Michigan resident Robert Williams was arrested for a crime he didn’t commit because a facial recognition system incorrectly suggested that he was the suspect seen in security camera footage. (Courtesy of the ACLU)

In January 2020, Farmington Hills, Michigan, resident Robert Williams spent 30 hours in police custody after an algorithm listed him as a potential match for a suspect in a robbery committed a year and a half earlier.

The city’s police department had sent images from the security footage at the Detroit watch store to Michigan State Police to run through its facial recognition technology. An expired driver’s license photo of Williams in the state police database was a possible match, the technology said.

But Williams wasn’t anywhere near the store on the day of the robbery.

Williams’ case, now a settled lawsuit that was filed in 2021 by the American Civil Liberties Union and Michigan Law School’s Civil Rights Litigation Initiative, was the first public case of wrongful arrest due to misuse of facial recognition technology (FRT) in policing.

But the case does not stand alone. Several more documented cases of false arrests due to FRT have come out of Detroit in the years following Williams’ arrest, and across the country, at least seven people have been falsely arrested after police found a potential match in the depths of FRT databases.

Williams’ lawsuit was the catalyst to changing the way the Detroit Police Department may use the technology, and other wrongful arrest suits and cases are being cited in proposed legislation surrounding the technology. Though it can be hard to legislate technology that gains popularity quickly, privacy advocates say unfettered use is a danger to everyone.

“When police rely on it, rely on them, people’s lives can be turned upside down,” said Nate Wessler, one of the deputy directors of the Speech, Privacy and Technology Project at the national ACLU.

How are police using FRT?

Facial recognition technology has become pervasive in Americans’ lives, and can be used for small personal tasks such as unlocking a phone, or in larger endeavors, like moving thousands of people through airport security checks.

The technology is built to assess a photo, often called a probe image, against a database of public photos. It uses biometric data like eye scans, facial geometry or distance between features to assess potential matches. FRT software converts the data into a unique string of numbers, called a faceprint, and will present a set of ranked potential matches from its database of images.

When police use these systems, they are often uploading images from a security camera or body-worn camera. Popular AI company Clearview, which often contracts with police and has developed a version specifically for investigations, says it hosts more than 50 billion facial images from public websites, including social media, mugshots and driver’s license photos.

Katie Kinsey, chief of staff and tech policy counsel for the Policing Project, an organization focused on police accountability, said that she’s almost certain that if you’re an adult in the U.S., your photo is included in Clearview’s database, and is scanned when police are looking for FRT matches.

“You’d have to have no presence on the internet to not be in that database,” she said.

The use of FRT by federal law enforcement agencies goes back as long as the technology has been around, more than two decades, Kinsey said, but local police departments increased their use in the last 10 years.

Usually, police are using it in the aftermath of a crime, but civil liberties and privacy concerns are heightened with the idea that the technology could be used to scan faces in real time, with geolocation data attached, she said. Kinsey, who often meets with law enforcement officers to develop best practices and legislative suggestions, said she believes police forces are wary of real-time uses.

Boston Police attempted to use it while searching for the suspects in the 2013 Boston Marathon bombing, for example, but grainy imaging hindered the technology in identifying the culprits, Kinsey said.

Wrongful arrests

FRT’s role in wrongful arrest cases usually come from instances in which police have no leads on a crime other than an image captured by security cameras, said Margaret Kovera, a professor of psychology at the John Jay College of Criminal Justice and an eyewitness identification expert.

Before the technology was available, police needed investigative leads to pin down suspects — physical evidence, such as a fingerprint, or an eyewitness statement, perhaps. But with access to security cameras and facial recognition technology, police can quickly conjure up several possible suspects that have a high likelihood of a match.

With millions of faces in a database, the pool of potential suspects feels endless. Because the technology finds matches that look so similar to the photo provided, someone choosing a suspect in a photo array can easily make a wrong identification, Kovera said. Without further investigation and traditional police work to connect the match chosen by the technology to a crime scene, the match is useless.

“You’re going to up the number of innocent people who are appearing as suspects and you’re going to decrease the number of guilty people,” Kovera said. “And just that act alone is going to mess up the ratio of positive identifications in terms of how many of them are correct and how many of them are mistaken.”

In the seven known cases of wrongful arrest following FRT matches, police failed to conduct sufficient follow-up investigation, which could have prevented the incidents. One man in Louisiana spent a week in jail, despite being 40 pounds lighter than a thief allegedly seen in surveillance footage. A woman who was eight months pregnant in Detroit was held in custody for 11 hours after being wrongfully arrested for carjacking, despite no mention of the carjacker appearing pregnant.

When Williams was arrested in January 2020, he was the ninth-best match for the person in the security footage, Michael King, a research scientist with the Florida Institute of Technology’s (FIT) Harris Institute for Assured Information, testified in the ACLU’s lawsuit. And detectives didn’t pursue investigation of his whereabouts before making the arrest.

Detroit police used the expired license image in a photo array presented to a loss-prevention contractor who wasn’t present at the scene of the crime. The loss prevention contractor picked Williams as the best match to the security cameras. Without further investigation of Williams’ whereabouts in October 2018, Detroit Police arrested him and kept him in custody for 30 hours.

The lawsuit says Williams was only informed after several lines of questioning that he was there because of a match via facial recognition technology. As part of the settlement, which Williams reached in the summer of 2024, Detroit Police had to change the way it uses facial recognition technology. The city now observes some of the strictest uses of the technology across the country, which is legislated on a state-by-state basis.

Police can no longer go straight from facial recognition technology results to a witness identification procedure, and they cannot apply for an arrest warrant based solely on the results of a facial recognition technology database, Wessler said. Because there can be errors or biases in the technology, and by its users, guardrails are important to protect against false arrests, he said.

Emerging laws

At the start of 2025, 15 states — Washington, Oregon, Montana, Utah, Colorado, Minnesota, Illinois, Alabama, Virginia, Maryland, New Jersey, Massachusetts, New Hampshire, Vermont and Maine —  had some legislation around facial recognition in policing. Some states, including Montana and Utah, require a warrant for police to use facial recognition, while others, such as New Jersey, say that defendants must be notified of its use in investigations.

At least seven more states are considering laws to clarify how and when the technology can be used: Lawmakers in Georgia, Hawaii, Kentucky, Massachusetts, Minnesota, New Hampshire and West Virginia have introduced legislation.

Like all AI technologies, facial recognition can have baked-in bias, or produce flawed responses. FRT has historically performed worse on groups of Black faces than on white, and has shown gender differences, too. AI is trained to get better over time, but people seem to think that simply by involving humans in the process, we’ll catch all the problems, Wessler said.

But humans actually tend to have something called “automation bias,” Wessler said — “this hardwired tendency of people to believe a computer output’s right as many times as you tell somebody the algorithm might get it wrong.”

So when police are relying on facial recognition technology as their primary investigative tool, instead of following older law enforcement practices, it’s “particularly insidious” when it goes wrong, Wessler said.

“I often say that this is a technology that is both dangerous when it works and dangerous when it doesn’t work,” Wessler said.

Kinsey said that in her work with the Policing Project, she’s found bipartisan support for placing guardrails on police using this technology. Over multiple meetings with privacy advocates, police forces, lawmakers and academics, the Policing Project developed a legislative checklist.

It outlines how police departments could use the technology with transparency, testing and standards strategies, officer training, procedural limits and disclosure to those accused of crimes. It also says legislation should require vendors to disclose documentation about their FRT systems, and that legislation should provide ways to address violations of their use.

The Policing Project also makes similar recommendations for congressional consideration, and while Kinsey said she does believe federal guidelines are important, we may not see federal legislation pass any time soon. In the meantime, we’ll likely continue to see states influencing each other, and recent laws in Maryland and Virginia are an example of a broad approach to regulating FRT across different areas.

Kinsey said that in her meetings with police, they assert that the technologies are essential to solving crimes. She said she believes there is space for FRT — and other technologies used by police, such as license plate readers and security cameras — but that unfettered use can do a lot of harm.

“We think some of them can absolutely provide benefits for solving crime, protecting victims,” Kinsey said. “But using those tools, using them according to rules that are public, transparent and have accountability, are not mutually exclusive goals. They can actually happen in concert.”

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The Iowa State Capitol is reflected in the Henry A. Wallace Building in Des Moines, Iowa. Iowa is among the states launching their own government efficiency operations aimed at rooting out inefficiencies and waste. (David Greedy/Getty Images)

Red states are echoing President Donald Trump’s quest to slash the size and cost of the federal government with their own initiatives aimed at making government smaller and more efficient.

In the first hours of his second term, Trump signed an executive order creating a temporary commission he dubbed the Department of Government Efficiency. He first announced DOGE, named after a viral meme and a cryptocurrency, in November as an effort led by billionaire Elon Musk to find billions in federal cuts.

In recent weeks, GOP governors and lawmakers have set up their own government efficiency task forces and committees to find ways to cut state spending.

The Texas House of Representatives recently announced plans for a 13-member Delivery of Government Efficiency, or DOGE, committee that will examine state agencies for inefficiencies, and Republican Lt. Gov. Dan Patrick said a DOGE bill would be one of his top legislative priorities. GOP leaders in Kansas, Missouri, New Hampshire, North Carolina, Oklahoma and Wisconsin have recently announced similar ventures.

Conservatives have long sought to shrink the size and cost of government. And it’s common practice for officials from both parties to hire outside consultants to help reduce inefficiency or waste in school, state and city bureaucracies. But the DOGE effort is gaining new steam as Republicans look to fall in line with Trump and blue and red states alike face massive budget gaps that will require some combination of spending cuts or increased taxes.

Democrats, however, argue that many states already have government watchdogs and efficiency panels, so the efforts might be redundant. And Democratic governors also have made gains in cutting red tape and increasing state efficiencies.

Cutting services or raising taxes: State lawmakers weigh how to fill big budget gaps

In her Condition of the State speech in January, Iowa Republican Gov. Kim Reynolds noted recent efforts to consolidate state agencies, centralize programs and reduce regulations, which she said had already saved Iowans $217 million. In 2023, the governor signed legislation to shrink the state’s 37 executive-level Cabinet agencies down to 16 and changed some of the powers of the governor and attorney general.

“We were doing DOGE before DOGE was a thing,” Reynolds said.

But in her address, Reynolds announced the launch of a state DOGE advisory body, which will be led by Emily Schmitt, a prominent business leader and Reynolds campaign donor. To pass meaningful property tax reform, Reynolds said Iowa must find more savings in state and local government.

Iowa Democrats noted that the state constitution already requires a government watchdog, the state auditor — currently Rob Sand, the only Democrat elected to statewide office.

In 2023, Reynolds signed a bill limiting the auditor’s access to certain information and barring his office from suing state agencies.

Sand, widely speculated to be a potential gubernatorial candidate, called it the “greatest pro-corruption bill and the worst perversion of checks and balances in Iowa’s history.”

“We have someone who has a whole office whose job is to work on this,” said Democratic state Rep. Adam Zabner. “I think we’re more likely to find efficiencies through the state auditor who Iowans elected to that role than we are through a major supporter of the governor’s campaigns.”

Zabner serves on the legislature’s long-standing government efficiency review committee, which examines state government operations every two years.

Zabner said it’s unclear how much true savings were realized from Reynolds’ realignment, as the state previously had hundreds of unfilled jobs. And he said those cuts haven’t necessarily improved the delivery of state services.

“We still have trouble getting all of our nursing homes inspected,” he said. “And there’s a lot of services like that where the delivery hasn’t really been improved.”

The Democratic Governors Association noted that blue-state governors also have taken steps to make state government more efficient and responsive. In November, Pennsylvania Democratic Gov. Josh Shapiro took executive action to speed up state permitting for economic development projects. And Colorado Gov. Jared Polis used a table saw to cut through a pile of outdated executive orders on dormant state committees and energy efficiency in December — the latest in his push to make state government more efficient and responsive to taxpayers.

“This isn’t a flashy trend for Governor Polis, it’s something he has carried out during his time in office,” Polis spokesperson Shelby Wieman said in a statement.

Waste or vital service?

Across the country, it’s unclear how much might be cut in efforts to weed out waste or inefficiencies — terms themselves that are entirely subjective.

“One person’s concept of waste is another person’s vital service,” said William Glasgall, public finance adviser at the Volcker Alliance, a nonprofit that works to support public sector workers.

Glasgall said government services are not designed to operate as efficiently as for-profit companies.

While many companies run multiple factory shifts per day to get the most out of their capital investment, schools and government offices with different missions mostly sit empty overnight, on weekends and during breaks. Similarly, cities must staff up police and fire department resources for disasters, even if their crews and equipment idle for long stretches.

Still, Glasgall said, governments have plenty of line items worth scrutinizing.

He pointed to the numerous tax breaks, incentives and abatements states award to individuals and businesses. In a paper last year, the Volcker Alliance estimated these programs reduce state revenues by $1 trillion a year — almost three times the amount state and local governments spent on education in 2021.

Often those forgone revenues are not transparent to taxpayers or scrutinized by state audits or budget offices, Glasgall said.

States contemplating cuts do so from a relatively strong position: A booming economy and federal pandemic aid ballooned state spending and reserve funds.

“States are cutting from a very, very high base,” Glasgall said. “So the cuts they’re making, I’m not sure they’re going to be terribly painful right now.”

Wisconsin Republican state Rep. Amanda Nedweski said the state should constantly be scrutinizing its operations and expenses. But she said the legislature often relies on agencies to self-monitor.

“We sort of operate state government in silos,” she said, “and there can often be redundancy in functions and redundancy in positions.”

Nedweski is leading the new state Assembly committee on Government Operations, Accountability, and Transparency, or GOAT.

Nedweski said the committee will take a big-picture look at state government but is also prepared to dive deep into issues such as regulation reform, the use of state office space, and how Wisconsin can leverage technology such as artificial intelligence to increase efficiency.

The GOP-controlled legislature will likely disagree with Democratic Gov. Tony Evers on budget priorities and programs. But Nedweski said the new committee can suggest meaningful changes that don’t necessarily require a reduction in state services.

“There’s a lot of things that can be reviewed and spending that can be shifted without being cut so we’re more efficiently and productively using our resources,” she said.

Nationwide coordination

The American Legislative Exchange Council, a conservative group known as ALEC that works with lawmakers nationwide, is pushing similar efforts in statehouses across the country.

While that organization ultimately wants to shrink governments, it views examining the effectiveness and costs of existing programs as a commonsense first step.

“One of the things we keep going back to is just the review of current government spending,” said Jonathan Williams, ALEC’s president and chief economist. “In so many cases, performance audits are not done on a regular basis in programs to look for these efficiencies.”

Blue and red states slash taxes despite warnings of hard times ahead

The organization just launched a government efficiency coalition to give state lawmakers best practices “to optimize all levels of government.”

“From our ALEC perspective, we hope that Washington [D.C.] does less going forward,” he said, “and the states and local governments probably need to do more in some cases.”

Many states will be confronting tough spending decisions as revenues flatten or decline.

“So, it’s going to be important to really tighten the belt, right-size government programs, and look for ways to provide those core government services more efficiently so we’re able to deliver real services to those truly at need,” Williams said. “And that, I think, is something that really plays into really a red-state or a blue-state outlook.”

But making governments more efficient can be a battle of inches.

Last week, the newly formed Kansas Senate Committee on Government Efficiency considered a bill that would nix requirements for certain state filings regarding labor organizations, tax abatements and water easements.

Clay Barker, general counsel for Kansas’ Republican secretary of state, told the committee that many of those documents are filed with other state offices and do little aside from creating work for the office.

If passed, the legislation is expected to save 400 hours of one-time IT labor and an ongoing 50 hours of labor annually, Barker said. But officials hope it will encourage other agencies to examine their operations for inefficiencies.

“This bill will not revolutionize state government,” he said.

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A public school teacher leads students to their classroom in New York City. Local and state officials are developing directives to support — or possibly thwart — potential visits by federal immigration authorities to public schools. (Michael Loccisano/Getty Images)

As Immigration and Customs Enforcement agents fan out across the country to conduct high-profile migrant arrests that President Donald Trump has called for, local and state officials are developing their own directives to support — or possibly thwart — potential ICE visits to public schools.

The Trump administration announced last month that it would reverse guidance in place since 2011 that restricted migrant arrests at “sensitive locations,” including schools, hospitals and places of worship.

In 2022, the most recent numbers available, there were about 850,000 children in the country illegally, according to the Pew Research Center. Long-standing federal policy from the U.S. Department of Education — backed by the U.S. Supreme Court — says that all children, regardless of their or their parents’ immigration status, are entitled to public elementary and secondary education.

Nevertheless, conservative states have signaled their willingness to cooperate with ICE.

“Florida schools will cooperate with all law enforcement working to enforce the nation’s laws on illegal immigration and keep our schools safe,” Sydney Booker, a spokesperson for the Florida Department of Education, told the Tallahassee Democrat.

In Alabama, State Superintendent Eric Mackey on Thursday released a statement that urged districts to “just keep having school,” while reminding them that badged law enforcement “should always be welcomed onto our campuses,” once their identity is confirmed. The statement did not say officers need a warrant.

And Oklahoma’s Board of Education last week voted to recommend a proposal that would require parents to report their and their child’s immigration status or provide proof of citizenship when enrolling them in public schools. The proposal, first pitched by Republican Superintendent Ryan Walters, now goes to the legislature.

In a statement released last week, Walters said “schools are crippled” by illegal immigration. Oklahoma would let ICE agents into schools, according to the statement, “because we want to ensure that deported parents are reconnected with their children and keep families together.”

Judge temporarily blocks Trump’s attempt to end birthright citizenship

Meanwhile, in Democratic-leaning states, officials are trying to remind school leaders of the limits of ICE’s authority.

New York Gov. Kathy Hochul and the state attorney general — both Democrats — along with the state education commissioner released a memo saying they “reaffirm that schools should remain a safe haven where all students are welcomed and provided a free public education.” Generally speaking, the memo says, law enforcement officers cannot interrogate or remove a student from school property without parental consent, unless they have a signed judicial warrant or other legal order.

Illinois’ State Board of Education released guidance urging local districts to develop processes for handling any ICE requests. Oregon’s Board of Education released guidance detailing the state’s sanctuary law, and how school leaders might respond to a visit or questions from law enforcement.

At the local level, some schools have already started creating their own policies. A group of public charter schools in Denver and Aurora, Colorado, said it would “avoid releasing any student to ICE without clear legal requirement to do so.”

Several state and local jurisdictions, including Chicago, made it clear to parents that ICE agents must have a judicial warrant, signed by a judge, to be admitted to a school. The system “WILL NOT admit ICE agents into our schools based upon an administrative warrant, an ICE detainer, or other document issued by an agency enforcing immigration law,” the district said in a letter to families.

The Los Angeles Unified School District has distributed “Know Your Rights” cards to help families know what they are required or not required to tell immigration officials. The Los Angeles School Police Department has also vowed that it will not engage in or assist with immigration enforcement activities.

Thomas Homan, the acting director of ICE, told CNN last week that his agency would not routinely raid schools, churches and hospitals, but that “there is no safe haven for public safety threats and national security threats.”

The U.S. Department of Homeland Security, which includes ICE, has told federal lawmakers it lacks billions in funding, resources and beds necessary to carry out a mass deportation campaign.

Amid the uncertainty, some parents have pulled their children out of school, said Viridiana Carrizales, the founder and CEO of Texas-based ImmSchools, a nonprofit that partners with school districts in New Jersey, New York, Pennsylvania and Texas to make them more welcoming to immigrant students.

“We have seen and have heard from districts that we are partnering with that, yes, they have seen a drop in attendance and that they have also seen families starting to withdraw their children from school,” Carrizales said.

“We want to make sure that kids continue to go to school. And if families don’t see schools as safe places, that is definitely going to impact that.”

Adriana Rivera, communications director at the Florida Immigrant Coalition, an immigration advocacy organization, echoed those concerns.

“Having children exposed to the possibility — no matter their immigration status — that they could be racially profiled or targeted sends chills down parents’ spines, and rightfully so.”

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Chemotherapy drugs used in cancer treatments can be administered in a health provider’s office or other out-patient setting. States are missing out on hundreds of millions of dollars in rebates for physician-administered drugs. (Chris Hondros/Getty Images)

Even as states worry about looming Medicaid cuts, they are failing to collect tens of millions of dollars in drug discounts every year, according to a report by a government watchdog.

Since 1991, state Medicaid agencies have been entitled to claim rebates from pharmaceutical companies. But between 2008 and 2020, the agencies failed to collect $392.8 million in rebates, according to little-noticed report released last spring by the inspector general’s office of the U.S. Department of Health and Human Services.

In addition, states should have claimed rebates totaling an unknown amount for another $362.3 million worth of drugs, the report found. The HHS inspector general examined 57 previous audits of state Medicaid agencies to compile the most recent report.

Only about 6% of overall Medicaid spending goes toward prescription drugs, but the cost is rising fast. Net Medicaid spending (after rebates) on prescriptions increased by an estimated 72% from 2017 to 2023, from $30 billion to $51 billion, according to KFF, a health research organization.

Medicaid, which provides health care coverage for people with low incomes, is funded jointly by the federal government and the states. States are bracing for federal cuts to the program, as the Trump administration and congressional Republicans look for ways to pay for extending tax cuts enacted during Trump’s first term in office.

As demand for weight-loss drugs rises, states grapple with Medicaid coverage

Deborah Williams, who has worked as a health policy analyst on Capitol Hill and at several drug companies, said states have long struggled with the administrative and technical burdens of invoicing for the discounts. To claim them, state Medicaid agencies must collect and submit data to manufacturers, detailing drug usage by Medicaid enrollees, within 60 days of the end of each quarter.

“It’s been a perennial problem for over 30 years,” said Williams, who now runs her own consulting firm, Health Policy Insights. “In general, the states are underfunded and the variability and the competence of the states … dramatically varies as well.”

New York, for example, left $21 million in rebates on the table and should have collected an unknown amount of money associated with another $11.7 million in costs.

The state spent $34.7 billion on Medicaid last year, but at a time when Medicaid funding is under scrutiny, the lost rebates matter, said Robin Feldman, a professor at UC Law San Francisco and an expert on pharmaceutical law.

“Every budget is limited. If drug prices were lower, then the government could spend those dollars expanding the program, or expanding who’s eligible for the program,” Feldman said in an interview. “One should never leave money on the table if humanly possible. It’s not good for economic efficiency and it’s not good for taxpayers and consumers.”

The report covers so-called physician-administered medications, or drugs (other than vaccines) that are often infused or injected in a doctor’s office or other outpatient setting.

States consider high costs, possible savings of covering weight-loss drugs for their workers

Kimberly Leonard, who oversees Medicaid pharmacy policy at the New York State Department of Health, said it’s more difficult to claim rebates for physician-administered drugs than it is for a bottle of pills.

To capture more of the missed rebates, Leonard said, New York has hired a small team of pharmacists and accountants to examine claims and has hired an outside vendor to help with invoicing claims.

Antonio Ciaccia, CEO of 46brooklyn Research, a nonprofit that studies drug pricing data, acts as a consultant for state Medicaid agencies. He said some states struggle to claim the rebates because they don’t have enough people with the technical expertise to review and plug in the necessary codes.

“There are massive logistical hurdles that you have to go through just to obtain what a system is supposed to give you,” Ciaccia said. He added that the fact that states have to hire consultants like him to claim what they are owed is evidence of a broken system.

The HHS report recommends that the federal government help states create better internal systems for capturing all the rebates they are due.

Williams said states’ struggles to claim the rebates are emblematic of a broader problem: When programs designed to generate savings are too complicated, they ultimately benefit drug manufacturers and insurance companies — not taxpayers or patients.

“The feds are not going to allocate more administrative dollars to make it work,” Williams said. “If after 30 years, [the states] haven’t managed to achieve operational excellence, they are not going to change it overnight. So, it’s a structural, systematic and a political problem.”

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Liane Freels, an associate licensed counselor based in Florence, Ala., sits in her office on Jan. 24, 2025. Freels has taken on some adult clients with maternal mental health issues knowing she won’t be reimbursed. “We are so passionate about reaching these moms and families who are suffering, that it is more important to us to make sure that happens and wait for the grant funding later,” said Freels. “But we’re both able [financially] to do that. A lot of counselors could never do this.” (Eric Schultz for Alabama Reflector)

This story first appeared in the Alabama Reflector.

Last fall, Patricia called her counselor in a panic. A 29-year-old North Alabama mom, she was about to lose her Medicaid coverage, which was set to expire in October, one year after the birth of her son.

Without Medicaid, she feared she would have no way to pay for the counseling sessions that helped her navigate a deep bout of postpartum depression. In the months since the birth of her son, she had weekly telehealth therapy with Liane Freels, an associate licensed counselor based in Florence, Alabama.

“It’s helped a lot,” said Patricia, who asked to be identified only by her first name. “I still have bad days, but they’re less frequent. I don’t feel like I’m constantly in a dark hole.

“It’s given me an outlet to process my emotions, to feel validated, and to learn coping techniques to get through panic attacks.”

But when Patricia called Freels, concerned about her loss of coverage, she got a shock: Medicaid wasn’t paying for her therapy sessions. Freels admitted she’d been providing them pro bono.

Alabama Medicaid covers mental health counseling by therapists like Freels for children and people under 21, but not for other adults. Freels takes on some adult clients with maternal mental health issues knowing she won’t be reimbursed. She and her business partner, Alisha Dreiling, have been working to secure grant funding so that their practice can provide maternal mental health services to families that struggle to afford it — and still keep the lights on.

“We are so passionate about reaching these moms and families who are suffering, that it is more important to us to make sure that happens and wait for the grant funding later,” said Freels. “But we’re both able [financially] to do that. A lot of counselors could never do this.”

On paper, Alabama Medicaid covers mental health treatment for moms with low incomes up to one year after a birth.

But in practice, say providers, advocates and patients, Medicaid’s severe underfunding and structural barriers keep treatment out of reach for many new moms until conditions like postpartum depression balloon into mental health crises.

“The majority of moms in our state are not screened, not educated, are not provided direct access to maternal mental health care from pregnancy through postpartum,” said Sarah Parkhurst, a Birmingham woman who founded Previa Alliance, an organization dedicated to connecting moms with mental health services. Parkhurst herself experienced postpartum depression and suicidal thoughts, and struggled to find a therapist who accepted her insurance.

“Moms are dying,” she said. “And babies are suffering.”

Nearly half of all births

In Alabama, it’s difficult to qualify for Medicaid. A single parent with one child, for example, can’t make more than $3,684 per year and get coverage under the program. Alabama is one of 10 states that hasn’t expanded Medicaid to adults making up to 138% of the Federal Poverty Level, or about $21,000 annually for an individual in 2024.

But for pregnant Alabamians, the limit is higher, making coverage available to more people with low incomes. As a result, Medicaid covers nearly half of all births statewide.

While Alabama lawmakers have spent years dithering over Medicaid expansion, the state did finally expand coverage for one group: pregnant women. Two years ago, in an effort to improve Alabama’s abysmal health outcomes for women and babies, the state followed most other states and extended its pregnancy Medicaid coverage from 60 days to one year following a birth.

The goal was to keep new mothers from losing their health coverage within weeks of having a child. Nearly half of pregnancy-related maternal deaths in the U.S. occur in the weeks or months after a birth. In Alabama, more than half of women who died from pregnancy-associated causes died between 43 days and one year after giving birth, according to the most recent data from the Alabama committee that investigates maternal deaths.

Mental health conditions, including suicide and overdose, are the leading underlying cause of pregnancy-related deaths. And they raise the chance of serious health complications for women during or after childbirth by 50%.

‘A hell of a year’

For Patricia and her family, the months leading up to the birth of her youngest felt almost unbearably hard.

Her husband’s mother unexpectedly died. Soon after, her older son — at the time not quite one-a year- old — was diagnosed with a life-threatening blood disorder that required regular trips to a St. Jude Children’s Research Hospital clinic. Her husband eventually lost his job after missing too many days of work, taking their son to medical appointments.

Alabama schools look to deliver more mental health resources for students

The family had to remain secluded to try to keep their son from getting sick, but he was hospitalized several times, including once with a COVID-induced infection that turned septic.

“We had a hell of a year before my youngest was born,” Patricia said. By the time he was 2- months- old, she said, “I felt like I had been through the biggest wringer of my life. I knew I needed help. I was really struggling with any bit of everyday life. Just brushing my teeth felt like the biggest chore in the world.”

She saw a post online that Freels’ clinic, WAC Counseling, was going to begin accepting clients with Medicaid. She assumed that because Medicaid covered her prenatal and childbirth care without any issues, that it would cover counseling, too.

Had she gone through the proper Medicaid channels, she likely wouldn’t have been able to choose a counselor like Freels. Medicaid recipients under age 21 can get mental health services from any provider who accepts Medicaid. But moms over 21 who use Medicaid are referred to either the state’s mental health crisis line, or to a community health center that contracts with Medicaid, according to an Alabama Medicaid representative.

There’s a community mental health center in Patricia’s county, she said, but it’s mainly associated with substance use disorders.

“Most people think if you go there, you must have a drug addiction,” she said.

But Freels took her on. And slowly, Patricia said, things began to look brighter.

‘Not in this for the money’

Freels is a former pediatrician who pivoted to counseling a few years ago, after seeing many of her pediatric patients’ parents struggling with mood disorders like depression and anxiety.

She and her partner are focused on providing maternal mental health services to people with low incomes. They hope that their practice, which opened last year, will be able to secure more grants to allow them to continue providing services while also keeping the doors open.

“We are not in this for the money, let me tell you,” Freels joked.

In her experience, most private counseling practices don’t accept Medicaid, largely due to extremely low reimbursement rates. Even when Medicaid covers therapy, it reimburses counselors at a rate far below what private insurers like Blue Cross Blue Shield of Alabama will pay. Blue Cross is the largest private insurer in the state.

Parkhurst’s organization recently finished a pilot program with Alabama moms across the state, providing screening and mental health services via telehealth. She said the program could only take women with private insurance because of the limited number of therapists that accept Medicaid and limited telehealth options. She said she’s also searching for grants or federal funding to help pay for moms with Medicaid to access counseling services.

“I know a lot of providers who want to serve these moms, but they have to make a living wage,” she said.

In addition to better reimbursement, Freels would like to see Medicaid’s administrative requirements eased or streamlined.

“That’s a big reason why [therapists] don’t want to take Medicaid,” she said. “If it’s not the reimbursement, it’s the headaches. We have to spend a lot of time on the phone to find a person [the client] can access who can give them a referral.”

Meanwhile, those with private insurance like Blue Cross don’t need a referral and can just call to make an appointment, she said.

Women like Patricia who have pregnancy Medicaid and want mental health services are supposed to contact their case manager to get connected with a provider — often a psychologist at a mental health center. In Parkhurst’s experience talking with moms on Medicaid, case managers sometimes have a difficult time getting clients timely care.

And then there are the practical barriers. Many women lack adequate transportation or child care, or can’t afford to take time off work to travel that far for appointments.

Medicaid does allow telehealth services, but Parkhurst said some services are required to be offered in person, via video chat, or require the recipient to first “jump through hoops.” Lack of high-speed internet can effectively shut off a telehealth option for some moms on Medicaid, she said.

“I think allowing telehealth with no limitations is important when you talk about mental health care,” said Parkhurst. “For some moms, we need to come to them.”

Amy Moor, a licensed professional counselor who’s based in Florence, said there’s still work to be done to improve how Alabamians are screened for pregnancy or postpartum mental health issues.

Because it’s so hard for adults to qualify for Medicaid in Alabama, many women only have coverage while they’re pregnant and during the first year after they give birth, which means they don’t have a primary care provider who sees them regularly and could notice that something’s not right.

“Women may have to have a psychotic mental health emergency to be seen,” she said. “It takes them being in a scary place, mentally, to be seen before that six-week checkup at the obstetrician.”

Hotlines, visiting nurses, and speaking out

There are solutions.

Freels, Moor and others praised Alabama Medicaid’s Nurse-Family Partnership program, which provides home visits and other services to families from pregnancy through two years postpartum. It also offers services led by a mental health nurse practitioner that include telehealth sessions.

It’s not available everywhere in the state, however, and there are restrictions on who qualifies.

But overall, “it’s an amazing program for Medicaid’s pregnant people,” said Freels. “They are on the front lines and recognize people who may benefit from counseling.”

National organizations like Postpartum Support International have helplines designed to connect people with providers, and the state also operates a 988 mental health crisis line.

Alabama mental health care recovering slowly from recession-era cuts

But the biggest solution, advocates and providers say, is expanding Medicaid to cover more people, and lawmakers allocating funding to support mental health services for people who fall in the insurance coverage gap.

If Medicaid is going to cover nearly half of the births in the state, said Parkhurst, “we have to reimburse well so providers can actually serve these moms. We have to allocate the appropriate funding. We have to have an even playing field so all moms can be served.”

Patricia continues to see Freels for counseling and said life has improved since those dark days after the birth of her youngest. Her husband found a new job with more flexible hours, and her older son is now much healthier.

In the meantime, she said she’s tried to be more open with friends and family about her struggles. For a long time, she said, she believed that she suffered from depression because she wasn’t praying hard enough, or didn’t trust in God enough.

But since she got help, she said, her husband and another relative have also sought treatment for their own mental health issues.

“The thought that these two people I love who also grew up in places where they were told if your mental health isn’t strong, your faith isn’t strong enough — just to know that I helped destigmatize this for them is amazing,” she said.

Alabama Reflector is part of States Newsroom, a national nonprofit news organization.

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Doctors and health care staff are pictured at an emergency department in Houston. Physicians are less likely to seek mental health care due to licensing concerns over outdated questions on licensure and credentialing applications that ask about any previous diagnosis, care or treatment. State medical boards and hospital systems are changing those forms. (Brandon Bell/Getty Images)

Medical doctors face higher rates of burnout and depression, and are twice as likely to die by suicide compared with the general population. The risks were magnified during the height of the COVID-19 pandemic.

But the problem existed long before the pandemic — and it remains. More than 40% of physicians, as well as medical school students and residents, don’t seek mental health care, citing fear of disclosure requirements on licensure forms as a main reason why.

That’s according to the American Medical Association, which represents physicians and medical students around the nation. The AMA and other groups have been pushing for legislative and regulatory changes.

More states and health systems are amending licensure and credentialing forms to remove mental health-related questions, such as asking about whether a doctor sought mental health care or treatment or received a mental health diagnosis. Others have codified such changes into state law.

The rationale for asking about mental health was to ensure patient safety. The AMA says safety can be addressed with general language that asks if the physician is suffering from any impairment that could interfere with patient care.

“Having any past diagnosis of a mental health need or a substance use problem is often not relevant,” said Dr. Jesse Ehrenfeld, the president of the AMA. “The key inquiry ought to be whether the impairment represents a current concern for safety and the physician’s ability to provide competent professional care.”

States are making it easier for physician assistants to work across state lines

Ehrenfeld recalled a classmate who had applied for a medical license in Colorado. He said that in response to a question about any prior mental health diagnosis or treatment, she responded that she’d seen a psychologist in high school. That held up her license for nine months, Ehrenfeld said.

Nationwide, at least 29 states have updated their forms to remove such questions in line with AMA standards, and as of September of last year, 375 hospitals had changed credentialing questions, according to the AMA.

Advocates say destigmatizing mental health care for doctors is paramount as the nation grapples with a shortage of health care workers. More than 76 million Americans live in federally designated shortage areas, and that’s projected to worsen as physicians consider leaving the field, driven by burnout and chronic overload.

Arguing the questions violate the Americans with Disabilities Act, other groups — including the Federation of State Medical Boards and the Dr. Lorna Breen Heroes’ Foundation — have also recommended updates to licensure application forms. The foundation is a physician mental health advocacy nonprofit named after New York City emergency room physician Dr. Lorna Breen, who died by suicide on April 26, 2020, after the hospital where she worked was inundated with COVID-19 patients.

In a U.S. Centers for Disease Control and Prevention study released this month, a quarter of health care providers reported mental health symptoms severe enough for a diagnosis. Among those, only 38% reported seeking care, while 20% said they didn’t need care, despite severe symptoms. An estimated 300 to 400 physicians die by suicide each year, with women physicians dying at higher rates.

Breen’s brother-in-law, Corey Feist, who is the foundation’s president and co-founder, said many doctors don’t seek help because they “assume that the rules are against them.”

“They avoid getting mental health treatment, or if they do get mental health treatment, they treat it as a scarlet letter,” Feist said.

The foundation has a communications toolkit for hospital systems and licensing bodies to help them disseminate updated forms to the workforce.

State and federal changes

The foundation also tracks state changes, and last year recognized licensing bodies in South Carolina, Tennessee and Virginia for meeting the foundation’s recommendations. Just last week, another board in Washington state joined the list, Feist said.

At the federal level, the Dr. Lorna Breen Health Care Provider Protection Act became law in 2022. It requires the U.S. Department of Health and Human Services to award grants to hospitals and professional associations to develop programs to promote mental health among providers. The law also requires dissemination of best practices for suicide prevention and campaigns to encourage providers to seek support.

Insurers often shortchange mental health care coverage, despite a federal law

Licensure application changes are a start, experts say. But broader changes will be needed to gain physicians’ trust so that they will seek care, said Dr. Kyra Reed, an emergency room physician in Indiana and an advocate for breaking barriers to mental health care for physicians.

“A culture change takes time,” Reed said. “You do have to have a reflection in leadership and in systems that reflect genuine caring and concrete strategies to support physicians in need.”

One strategy to combat mistrust, she said, is for health care employers to provide opt-out therapy services as part of employment from the beginning of a person’s tenure. “If you standardize something, then you normalize intervention, which then makes people feel less stigmatized,” she said.

Reed went through her own experience of postpartum depression in 2020 and now shares her story at national conferences and with peers to destigmatize the issue.

“I was more worried about my career and job in that moment than calling for help. That was a stark moment for me,” she said. “As a physician … you think you should be able to help yourself, because you help others in that situation. And when you can’t, it’s mind-boggling.”

New laws and volunteer groups

In 2020, at the start of the COVID-19 pandemic, Virginia became the first state to enact a law mandating a program that provides physicians with 24/7 confidential mental health support without fear of repercussions against their licenses. The law was updated last year expanding to dentists, dental hygienists and dental students.

Other states have passed similar laws since then, including Arizona, Georgia, Indiana and South Dakota, according to the AMA, and provisions of a Minnesota law went into effect last year.

Meanwhile, volunteer groups have helped with access to care outside of employee assistance programs, which some doctors may avoid using, fearing a lack of confidentiality.

The Oregon Wellness Program supports licensed physicians and physician assistants, medical students, nurses and nurse practitioners in the state. Run by volunteer psychiatrists, the program receives state funding and serves about 1,000 health professionals per year.

“Often people are insured through their employer, and so there was fear that the employer would then know that they were seeking mental health services,” said volunteer psychiatrist Dr. Mandi Hudson. “It offers a level of protection and confidentiality that didn’t previously exist.”

Through the program, health care workers can be seen without having to wait six months or a year to get an appointment, Hudson said.

The Physician Support Line is a national mental health hotline for doctors that was launched in response to the pandemic. At its peak, the line took an average of 30 calls per day.

“We were just volunteer people coming together, doing this work,” said Chicago-based psychiatrist Dr. Smita Gautam. “We’re not affiliated to any health care organization, health care system, university, medical board for any licensure organization. So, we are a very independent grassroots organization, and we’ve kept it that way so that physicians feel free to talk to us.”

Gautam added that fear of licensing issues is a concern she hears often from physicians — including those practicing in states where forms have updated.

“This has sort of percolated so much that even if a physician is in a ‘friendly state,’ they may not know about it. There’s this free-floating anxiety about, ‘Will I get reported?’” she said.

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The Lyndon Baines Johnson Department of Education Building pictured on Nov. 25, 2024. (Photo by Shauneen Miranda/States Newsroom)  

WASHINGTON — President Donald Trump signed executive orders Wednesday that prioritize school choice funding and seek to end what the administration sees as “radical indoctrination in K-12 schooling.”

Trump is carrying through on education-related campaign promises he made as part of his sweeping vision to “save American education.” These efforts mark the latest in a deluge of wide-ranging executive orders the president began signing since he took office last week.

One executive order directs the U.S. Education Department secretary “to issue guidance regarding how States can use Federal formula funds” to support K-12 school choice initiatives within the next two months.

Linda McMahon, Trump’s pick for Education secretary, has yet to sit before a Senate panel for a confirmation hearing.

McMahon — a former World Wrestling Entertainment executive, the prior head of the Small Business Administration during Trump’s first administration and a wealthy donor — could be pivotal to carrying out Trump’s sweeping education agenda.

The order also directs the Education secretary to “include education freedom as a priority in discretionary grant programs, as appropriate and consistent with applicable law.”

Trump is also tasking the Department of Health and Human Services with issuing guidance on how states receiving block grants “can use them to expand educational choice and support families who choose educational alternatives to governmental entities, including private and faith-based options.”

He is also requiring Defense Secretary Pete Hegseth to review how any “military-connected families” could use Department of Defense funds to attend a school of their choice and must submit a plan to describe these mechanisms and the steps to implement them.

Trump is asking the same for the Department of the Interior — requiring that the agency’s next leader review how anyone eligible to attend a school within the Bureau of Indian Education can use federal funds to attend a school of their choosing.

Former North Dakota Gov. Doug Burgum, Trump’s pick to lead the department, appears to be on a smooth path to becoming the next Interior secretary.

‘Radical indoctrination’ in K-12 schools

Meanwhile, Trump signed a sweeping executive order that aims to bar federal funding for schools that teach “discriminatory equity ideology,” which the administration describes as “an ideology that treats individuals as members of preferred or disfavored groups, rather than as individuals, and minimizes agency, merit, and capability in favor of immoral generalizations.”

The order also requires the respective secretaries of Education; Defense; and Health and Human Services; to provide Trump with an “ending indoctrination strategy” in the next 90 days.

The plan would include recommendations for “eliminating Federal funding or support for illegal and discriminatory treatment and indoctrination in K-12 schools.”

Trump also signed another executive order Wednesday that takes additional measures to try to combat antisemitism on college campuses. 

Calvin Gorman, 50, left, walks last year near Gallup, N.M., on the way from his job in Gallup to his home in Fort Defiance, Ariz., part of the Navajo Nation. American Indians in Western and Midwestern states had the lowest life expectancy of any group in the country in 2021. (Tim Henderson/Stateline)

There’s growing evidence that some American demographic groups need more help than others to live longer, healthier lives.

American Indians in Western and Midwestern states have the shortest life expectancy as of 2021, 63.6 years. That’s more than 20 years shorter than Asian Americans nationwide, who can expect to live to 84, according to a recent study by the Institute for Health Metrics and Evaluation at the University of Washington.

White residents live shorter lives in Appalachia and some Southern states, as do Black residents in highly segregated cities and in the rural South, the study found.

The data illustrates how Americans’ life expectancy differs based not only on race, but also on geography.

“Not everybody in this country is doing exactly the same even within a racial group, because it also depends on where they live,” said Dr. Ali Mokdad, an author of the study and the chief strategy officer for population health at the University of Washington.

“Eliminating these disparities will require investing in equitable health care, education, and employment, and confronting factors that fuel inequalities, such as systemic racism,” the report, which was published in November, concluded.

Yet the United States is seeing a surge of action this month to pull back on public awareness and stem investments in those areas.

Junk food and drug use cut into life expectancy gains for states

In President Donald Trump’s first two weeks, he has stripped race and ethnicity health information from public websites, blocked public communication by federal health agencies, paused federal research and grant expenditures, and ordered a ban on diversity, equity and inclusion programs across the board, all of which can draw attention — and funding — to the needs of specific demographic groups.

The administration has removed information about clinical trial diversity from a U.S. Food and Drug Administration website, and has paused health agencies’ communications with the public and with medical providers, including advisories on communicable diseases, such as the flu, that disproportionately affect underserved communities.

The new administration’s policies are headed the wrong way, said Dr. Donald Warne, a physician and co-director of the Johns Hopkins Center for Indigenous Health. “With the stroke of a pen, they’re gonna make it worse.”

One of Trump’s actions on his first day in office was to dismantle equity programs, including reversing a 2021 Biden executive order promoting more federal support for Indigenous education, including tribal colleges and universities.

The problems Indigenous people face are inextricably linked to “toxic stress” and “just pure racism,” Warne said. “Less access to healthy foods, just chronic stress from racism and marginalization, historical trauma — all of these things lead to poor health outcomes.”

The South Dakota county where Warne grew up as a member of the Oglala Lakota tribe (the county is named after the tribe) has one of the lowest life expectancies in the country, 60.1 years as of 2024, according to localized estimates from County Health Rankings & Roadmaps, an initiative of the University of Wisconsin’s Population Health Institute.

‘10 Americas’

The Institute for Health Metrics and Evaluation study parceled the country into what it called “10 Americas,” each with different 2021 life expectancies.

Black Americans were represented by three groups; those in the rural and low-income South had the worst life expectancies (68 years) compared with those living in highly segregated cities (71.5) and other areas (72.3).

Asian Americans nationwide have the longest life expectancy at 84, yet can also suffer from stereotypes and locality based problems that prevent them from getting the best care, said Lan Ðoàn, an assistant professor in the Department of Public Health Section for Health Equity at New York University’s Grossman School of Medicine.

Considering Asian Americans as a single entity masks health differences, such as the high incidence of heart disease among South Asians and Filipino Americans, she said, and discourages the necessary study of individual groups.

“It perpetuates the ‘model minority’ myth where Asian people are healthier, wealthier and more successful than other racial groups,” Ðoàn said.

That’s another reason for alarm over the new administration’s attitude about health equity, said Dr. Mary Fleming, an OB-GYN and director of Harvard T.H. Chan School of Public Health’s Leadership Development to Advance Equity in Health Care program.

“With DEI (diversity, equity and inclusion programs) under attack, it hinders our ability to name a thing, a thing,” Fleming said. “Racism is still a major contributor to inequitable health outcomes, and without naming it and addressing it, it will make it more difficult to uproot it.”

Among white people and Hispanics, lifespans differ by region, according to the “10 Americas” in the Institute for Health Metrics and Evaluation study. Latinos live shorter lives in the Southwest (76) than elsewhere (79.4), and white people live longer (77.2) if they’re not in Appalachia or the lower Mississippi Valley (71.1), or in rural areas and low-income Northern states (76.7).

An earlier Stateline story reported that policy, poverty, rural isolation and bad habits are shortening lives in West Virginia compared with New York. Even though the states had very similar life expectancies in 1990, West Virginia is projected to be at the bottom of the rankings by 2050, while New York is projected to be at the top.

Hyperlocal health problems

More research at a very local level is needed to find the policies and practices needed to start bridging longevity gaps, said Mokdad, the study author.

Since poverty seems to dictate so much of life expectancy, it’s fruitful to look at places where lifespans have grown in recent decades despite high poverty, Mokdad said. For example, lifespans have increased in the Bronx, New York, and Monongalia County, West Virginia, despite high poverty. By contrast, they have dipped in relatively high-income areas such as Clark County, Indiana, and Henry County, Georgia.

Clark County, on the Kentucky border, has a mix of urban and rural health issues that belie the relatively high income of some residents near Louisville, said Dr. Eric Yazel, health officer for the county and an emergency care physician.

Part of the county is also very rural, in a part of Indiana where there was an HIV outbreak among intravenous drug users in 2014.

“In a single county we see public health issues that are both rural and urban,” Yazel said. “As with a lot of areas along the Ohio River Valley, we were hit hard by the opioid epidemic and now have seen a resurgence of methamphetamine, which likely contributed to the [life expectancy] decreases.”

Nationally, a spike in overdoses has begun to ease in recent years, but only among white people. Overdose death rates among Black and Native people have grown.

Overdose deaths are rising among Black and Indigenous Americans

Indigenous people also were the hardest hit during the COVID-19 pandemic, with expected lifespans dropping almost seven years between 2019 and 2021.

Calvin Gorman, 50, said several friends his age in Arizona’s Navajo Nation died needlessly in the pandemic. He blames it on alcohol and pandemic isolation.

“They said to just stay inside. Just stay inside. Some of them took some bottles into the house and they never came out again. I heard they died in there,” said Gorman, who commutes on foot and by hitchhiking from his home in Fort Defiance, Arizona, to a job at a gas station in Gallup, New Mexico.

Warne, the Oglala Lakota physician from South Dakota, said alcohol and substance use may have been one factor in Native deaths during the pandemic, as people “self-medicated” to deal with stress. But overall, he said, the main drivers of early deaths in Native communities are high rates of infant mortality, road accidents and suicides.

Warne now lives and practices medicine in North Dakota.

“There’s a huge challenge for people who grow up in these settings, but many of us do move forward,” Warne said. “A lot of us wind up working in other places instead of in our home, because there just aren’t the opportunities. We should be looking at economic development as a public health intervention.”

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