national surveys showing that patients often wait weeks to months before they receive medical care.

About a decade ago, new patients could often book appointments within days to a few weeks; but today, there are fewer available medical appointments and medical professionals to treat them. This is particularly true for many medical practices serving women, older adults and rural communities.

One of us – Dr. Montgomery – is a women’s health nurse practitioner who routinely sees patients wait months for new appointments in the mid-Atlantic. These delays translate into postponed cancer screenings, delayed medication management and untreated chronic conditions.

Research consistently shows that nursing shortages are associated with worse patient outcomes, including higher mortality and delayed treatment.

Nursing left off the professional degree list

Under the new law, the Department of Education created a classification system that distinguishes professional from nonprofessional graduate degrees. Nursing is now considered a nonprofessional degree.

As a result, graduate nursing students will soon face lower borrowing limits than they currently do.

Previously, there was no need to label nursing as professional or not, because federal student loan borrowing was not capped in a way that required this distinction.

Now, students in professional graduate programs, such as medicine and law, may borrow up to $50,000 per year in federal loans and $200,000 in total.

Graduate nursing students, by contrast, will soon face a federal student loan cap of $20,500 per year and $100,000 total over the course of their education – a significant reduction from prior borrowing options.

The new law also eliminates the Direct PLUS Loan program. This separate, federal student loan program allows students to borrow up to the full cost of attendance of graduate nursing school after they reached annual loan limits on traditional federal loans.

More than 140 members of Congress from both political parties urged the Department of Education in December 2025 to reverse course and classify nursing as a professional degree.

The faculty bottleneck

Graduate loan limits will worsen another critical problem – the shortage of nursing faculty.

There are currently 1,693 full-time vacancies for nursing faculty positions, according to a survey in 2024 by the American Association of Colleges of Nursing. Of those open positions, 84% require or prefer a doctoral degree.

Universities cannot admit nursing students if there are not enough faculty to teach them.

Nursing programs in the U.S. turned away more than 80,000 qualified applicants to baccalaureate and graduate nursing programs in 2023, in part because they did not have enough faculty.

Better solutions exist

There are policy changes that could prevent this domino effect.

Policymakers could classify nursing as a professional degree for loan purposes, aligning borrowing limits with the documented costs of accredited programs.

Congress and individual states could expand scholarships and loan-repayment programs for nurses who teach or serve in rural and underserved communities.

Universities and governments could work together to share nurse training costs.

Graduate nursing education is not a luxury. It is a cornerstone of the country’s health care system.

Helping nurses afford an education is not just about nurses – it is about patients, communities and the future of medical care in the U.S.

READ ORIGINAL STORY HERE

The Global Health System Can Build Back Better After US Aid Cuts – Here’s How

A study volunteer in an Ebola vaccine trial receives inoculation at Redemption Hospital in Monrovia in 2017. NIAID/Wikimedia Commons

BY JONATHAN E. COHEN

PROFESSOR OF CLINICAL POPULATION AND

PUBLIC HEALTH SCIENCES, KECK SCHOOL OF

MEDICINE AND DIRECTOR OF POLICY 

ENGAGEMENT, INSTITUTE ON INEQUALITIES

AND GLOBAL HEALTH, UNIVERSITY OF

SOUTHERN CALIFORNIA

Steep cuts in US government funding have thrown much of the field of global health into a state of fear and uncertainty. Once a crown jewel of US foreign policy, valued at some US$12 billion a year, global health has been relegated to a corner of a restructured State Department governed by an “America First” agenda.

Whatever emerges from the current crisis, it will look very different from the past.

As someone who has spent a 25-year career in global health and human rights and now teaches the subject to graduate students in California, I am often asked whether young people can hope for a future in the field. My answer is a resounding yes.

More than ever, we need the dedication, humility and vision of the next generation to reinvent the field of global health, so that it is never again so vulnerable to the political fortunes of a single country. And more than ever, I am hopeful this will be the case.

To understand the source of my hope, it is important to recall what brought US engagement in global health to its current precipice – and how a historic response to specific diseases paradoxically left African health systems vulnerable.

Disease and dependency

Over two decades ago, the field of global health as we currently know it emerged out of the global response to HIV/Aids – among the deadliest pandemics in human history. The pandemic principally affected people of reproductive age and babies born to HIV-positive parents.

The creation of the US President’s Emergency Plan for Aids Relief (Pepfar) in 2003 was at the time the largest-ever bilateral programme to combat a single disease. It redefined the field of global health for decades to come, with the US at its centre. While both the donors and issues in the field would multiply over the years, global health would never relinquish its origins in American leadership against HIV/Aids.

Pepfar placed African nations in a state of extreme dependence on the US. We are now witnessing the results – not for the first time. The global financial crisis of 2008 reduced development assistance to health, which generated new thinking about financing and domestic resource mobilisation.

Yet, the US continued to underwrite Africa’s disease responses through large contracts to American universities and implementers. This was for good reason, given the urgency of the problem, the growing strength of Africa’s health systems as a result of Pepfar, and the moral duty of the world’s richest country.

With the rise of right-wing populism and the polarising effects of COVID-19, global health would come to be seen by many Americans as an elite enterprise. The apparent trade-off between public health countermeasures and economic life during COVID-19 – a false choice to experts who know a healthy workforce to be a precondition for a strong economy – alienated many voters from the advice of disease prevention experts. The imperative to “vaccinate the world” and play a leadership role in global health security lacked a strong domestic constituency. It proved no match for monopolistic priorities of the pharmaceutical industry and the insularity and economic anxieties of millions of Americans.

This history set the stage for the sudden abdication of US global health leadership in early 2025. By the time the Department of Government Efficiency came for USAID, many viewed global health as a relic of the early response to HIV/Aids, an excuse for other governments to spend less on health, or an industry of elites. The field was an easy target, and the White House must have known it.

Yet therein lies the hope. If global health came of age around a single disease, an exercise of US soft power, and a cadre of elite experts, it now has an opportunity to change itself from the ground up. What can emerge is a new global health compact, in which African governments design robust health systems for themselves and enlist the international community to assist from behind.

Opportunity to build back better

To build a new global health compact for Africa, the first change must be from a focus on combating individual diseases to ensuring that all people have the opportunity for health and well-being throughout their lives. Rather than allowing entire health systems to be defined by the response to HIV/Aids, tuberculosis and malaria, Africa needs integrated systems that promote:

primary care, which brings services for the majority of health needs closer to communities

health promotion, which enables people to take control of all aspects of their health and well-being

long-term care, which helps all people function and maintain quality of life over their entire lifespan.

No global trend compels this shift more than population ageing, which will soon engulf every nation as a result of lengthening life expectancy and declining fertility. As the proportion of older adults grows to outstrip that of children, societies need systems of integrated healthcare that help people manage multiple diseases. They don’t need fragmented programmes that produce conflicting medical advice, dangerous drug interactions, and crippling bureaucracy. Time is running out to make this fundamental shift.

Second, there is a need to shift the relationship between low-income and high-income nations towards shared investment in the service of local needs. This is beginning to happen in some places, and it will require greater sacrifices on all sides.

Low-income governments need to spend a higher percentage of their GDP on healthcare. That will in turn require addressing the many factors that stymie the redistribution of wealth, from corruption to debt to lack of progressive taxation. The US and other high-income countries need to pay their fair share, while also sharing decision-making over how global public goods, from vaccines to disease surveillance to health workers, are shared and distributed in an interconnected world.

Third, there is need to change the narrative of global health in wealthy countries such as the US to better connect to the concerns of voters who are hostile to globalism itself. This means addressing people’s real fears that public health measures will cost them their job, force them to close their business, or advance a pharmaceutical industry agenda. It means justifying global health in terms that people can relate to and agree with – that is, helping to save lives without taking responsibility for other countries’ health systems.

It means forging unlikely alliances between those who believe in leadership from the so-called global south and those who take an insular view of America’s role in the world.

Leading from behind

Make no mistake. I am not counting on this – or any – US administration to reinvent global health on terms that are more responsive to current disease trends, more equitable between nations, and more relevant to American voters.

But nor would I want them to. To create the global health for the future, the leadership must come not only from the US, but rather from a shared commitment among the community of nations to give and receive according to their capacities and needs. And that is something to hope for.

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Cutting HIV Aid Means Undercutting US Foreign And Economic Interests − Nigeria Shows The Human Costs

The welfare of entire families depends on access to HIV medication. Here, a woman who is the sole provider of several children takes antiretroviral treatment. Saurabh Das/AP Photo

B Y KATHRYN RHINE

ASSOCIATE PROFESSOR OF GENERAL

INTERNAL MEDICINE, UNIVERSITY OF

COLORADO ANSCHUTZ MEDICAL

CAMPUS

A little over two decades ago, addressing Nigeria’s HIV crisis topped U.S. President George W. Bush’s priorities. Africa’s most populous nation had 3.5 million HIV cases, and the disease threatened to destabilize the region and ultimately compromise U.S. interests. These interests included securing access to Nigeria’s substantial oil reserves, maintaining regional military stability and protecting trade partnerships worth billions.

Following years of agitation from AIDS activists, Bush launched the President’s Emergency Plan for AIDS Relief, or PEPFAR, in 2003. This U.S.-led HIV treatment program has since saved tens of millions of lives around the globe.

While living in Nigeria for my work as a medical anthropologist, I witnessed PEPFAR’s rollout and saw firsthand how the powerful therapies it provided transformed Nigerian lives. The women I worked with told me they could finally put aside the fears of death or abandonment that had consumed their days. Instead, they could focus on a newly expanded horizon of possibilities: building careers, finding love, having healthy children.

Now, however, a serious threat to preventing and treating HIV worldwide looms. The Trump administration’s decision to substantially restrict access to a vital HIV prevention tool – PEPFAR-funded preexposure prophylaxis, or PrEP – would cut off ongoing treatment for millions of people and block future access for countless others who need this protection.

The timing is devastating: Scientists recently made a major advance in HIV prevention. Named the 2024 Breakthrough of the Year by the journal Science, the drug lenacapavir offers six months of HIV protection with one injection. Unlike previous PrEP options that required daily pills, which created significant barriers to consistent access and adherence, this twice-yearly injection dramatically simplifies prevention.

By undermining access to a treatment that has been essential to reducing HIV rates, the Trump administration’s new restrictions threaten to derail two decades of bipartisan investment in eliminating HIV globally. The consequences extend well beyond individual lives.

Afterlife of aid

“Some people that have it, they choose to be wicked and just spread it all around,” confided Elizabeth, a woman I interviewed during my time in Nigeria. I am using a pseudonym to protect her privacy. “They say, ‘Somebody gave it to me, so I am going to spread it too.’ But if they know that they can live positively with the virus, it would reduce their evil thoughts.”

Elizabeth’s words reveal a concerning dynamic: When hope for treatment disappears, a dangerous desperation can take its place. Patients who feel abandoned by health care systems might lose motivation to protect others from HIV. They may also stop seeking medical care, abandon prevention measures and turn away from future aid.

Cultural anthropologists use the phrase “the afterlife of aid” to describe what happens after global aid programs are withdrawn or drastically reduced. Communities are left not just without resources but with a lasting sense of betrayal that undermines their willingness to seek help, creating cycles of skepticism that can persist for generations.

Treatment as hope

In my fieldwork, I’ve witnessed how managing life with the virus involves far more than taking medications. It requires carefully navigating personal relationships, family obligations, cultural expectations and hopes for the future.

Many of the women I worked with had contracted HIV from their husbands or boyfriends. Some even suspected their partners’ positive status but were unable to protect themselves. Before these medications, women – both HIV positive and HIV negative – had to choose between risking rejection or risking transmission.

Elizabeth and David’s story illustrates these challenges. They had been together for more than a year when David proposed. “When I sensed he was serious about marriage, I knew I had to tell him my status,” Elizabeth told me during one of our many conversations. Though initially shocked, he remained committed to their relationship.

Elizabeth had maintained a decade of careful adherence to her HIV treatment, but the couple still struggled with consistent condom use. David described using condoms as akin to “eating candy with the wrapper still on it.” He also was eager to have a baby. While PrEP had greatly reduced transmission risk, it placed the full burden of protecting her husband on Elizabeth.

The path Elizabeth navigated highlights how Nigerian cultural expectations complicated their situation. When proving one’s fertility is often considered essential to establishing gender identity, the pressure to have sex without protection created additional tension. Moreover, Elizabeth’s need to balance her own health needs with her husband’s desires reflected the delicate negotiation many Nigerian women face between personal well-being and marriage.

As Elizabeth prepared for the birth of their child, she expressed both joy and anxiety: “I have to stay healthy for both of them now.”

Politicizing global health

Previous interruptions in aid foreshadow what’s at stake when shifts in U.S. political priorities compromise global health funding.

Consider the global spike in maternal and child mortality when President Ronald Reagan instituted the Mexico City Policy, often referred to as the “global gag rule.” It blocked U.S. funding to all international nongovernmental organizations that provided or even referred abortion services.

This policy has been repeatedly implemented by Republican administrations – including those of George H.W. Bush, George W. Bush and Donald Trump during his first term – and subsequently rescinded by Democratic presidents, creating a disruptive cycle of funding uncertainty. Among these affected organizations are recipients of PEPFAR funds.

The human cost of this policy pendulum is measurable and significant. Researchers have found that when this law is enacted, nations across the globe suffer increased death rates for newborns and mothers as well as jumps in HIV cases. In countries heavily dependent on U.S. aid, the Mexico City Policy has resulted in approximately 80 additional child deaths and nine additional maternal deaths per 100,000 live births annually and about one additional HIV infection per 10,000 uninfected people.

My research in Nigeria also reveals the fragile progress that now hangs in the balance. Before treatments arrived, HIV ravaged Nigerian communities. In 2001, nearly 6% of the population had HIV, totaling around 3.5 million people. The Hausa language reflected this trauma: Terms for AIDS also meant “lifeless body” and “nearby grave.”

Following the rollout of HIV treatments, Nigeria’s cases dropped dramatically – by 2010, prevalence had fallen to 4.1%. Declines continued steadily as treatment access expanded from 360,000 people in 2010 to over 1 million by 2018. This progress was heavily dependent on international support, with PEPFAR and other global donors providing over 80% of the US$6.2 billion spent fighting HIV in Nigeria between 2005 to 2018.

In 2019, around 1.3% of the population had HIV, or 1.9 million people.
From personal choice to global security

What’s at stake isn’t just increasing HIV rates. The Trump administration’s reductions in foreign aid threaten to unravel over two decades of U.S. investment in global security and economic growth.

Public health crises rarely stay contained within national boundaries. When health systems fail in West Africa, diseases can quickly spread overseas and require costly emergency responses. The 2014 Ebola outbreak demonstrated this reality, when cases reached America and prompted a $5.4 billion emergency response. Similarly, the 2009 H1N1 influenza pandemic, which infected around 60 million Americans, showed how quickly infectious diseases circle the globe when surveillance and containment systems are inadequate.

Inconsistent aid, in turn, undermines American global leadership and creates openings for competing powers to establish their influence. China has actively exploited these gaps, establishing bilateral trade with Africa reaching $295 billion in 2024. While the U.S. reduced its global health engagement during previous administrations, China expanded its global health diplomacy, partnering on issues ranging from infectious disease prevention and control to health emergency response and health technology innovation.

Meanwhile, restrictions in PrEP access risk recreating the same impossible choices women faced at the advent of the epidemic: choosing between disclosing their status and risking abandonment; accepting unprotected sex and risking transmission, or refusing unprotected sex and risking violence or loss of economic support.

I believe the result is a far less safe world where preventable suffering continues, hard-won progress unravels and the promise of an AIDS-free generation remains unfulfilled.

Doctor Shortages Have Hobbled Health Care For Decades − And The Trend Could Be Worsening

BY ROCHELLE WALENSKY AND NICOLE MCCANN

Americans are increasingly waiting weeks or even months to get an appointment to see a health care specialist.

This delay comes at a time when the population of aging adults is rising dramatically. By 2050, the number of adults over 85 is expected to triple, which will intensify the strain on an already stretched health care system. We wrote about this worsening challenge and its implications for the health care workforce in a January 2025 report in the New England Journal of Medicine.

We are health care scholars who are acutely aware of the severe shortfall of specialists in America’s health care system. One of us, Rochelle Walensky, witnessed the consequences of this shortage firsthand as the director of the Centers for Disease Control and Prevention from January 2020 to June 2023, during the critical early years of the pandemic.

The COVID-19 pandemic brought the physician and overall health care workforce shortage to the forefront. Amid the excess daily deaths in the U.S. from COVID-19, many people died of potentially preventable deaths due to delayed care for heart attacks, deferred cancer screenings and overwhelmed emergency departments and intensive care units.

Even before the pandemic, 80% of U.S. counties lacked a single infectious disease physician. Before going to the CDC, I – Dr. Walensky – was chief of the Division of Infectious Diseases at Massachusetts General Hospital. When COVID-19 hit our hospitals, we were in desperate need of more infectious disease expertise. I was just one of them.

At the local level, these infectious disease-trained subspecialists provide essential services when it comes to preventing and controlling transmissible outbreaks, carrying out diagnostic testing, developing treatment guidelines, informing hospital capacity planning and offering resources for community outreach. Each of these experts plays a vital role at the bedside and in systems management toward effective clinical, hospital and community responses to infectious disease outbreaks.

Uneven health care outcomes and access

For decades, experts have warned of an impending decline in the physician workforce.

Now, Americans across all regions, specialties and socioeconomic backgrounds are experiencing that decline firsthand or personally.

The National Center for Health Workforce Analysis projects a national shortage of 140,000 physicians by 2036, with that shortfall spanning multiple specialties, including primary care, obstetrics, cardiology and geriatrics.

However, some geographic areas in the country – especially some of those with the poorest health – are disproportionately affected. The brunt of the effect will be felt in rural areas: An estimated 56% shortage is predicted in nonmetro areas, versus only 6% in metro areas.

States such as Massachusetts, New York and Maryland boast the highest density of physicians per 100,000 people, while states such as Idaho, Mississippi and Oklahoma rank among those with the lowest. And even in states with the highest physician density, demand may still overwhelm access.

Although doctor shortages do not necessarily cause poor health outcomes, regions with fewer physicians tend to have lower life expectancy. The mean life expectancy in Mississippi is six years lower than that of Hawaii and more than four years below the national average. This underscores the substantial differences in health outcomes depending on where you live in the U.S.

Notably, areas with fewer doctors also see higher rates of chronic conditions such as chronic pulmonary disease, diabetes and poor mental health. This crisis is further exacerbated by the aging baby boomer population, which places increasing demand on an already strained health care system due to rising rates – especially among those over 85 – of multiple chronic diseases, complex health care needs and the concurrent use of multiple medications.

How the US reached this point

Some of these workforce challenges stem from the unintended consequences of policy changes that were originally aimed at improving the rigor of medical education or curtailing a once-anticipated physician glut.

For example, the 1910 Flexner Report was commissioned to restructure American medical education with the goals of standardizing curricula and improving quality. While the report succeeded at those goals, it was shortsighted in important ways. For instance, it recommended closing rather than strengthening 89 of the 155 existing medical schools at the time. This created medical school deserts that persist in some U.S. regions to this day.

Additionally, the report further divided the study of medicine, focused on disease, from the study of public health, which is focused on health care systems, populations and society. This separation has led to siloed communication and data systems that continue to hinder coordinated responses to public health crises.

Decades after the Flexner Report, in 1980, policymakers anticipated a physician oversupply based on medical school enrollment projections and government investments in the medical workforce. In response, funding constraints were introduced by Congress to limit residency and fellowship training slots available after medical school.

But by the early 2000s, discussions shifted to concerns about physician shortages. Despite the calls for reforms to address the issues more than a decade ago, the funding and training constraints have remained largely unchanged. These have created a persistent bottleneck in postgraduate medical training that requires acts of Congress to reverse.

Forces shaping the physician bottleneck

In the wake of the Dobbs vs. Jackson Women’s Health Organization decision, states with restrictive abortion policies are now facing an emerging and troubling workforce challenge: It may get more difficult to recruit and retain tomorrow’s medical school grads.

Research surveys suggest that 82% of future physicians, not just obstetricians, prefer to train and work in states that uphold abortion access. While it may seem obvious that obstetricians would want to avoid the increasing liabilities associated with the Dobbs decision, another point is less obvious: Most medical trainees are between the ages of 25 and 35, prime childbearing years, and may themselves want access to a full range of obstetric care.

And given that 20% of physicians are married to other physicians and an additional 25% to other health professionals, marriage within the health care workforce may also play a substantial role. A physician choosing not to practice in one of the 14 states with limited abortion access, many of which already rank among the poorest in health outcomes and lowest in physician densities, may not only take their expertise but also their partner’s elsewhere.

Shifting the trajectory

The doctor shortage requires a combination of solutions, starting with addressing the high cost of medical education and training. Medical school enrollment has increased by only 10% over the past decade, far insufficient to address both the shortage today and the projected growth of the aging population needing care.

In addition, many students carry large amounts of debt, which frequently limits who can pursue the profession. And existing scholarship and compensation programs have been only modestly effective in incentivizing providers to work in high-need areas.

In our New England Journal of Medicine report, we laid out several specific strategies that could help address the shortages and the potential workforce crisis. For instance:

Rather than the traditional medical education model – four years of broad medical training followed by three to seven years of residency – medical schools could offer more specialized training pathways. These streamlined programs would focus on the skills needed for specific medical specialties, potentially reducing training duration and costs.

Reforming physician compensation could also help address imbalances in the health care system. Specialists and subspecialists typically earn substantially more than primary care doctors, despite the high demand for primary care. Raising primary care salaries and offering incentives, such as student loan forgiveness for physicians in high-need areas, could encourage more doctors to practice where they are needed most.

Additionally, addressing physician burnout is crucial, particularly in primary care, where administrative burdens such as billing and charting contribute to stress and attrition. Reducing these burdens, potentially through novel AI-driven solutions, could allow doctors to focus more on patient care and less on paperwork.

These are just an assortment of strategies we propose, and time is of the essence. One thing is certain: The U.S. urgently needs more doctors, and everyone’s health depends on it.

READ ORIGINAL STORY HERE

A Brief History Of Medicaid And America’s Long Struggle To Establish A Health Care Safety Net

President Lyndon B. Johnson, left, next to former President Harry S. Truman, signs into law the measure creating Medicare and Medicaid in 1965. AP Photo

BY BEN ZDENCANOVIC

POST DOCTORAL ASSOCIATE 

IN HISTORY AND POLYCY

UCLA

The Medicaid system has emerged as an early target of the Trump administration’s campaign to slash federal spending. A joint federal and state program, Medicaid provides health insurance coverage for more than 72 million people, including low-income Americans and their children and people with disabilities. It also helps foot the bill for long-term care for older people.

In late February 2025, House Republicans advanced a budget proposal that would potentially cut US$880 billion from Medicaid over 10 years. President Donald Trump has backed that House budget despite repeatedly vowing on the campaign trail and during his team’s transition that Medicaid cuts were off the table.

Medicaid covers one-fifth of all Americans at an annual cost that coincidentally also totals about $880 billion, $600 billion of which is funded by the federal government. Economists and public health experts have argued that big Medicaid cuts would lead to fewer Americans getting the health care they need and further strain the low-income families’ finances.

As a historian of social policy, I recently led a team that produced the first comprehensive historical overview of Medi-Cal, California’s statewide Medicaid system. Like the broader Medicaid program, Medi-Cal emerged as a compromise after Democrats failed to achieve their goal of establishing universal health care in the 1930s and 1940s.

Instead, the United States developed its current fragmented health care system, with employer-provided health insurance covering most working-age adults, Medicare covering older Americans, and Medicaid as a safety net for at least some of those left out.

Health care reformers vs. the AMA

Medicaid’s history officially began in 1965, when President Lyndon B. Johnson signed the system into law, along with Medicare. But the seeds for this program were planted in the 1930s and 1940s. When President Franklin D. Roosevelt’s administration was implementing its New Deal agenda in the 1930s, many of his advisers hoped to include a national health insurance system as part of the planned Social Security program.

Those efforts failed after a heated debate. The 1935 Social Security Act created the old-age and unemployment insurance systems we have today, with no provisions for health care coverage.

Nevertheless, during and after World War II, liberals and labor unions backed a bill that would have added a health insurance program into Social Security.

Harry Truman assumed the presidency after Roosevelt’s death in 1945. He enthusiastically embraced that legislation, which evolved into the “Truman Plan.” The American Medical Association, a trade group representing most of the nation’s doctors, feared heightened regulation and government control over the medical profession. It lobbied against any form of public health insurance.

During the late 1940s, the AMA poured millions of dollars into a political advertising campaign to defeat Truman’s plan. Instead of mandatory government health insurance, the AMA supported voluntary, private health insurance plans. Private plans such as those offered by Kaiser Permanente had become increasingly popular in the 1940s in the absence of a universal system. Labor unions began to demand them in collective bargaining agreements.

The AMA insisted that these private, employer-provided plans were the “American way,” as opposed to the “compulsion” of a health insurance system operated by the federal government. They referred to universal health care as “socialized medicine” in widely distributed radio commercials and print ads.

In the anticommunist climate of the late 1940s, these tactics proved highly successful at eroding public support for government-provided health care. Efforts to create a system that would have provided everyone with health insurance were soundly defeated by 1950.

JFK and LBJ

Private health insurance plans grew more common throughout the 1950s.

Federal tax incentives, as well as a desire to maintain the loyalty of their professional and blue-collar workers alike, spurred companies and other employers to offer private health insurance as a standard benefit. Healthy, working-age, employed adults – most of whom were white men – increasingly gained private coverage. So did their families, in many cases.

Everyone else – people with low incomes, those who weren’t working and people over 65 – had few options for health care coverage. Then, as now, Americans without private health insurance tended to have more health problems than those who had it, meaning that they also needed more of the health care they struggled to afford.

But this also made them risky and unprofitable for private insurance companies, which typically charged them high premiums or more often declined to cover them at all.

Health care activists saw an opportunity. Veteran health care reformers such as Wilbur Cohen of the Social Security Administration, having lost the battle for universal coverage, envisioned a narrower program of government-funded health care for people over 65 and those with low incomes. Cohen and other reformers reasoned that if these populations could get coverage in a government-provided health insurance program, it might serve as a step toward an eventual universal health care system.

While President John F. Kennedy endorsed these plans, they would not be enacted until Johnson was sworn in following JFK’s assassination. In 1965, Johnson signed a landmark health care bill into law under the umbrella of his “Great Society” agenda, which also included antipoverty programs and civil rights legislation.

That law created Medicare and Medicaid.

From Reagan to Trump

As Medicaid enrollment grew throughout the 1970s and 1980s, conservatives increasingly conflated the program with the stigma of what they dismissed as unearned “welfare.” In the 1970s, California Gov. Ronald Reagan developed his national reputation as a leading figure in the conservative movement in part through his high-profile attempts to cut and privatize Medicaid services in his state.

Upon assuming the presidency in the early 1980s, Reagan slashed federal funding for Medicaid by 18%. The cuts resulted in some 600,000 people who depended on Medicaid suddenly losing their coverage, often with dire consequences.

Medicaid spending has since grown, but the program has been a source of partisan debate ever since.

In the 1990s and 2000s, Republicans attempted to change how Medicaid was funded. Instead of having the federal government match what states were spending at different levels that were based on what the states needed, they proposed a block grant system. That is, the federal government would have contributed a fixed amount to a state’s Medicaid budget, making it easier to constrain the program’s costs and potentially limiting how much health care it could fund.

These efforts failed, but Trump reintroduced that idea during his first term. And block grants are among the ideas House Republicans have floated since Trump’s second term began to achieve the spending cuts they seek.

The ACA’s expansion

The 2010 Affordable Care Act greatly expanded the Medicaid program by extending its coverage to adults with incomes at or below 138% of the federal poverty line. All but 10 states have joined the Medicaid expansion, which a U.S. Supreme Court ruling made optional.

As of 2023, Medicaid was the country’s largest source of public health insurance, making up 18% of health care expenditures and over half of all spending on long-term care. Medicaid covers nearly 4 in 10 children and 80% of children who live in poverty. Medicaid is a particularly crucial source of coverage for people of color and pregnant women. It also helps pay for low-income people who need skilled nursing and round-the-clock care to live in nursing homes.

In the absence of a universal health care system, Medicaid fills many of the gaps left by private insurance policies for millions of Americans. From Medi-Cal in California to Husky Health in Connecticut, Medicaid is a crucial pillar of the health care system. This makes the proposed House cuts easier said than done.

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CDC Layoffs Strike Deeply At Its Ability To Respond To The Current Flu, Norovirus And Measles Outbreaks And Other Public Health Emergencies

The CDC’s headquarters are in Atlanta. Nathan Posner/Anadolu Agency via Getty Images

BY JORDAN MILLER

TEACHING PROFESSOR OF PUBLIC,

HEALTH, ARIZONA STATE UNIVERSITY

In just a few short weeks, the Trump administration has brought drastic changes to the Centers for Disease Control and Prevention and public health. Beginning with the removal of websites and key public health datasets in January 2025, the Trump administration has taken actions to dismantle established public health infrastructure as part of its second-term agenda.

In addition, the administration has begun a widespread purge of the federal public health workforce. As of Feb. 19, around 5,200 employees at the CDC and the National Institutes of Health had been let go. About 10% of the CDC’s staff have been removed, with plans for additional firings.

As a teaching professor and public health educator, I, like thousands of other health professionals, rely on CDC data and educational resources throughout my work. CDC websites are the first stop for health information for my students and for health care practitioners, and are vital to protecting the U.S. from infectious diseases, like avian flu and COVID-19, as well as noninfectious health conditions, such as diabetes and heart disease.

Here’s a quick look at what the CDC does to protect Americans’ health, and how it’s likely to be affected by the Trump administration’s actions:

Gutting the CDC’s capacity

Prior to the February cuts, the CDC employed over 10,000 full-time staff in roles spanning public health, epidemiology, medicine, communications, engineering and beyond to maintain this critical public health infrastructure.

In addition to the centers’ wide variety of functions to protect and promote public health in the U.S., a vast amount of research in the U.S. relies on CDC data. The CDC obtains data from all 50 states, territories and the District of Columbia, which is collated into widely utilized databases such as the National Health and Nutrition Examination Survey, National Health Interview Survey and Behavioral Risk Factor Surveillance System.

Several of these datasets and CDC websites were removed at the start of the second Trump term, and while they are currently back online due to a federal court order, it remains to be seen if these important sources of information will remain accessible and updated going forward.

The CDC also publishes the Morbidity and Mortality Weekly Report, which allows for ongoing and timely surveillance of key health conditions. The reports cover a wide range of topics, including wildfires, motor vehicle accidents, autism, asthma, opioids, mental health and many others. The CDC plays a central role in monitoring and reporting the spread of flu in winter months through its FluView, which informs clinical practice as well as public health interventions.

Physicians are reporting that their ability to respond to the surges in respiratory viruses they are seeing has been hobbled by the missing data and by prohibitions on CDC staff communicating outside the agency.

The CDC’s famed “disease detectives,” part of the Epidemic Intelligence Service, appear to have been spared following public outcry after more than half of its members were initially told they would be let go as part of the Feb. 14 mass layoffs.

It remains to be seen if this group will remain intact long term. Concerns are growing that shakeups to the nation’s infectious disease surveillance teams will hamper the government’s ability to respond effectively at a time when avian flu and measles are growing concerns in the U.S.

History of the CDC

The CDC began as a small branch of the U.S. Public Health Service in 1946 as an outgrowth of successes fighting malaria in southern states during World War II and before. Its founder, Dr. Joseph W. Mountin, envisioned that it would come to serve all states, addressing all communicable diseases. Since that time, the CDC has evolved into the nation’s premier public health organization, leveraging both clinical and population health sciences to prevent and mitigate challenges to the nation’s health.

In its first 40 years, the CDC helped eradicate smallpox and identify the causes of Legionnaires’ disease, toxic shock syndrome and HIV.

As the country’s primary health challenges have shifted from communicable diseases to noncommunicable ones over recent decades, the organization has adapted, expanding its reach and priorities to meet changing public health needs. The CDC also has the ability to flex and scale up efforts rapidly when needed to respond to novel outbreaks, which is essential for containing infectious diseases and preventing escalation.

CDC’s global reach

Recognizing that health does not exist in a vacuum, the CDC also operates internationally to mitigate health challenges that could threaten health in the U.S. over time. The agency is active in addressing diseases that are endemic in certain areas, such as tuberculosis and HIV. It also responds to outbreaks from emerging threats, like Ebola and Marburg virus disease.

The CDC played a crucial role in responding to the COVID-19 pandemic, coordinating with the World Health Organization, domestic health agencies and others to plan and execute a robust response.

In 2024, the CDC worked with the WHO to respond to a Marburg virus outbreak in Rwanda that lasted for several months. On average, about half of people infected with Marburg virus do not survive, so early detection and effective response are essential to prevent loss of life and contain outbreaks before they spread widely.

On Jan. 20, 2025, the White House announced President Donald Trump’s plans to withdraw from the WHO. This move further weakens the country’s ability to manage and mitigate threats to Americans’ health and national security.

Not only does the WHO do essential work to protect children around the world from needless death due to starvation, but it monitors and responds to infectious diseases. The U.S. has been the largest contributor to the WHO, with approximately 12%-15% of its operating costs coming from the U.S. That means that removal of U.S. support will also affect the WHO’s capacity to respond to international public health issues.

As the COVID-19 pandemic made plain, a delayed response to infectious disease outbreaks can exponentially increase long-term costs and consequences. It remains to be seen what impact the established relationships between the CDC and the WHO will have on their ability to coordinate effectively during times of crisis.

Future health care workforce threatened

The reach, flexibility, adaptability and robust foundation of relationships developed over the past eight decades enable the CDC to respond to threats quickly, wherever in the world they arise. This is important for protecting health, and it plays a vital role in global and national security as well.

In addition to its direct actions to promote public health, the CDC provides workforce development and training to help create an enduring public health infrastructure in the U.S. and abroad. This is more important than ever, as systemic factors have placed pressure on health professionals. The domestic public health workforce has shrunk drastically, losing 40,000 workers since the start of the Great Recession in 2009 due to economic constraints and social pressures during the pandemic. The CDC’s workforce development efforts help counteract these trends.

Public health workers were reporting high rates of burnout and stress even before the COVID-19 pandemic, which the pandemic worsened. Cuts to the federal workforce, as well as funding for public health programs, will no doubt add to these strains.

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Opioid-Free Surgery Treats Pain At Every Physical And Emotional Level

AUTHORS:

HEATHER MARGONARI

LEAD COORDINATOR FOR

THE OPIOID FREE PATHWAY,

UNIVERSITY OF PITTSBURG

JACQUES E. CHELLY

PROFESSOR OF ANESTHESIOLOGY,

PERIOPERATIVE MEDICINE AND

OTHOPEDIC SURGERY,

UNIVERSITY OF PITTSBURG

SHIEV K. GOEL

CLINICAL ASSOCIATE PROFESSOR

OF ANESTHESIOLOGY,

UNIVERSITY OF PITTSBURG

The opioid crisis remains a significant public health challenge in the United States. In 2022, over 2.5 million American adults had an opioid use disorder, and opioids accounted for nearly 76% of overdose deaths.

Some patients are fearful of using opioids after surgery due to concerns about dependence and potential side effects, even when appropriately prescribed by a doctor to manage pain. Surgery is often the first time patients receive an opioid prescription, and their widespread use raises concerns about patients becoming long-term users. Leftover pills from a patient’s prescriptions may also be misused.

Researchers like us are working to develop a personalized and comprehensive surgical experience that doesn’t use opioids. Our approach to opioid-free surgery addresses both physical and emotional well-being through effective anesthesia and complementary pain-management techniques.

What is opioid-free anesthesia?

Clinicians have used morphine and other opioids to manage pain for thousands of years. These drugs remain integral to anesthesia.

Most surgical procedures use a strategy called balanced anesthesia, which combines drugs that induce sleep and relax muscles with opioids to control pain. However, using opioids in anesthesia can lead to unwanted side effects, such as serious cardiac and respiratory problems, nausea and vomiting, and digestive issues.

Concerns over these adverse effects and the opioid crisis have fueled the development of opioid-free anesthesia. This approach uses non-opioid drugs to relieve pain before, during and after surgery while minimizing the risk of side effects and dependency. Studies have shown that opioid-free anesthesia can provide similar levels of pain relief to traditional methods using opioids.

Opioid-free anesthesia is currently based on a multimodal approach. This means treatments are designed to target various pain receptors beyond opioid receptors in the spinal cord. Multimodal analgesia uses a combination of at least two medications or anesthetic techniques, each relieving pain through distinct mechanisms. The aim is to effectively block or modulate pain signals from the brain, spinal cord and the nerves of the body.

For instance, nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen work by inhibiting COX enzymes that promote inflammation. Acetaminophen, or Tylenol, similarly inhibits COX enzymes. While both acetaminophen and NSAIDs primarily target pain at the surgical site, they can also exert effects at the spinal level after several days of use.

A class of drugs called gabapentinoids, which include gabapentin and pregabalin, target certain proteins to dampen nerve signal transmission. This decreases neuropathic pain by reducing nerve inflammation.

The anesthetic ketamine disrupts pain pathways that contribute to a condition called central sensitization. This disorder occurs when nerve cells in the spinal cord and brain amplify pain signals even when the original injury or source of pain has healed. As a result, normal sensations such as light touch or mild pressure may be perceived as painful, and painful stimuli may feel more intense than usual. By lessening pain sensitivity, ketamine can help reduce the risk of chronic pain.

Regional anesthesia involves injecting local anesthetics near nerves to block pain signals to the brain. This method allows patients to remain awake but pain-free in the numbed area, reducing the need for general anesthesia and its side effects. Common regional techniques include epidurals, spinal anesthesia and nerve blocks.

By activating different pain pathways simultaneously, multimodal approaches aim to enhance pain relief synergistically.

Psychology of pain perception

Psychological factors can significantly influence a patient’s perception of pain. Research indicates that mental health conditions such as anxiety, depression and sleep disturbances can increase pain levels by up to 50%. This suggests that addressing mood and sleep issues can be essential for pain management and improving overall patient well-being.

Psychological states can intensify the perception of pain by significantly influencing the neural pathways related to pain processing. For example, anxiety and stress activate the body’s fight or flight response, prompting the release of stress hormones that heighten nerve sensitivity. This can make pain feel more intense. Research has also found that higher anxiety levels before surgery are linked to increased anesthesia use during surgery and opioid consumption after surgery.

Complementary and alternative techniques that address psychological factors can reduce pain and opioid use by modulating pain transmission in the nervous system and activating neurochemical pathways that promote pain relief.

For example, aromatherapy uses essential oils to stimulate the olfactory system. This can help reduce pain perception and enhance overall well-being by evoking emotional responses and promoting relaxation.

Music therapy stimulates the auditory system, which can distract patients from pain, lower anxiety levels and foster emotional healing. This can ultimately lead to reduced pain perception.

Relaxation exercises, such as deep breathing and progressive muscle relaxation, activate the parasympathetic nervous system and help promote a state of rest. Engaging the parasympathetic system helps the body conserve energy, slow your heart rate, lower blood pressure and relieve muscle tension. This can lead to decreased pain sensitivity by promoting a state of calmness.

Acupuncture involves inserting thin needles into specific body points, stimulating the release of endorphins and other neurotransmitters. These molecules can interrupt pain signals and promote healing processes within the body.

Moving toward opioid-free surgery

Transitioning away from opioids in surgery requires a shift in both practice and mindset across the entire health care team. Beyond anesthesiologists, other providers, including surgeons, nurses and medical trainees, also use opioids in patient care. All providers would need to be open to using alternative pain management techniques throughout the surgical process.

In response to the increasing patient demand for opioid-free surgical care, our team at the University of Pittsburgh Medical Center launched the patient-initiated Opioid-Free Surgical Pain Management Program in May 2024. To address both the physical and emotional dimensions of pain while optimizing recovery and safety, we recruited surgeons, anesthesiologists, nurses, pharmacists and hospital administrators to participate in the initiative.

Over the course of six months, our team enrolled 109 patients, 79 of whom successfully underwent surgeries without opioids. Barriers to participating in the program included patient perception of severe pain, inadequately addressing stress and anxiety before the operation and limited education in the department about the program.

However, subsequent refinements to the program – such as giving patients muscle relaxants while they were recovering from anesthesia – improved participation and reduced opioid use. Importantly, none of the 19 patients who received opioids while recovering in the hospital post-op required further opioid prescriptions at discharge.

These results reflect the promise of our pathway to minimize reliance on opioids while ensuring effective pain management. Enhanced psychological support for patients and education for providers in surgery departments can broaden the effectiveness of a comprehensive approach to managing pain.

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Women Are At A Higher Risk Of Dying From Heart Disease − In Part Because Doctors Don’t Take Major Sex And Gender Differences Into Account

AUTHORS:

AMY HUEBSCHMANN

PROFESSOR OF MEDICINE,

UNIVERSITY OF COLORADO

ANSCHUTZ MEDICAL CAMPUS

JUDITH REGENSTEINER

PROFESSOR OF MEDICINE,

UNIVERSITY OF COLORADO

ANSCHUTZ MEDICAL CAMPUS

A simple difference in the genetic code – two X chromosomes versus one X chromosome and one Y chromosome – can lead to major differences in heart disease. It turns out that these genetic differences influence more than just sex organs and sex assigned at birth – they fundamentally alter the way cardiovascular disease develops and presents.

While sex influences the mechanisms behind how cardiovascular disease develops, gender plays a role in how health care providers recognize and manage it. Sex refers to biological characteristics such as genetics, hormones, anatomy and physiology, while gender refers to social, psychological and cultural constructs. Women are more likely to die after a first heart attack or stroke than men. Women are also more likely to have additional or different heart attack symptoms that go beyond chest pain, such as nausea, jaw pain, dizziness and fatigue. It is often difficult to fully disentangle the influences of sex on cardiovascular disease outcomes versus the influences of gender.

While women who haven’t entered menopause have a lower risk of cardiovascular disease than men, their cardiovascular risk accelerates dramatically after menopause. In addition, if a woman has Type 2 diabetes, her risk of heart attack accelerates to be equivalent to that of men, even if the woman with diabetes has not yet gone through menopause. Further data is needed to better understand differences in cardiovascular disease risk among nonbinary and transgender patients.

Despite these differences, one key thing is the same: Heart attack, stroke and other forms of cardiovascular disease are the leading cause of death for all people, regardless of sex or gender.

We are researchers who study women’s health and the way cardiovascular disease develops and presents differently in women and men. Our work has identified a crucial need to update medical guidelines with more sex-specific approaches to diagnosis and treatment in order to improve health outcomes for all.

Gender differences in heart disease

The reasons behind sex and gender differences in cardiovascular disease are not completely known. Nor are the distinct biological effects of sex, such as hormonal and genetic factors, versus gender, such as social, cultural and psychological factors, clearly differentiated.

What researchers do know is that the accumulated evidence of what good heart care should look like for women compared with men has as many holes in it as Swiss cheese. Medical evidence for treating cardiovascular disease often comes from trials that excluded women, since women for the most part weren’t included in scientific research until the NIH Revitalization Act of 1993. For example, current guidelines to treat cardiovascular risk factors such as high blood pressure are based primarily on data from men. This is despite evidence that differences in the way that cardiovascular disease develops leads women to experience cardiovascular disease differently.

In addition to sex differences, implicit gender biases among providers and gendered social norms among patients lead clinicians to underestimate the risk of cardiac events in women compared with men. These biases play a role in why women are more likely than men to die from cardiac events. For example, for patients with symptoms that are borderline for cardiovascular disease, clinicians tend to be more aggressive in ordering artery imaging for men than for women. One study linked this tendency to order less aggressive tests for women partly to a gender bias that men are more open than women to taking risks.

In a study of about 3,000 patients with a recent heart attack, women were less likely than men to think that their heart attack symptoms were due to a heart condition. Additionally, most women do not know that cardiovascular disease is the No. 1 cause of death among women. Overall, women’s misperceptions of their own risk may hold them back from getting a doctor to check out possible symptoms of a heart attack or stroke.

These issues are further exacerbated for women of color. Lack of access to health care and additional challenges drive health disparities among underrepresented racial and ethnic minority populations.

Sex difference in heart disease

Cardiovascular disease physically looks different for women and men, specifically in the plaque buildup on artery walls that contributes to illness.

Women have fewer cholesterol crystals and fewer calcium deposits in their artery plaque than men do. Physiological differences in the smallest blood vessels feeding the heart also play a role in cardiovascular outcomes.

Women are more likely than men to have cardiovascular disease that presents as multiple narrowed arteries that are not fully “clogged,” resulting in chest pain because blood flow can’t ratchet up enough to meet higher oxygen demands with exercise, much like a low-flow showerhead. When chest pain presents in this way, doctors call this condition ischemia and no obstructive coronary arteries. In comparison, men are more likely to have a “clogged” artery in a concentrated area that can be opened up with a stent or with cardiac bypass surgery. Options for multiple narrowed arteries have lagged behind treatment options for typical “clogged” arteries, which puts women at a disadvantage.

In addition, in the early stages of a heart attack, the levels of blood markers that indicate damage to the heart are lower in women than in men. This can lead to more missed diagnoses of coronary artery disease in women compared with men.

The reasons for these differences are not fully clear. Some potential factors include differences in artery plaque composition that make men’s plaque more likely to rupture or burst and women’s plaque more likely to erode. Women also have lower heart mass and smaller arteries than men even after taking body size into consideration.

Reducing sex disparities

Too often, women with symptoms of cardiovascular disease are sent away from doctor’s offices because of gender biases that “women don’t get heart disease.”

Considering how symptoms of cardiovascular disease vary by sex and gender could help doctors better care for all patients.

One way that the rubber is meeting the road is with regard to better approaches to diagnosing heart attacks for women and men. Specifically, when diagnosing heart attacks, using sex-specific cutoffs for blood tests that measure heart damage – called high-sensitivity troponin tests – can improve their accuracy, decreasing missed diagnoses, or false negatives, in women while also decreasing overdiagnoses, or false positives, in men.

Our research laboratory’s leaders, collaborators and other internationally recognized research colleagues – some of whom partner with our Ludeman Family Center for Women’s Health Research on the University of Colorado Anschutz Medical Campus – will continue this important work to close this gap between the sexes in health care. Research in this field is critical to shine a light on ways clinicians can better address sex-specific symptoms and to bring forward more tailored treatments.

The Biden administration’s recent executive order to advance women’s health research is paving the way for research to go beyond just understanding what causes sex differences in cardiovascular disease. Developing and testing right-sized approaches to care for each patient can help achieve better health for all.

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