For Freida Lockaby, an unemployed 56-year-old woman who lives with her dog in an aging mobile home in Manchester, Ky., one of America’s poorest places, the Affordable Care Act was life altering.

The law allowed Kentucky to expand Medicaid in 2014 and made Lockaby – along with 440,000 other low-income state residents – newly eligible for free health care under the state-federal insurance program. Enrollment gave Lockaby her first insurance in 11 years.

“It’s been a godsend to me,” said the former Ohio school custodian who moved to Kentucky a decade ago.

Lockaby finally got treated for a thyroid disorder that had left her so exhausted she’d almost taken root in her living room chair. Cataract surgery let her see clearly again. A carpal tunnel operation on her left hand eased her pain and helped her sleep better. Daily medications brought her high blood pressure and elevated cholesterol level under control.

But Lockaby is worried her good fortune could soon end. Her future access to health care now hinges on a controversial proposal to revamp the program that her state’s Republican governor has submitted to the Obama administration.

Next year will likely bring more uncertainty when a Trump administration and a GOP-controlled Congress promise to consider Obamacare’s repeal, including a potential reduction in the associated Medicaid expansion in 31 states and the District of Columbia that has led to health coverage for an estimated 10 million people.

Kentucky Gov. Matt Bevin, who was elected in 2015, has argued his state can’t afford Medicaid in its current form. Obamacare permitted states to use federal funds to broaden Medicaid eligibility to all adults with incomes at or below 138 percent of the federal poverty level, now $11,880 for individuals. Kentucky’s enrollment has doubled since late 2013 and today almost a third of its residents are in the program. The Medicaid expansion under Obamacare in Kentucky has led to one of the sharpest drops in any state’s uninsured rate, to 7.5 percent in 2015 from 20 percent two years earlier.

Kentucky’s achievement owed much to the success of its state-run exchange, Kynect, in promoting new coverage options under the health law. Kynect was launched under Bevin’s Democratic predecessor, Steve Beshear, and dismantled by Bevin this year.

Bevin has threatened to roll back the expansion if the Obama administration doesn’t allow him to make major changes, such as requiring Kentucky’s beneficiaries to pay monthly premiums of $1 to $37.50 and require nondisabled recipients to work or do community service for free dental and vision care.

Budget pressures are set to rise next year in the 31 states and the District of Columbia where Medicaid was expanded as the federal government reduces its share of those costs. States will pick up 5 percent next year and that will rise gradually to 10 percent by 2020. Under the health law, the federal government paid the full cost of the Medicaid expansion population for 2014-2016.

In a state as cash-strapped as Kentucky, the increased expenses ahead for Medicaid will be significant in Bevin’s view — $1.2 billion from 2017 to 2021, according to the waiver request he’s made to the Obama administration to change how Medicaid works in his state.

Trump’s unexpected victory may help Bevin’s chances of winning approval. Before the election, many analysts expected federal officials to reject the governor’s plan by the end of the year on the grounds that it would roll back gains in expected coverage.

A Trump administration could decide the matter differently, said Emily Beauregard, executive director of Kentucky Voice for Health, an advocacy group that opposes most waiver changes because they could reduce access to care.

“I think it’s much more likely that a waiver could be approved under the Trump administration,” she said. “On the other hand, I wonder if the waiver will be a moot point under a Trump administration, assuming that major pieces of the [Affordable Care Act] are repealed.”

Lockaby is watching with alarm: “I am worried to death about it.”

Life already is hard in her part of Kentucky’s coal country, where once-dependable mining jobs are mostly gone.

In Clay County where Lockaby lives, 38 percent of the population live in poverty. A fifth of the residents are disabled. Life expectancy is eight years below the nation’s average.

Clay’s location places it inside an area familiar to public health specialists as the South’s diabetes and stroke belt. It’s also in the so-called “Coronary Valley” encompassing the 10-state Ohio/Mississippi valley region.

About 60 percent of Clay County’s 21,000 residents are covered by Medicaid, up from about a third before the expansion. The counties uninsured rate for nonelderly adults has fallen from 29 percent to 10 percent.

Still, the increase in insurance coverage hasn’t made Clay’s people healthier yet. Local health officials here say achieving that will take a decade or more. Instead, they cite progress in smaller steps: more cancer screenings, more visits to mental health professionals and more prescriptions getting filled. Harder lifestyle changes that are still ahead — such as eating better, quitting smoking and regular exercise — will take more than a couple years to happen, said Aaron Yelowitz, associate professor of economics at the University of Kentucky.

One hopeful spot is the Grace Community Health Center in downtown Manchester, where patient visits are up more than 20 percent since 2014. Those without insurance pay on a sliding scale, which can mean a visit costs $50 or more.

That was too much for Ramiro Salazar, 47, who lives with his wife and two children on a $733 monthly income. With Medicaid, he sees a doctor for his foot and ankle pain, meets regularly with a psychologist for anxiety and gets medications — all free to him. Medicaid even covers his transportation costs to doctors, vital because a specialist can be 40 miles away.

Salazar is worried about Bevin’s plans, especially the additional costs. “I probably couldn’t afford it as I’m unemployed,” he said. “It would hurt me pretty bad.”

Any development that could take away health coverage from people with mental health issues worries Joan Nantz, a psychologist who works part time at Grace and whose appointment calendar is booked three weeks out because of patient demand. More than 90 percent of her clients are on Medicaid.

“If something happens to this program, I can’t begin to think what impact it would have on society,” she said. Without counseling, people with mental health issues will resort to illegal drugs and be more likely to commit crimes and domestic violence, Nantz said.

Just five primary care doctors in Manchester treat adults in Clay and surrounding counties. Manchester Memorial Hospital has tried to recruit more without success.

“We had a painful primary care shortage here five years ago and now it’s worse,” said Dr. Jeffrey Newswanger, an emergency room physician and chief medical officer at the hospital. “Just because they have a Medicaid card doesn’t mean they have doctors.”

The emergency room is busier than ever seeing patients for primary care needs, he said.

Newswanger sees both sides to the debate over Medicaid. The hospital gained because more patients are now covered by insurance, and the ER’s uninsured rate dropped to 2 percent from 10 percent in 2013.

“Eliminating the expansion altogether would be painful for the hospital and a disaster for the community,” he said.

But, Newswanger also appreciates some of Bevin’s proposals.

“No one values something that they get for free,” he said, and incentives are needed to make people seek care in doctors’ offices instead of expensive ERs.

Christie Green, public health director of the Cumberland Valley District Health Department that covers Clay County, said making the poor pay more or scrapping Medicaid’s expansion would be a setback to improving people’s health.

Last year, Green helped Manchester build a three-mile trail along a park and install a swinging bridge across a small creek. Both additions were intended to promote physical fitness in a place where more than a third smoke — both far above national averages.

Progress is slow. The path is used regularly. But drug addicts congregate daily by the bridge and it rarely gets traffic.

“There is a lot to overcome here,” Green said.

This story was produced through collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health care policy research organization. You can follow Phil Galewitz on Twitter: @philgalewitz.

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The World Health Organization announced Friday that it no longer considers the Zika epidemic a public health emergency of international concern.

But Zika’s threat to pregnant women and babies is not going away anytime soon, the agency says. Instead, the virus is now a chronic problem, says the WHO’s Dr. Pete Salama.

“It is really important that we communicate this very clearly: We are not downgrading the importance of Zika,” Salama says. “In fact, by placing this as a longer term program of work, we’re sending the message that Zika is here to stay. And WHO’s response is here to stay, in a robust manner.”

One thing is clear: Zika is still spreading. And microcephaly cases are still growing. Argentina reported its first potential case this week. And Florida continues to find people who caught Zika inside the state.

For these reasons, pregnant women — and their partners — still need to pay attention to where they travel, says Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention.

“Regardless of how WHO defines Zika, [the disease] is unprecedented, and it’s an extraordinary risk for pregnant women,” Frieden says. “That’s why it’s important that pregnant women not travel to places where Zika is spreading.”

Right now, those places include countries across Latin America, the Caribbean, parts of Southeast Asia — and neighborhoods in Miami.

WHO first declared Zika a public health emergency back in February. Back then, the situation looked dire.

Brazil was investigating more than 4,000 cases of microcephaly — a horrible birth defect where babies have brain damage and small heads. And health officials were predicting thousands of more cases, as Zika spread across the Western Hemisphere.

“If this pattern is confirmed beyond Latin America and the Caribbean, the world will face a severe public health crisis,” WHO’s director-general, Dr. Margaret Chan, said in February.

But so far, that pattern hasn’t repeated itself. Brazil has confirmed the most Zika-linked microcephaly cases, about 2,100. Other counties in Latin America have reported far fewer. Colombia has the second highest with 58 confirmed cases and the U.S. is third with 31, WHO said Thursday.

Such a vast difference between the situation in Brazil versus other countries has raised some eyebrows. Could some other factor in Brazil be increasing the risk of microcephaly there? Perhaps a pesticide or another virus?

“I think it’s too early to draw conclusions,” says Alessandro Vespignani, who models the spread of Zika virus at Northeastern University in Boston.

Colombia is still investigating more than 300 microcephaly cases to see if they’re linked to Zika. Several countries, such as Venezuela and Haiti, have not been vigilant about reporting cases. And countries that are on top of reporting, such as Mexico and Puerto Rico, aren’t expected to have microcephaly cases until next year — it takes around 9 months after a Zika outbreak strikes for the bulk of microcephaly cases to appear.

“We can’t rule out the possibility that something unique is happening in Brazil,” Vespignani says. “But, right now, we have to wait and see what happens elsewhere.”

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In mid-August, an affable, 40-year-old man from Everett, Mass., overdosed at his mom’s home after almost 25 years of heroin use. Joe Salemi had overdosed before, but this time couldn’t be revived. Salemi’s brother, Anthony, says he was pretty sure when his brother died that there must have been something besides heroin in the syringe. The medical examiner later confirmed it.

“I knew, deep in my mind, it was going to be the stuff that everyone’s talking about now — fentanyl,” Anthony says. “Because I never thought straight heroin would kill him.”

Anthony Salemi was familiar with fentanyl. He’d been prescribed the powerful painkiller after surgery in 2006. Anthony had warned his younger brother about reports that dealers were adding an illicit version of the drug to heroin, sometimes promising a more intense high. Fentanyl is more than 50 times more potent than heroin, according the Centers for Disease Control and Prevention.

But people like Joe rarely know for sure if there is fentanyl in the tiny plastic bags of illegal powder they buy — or how much. Just a few grains of pure fentanyl, doctors say, is enough to kill most users. In Massachusetts, 75 percent of the people who overdosed this year tested positive for the drug.

“It just seems like the dealers and the drugs are ravaging the whole country, says Anthony Salemi. “The supply just keeps coming in, no matter how many cops you put at the border, it just keeps coming in. This is scary.”

The Obama administration agrees that the increasing supply of fentanyl on the street is a major challenge and says agencies are doing a lot. But reducing the supply is complicated.

Fentanyl is a synthetic opioid, constructed with lab chemicals — unlike heroin or morphine, which start with the opium sap of a poppy plant. Drug enforcement agents say clandestine labs across China are the main source of the illegally sold fentanyl.

Producers then ship the drug to Mexico, where drug cartels mix it into heroin or press it into blue, pink or white tablets that look like prescription pills for anxiety or pain. The powder or pills are delivered to dealers, or directly to users, via the Internet or darknet, an online area used for illegal purchases.

“Synthetic drugs are a real winner because they are easy to make, and they’re cheap to produce,” says Kara McDonald, director of policy, planning and coordination at the international narcotics and law enforcement bureau of the U.S. Department of State.

“They’re not dependent on a season or the weather like a plant-based drug,” McDonald says. “And with the distribution system — through mail order — they can be delivered directly to the door in some cases. Like a pizza.”

The profit margin is huge, says Drug Enforcement Administration spokesperson Russ Baer. He says it costs from $3,000 to $4,000 to produce a kilo — 2.2 pounds — of fentanyl. The fentanyl is then cut with cheap fillers to make pills, or mixed into bags and fraudulently sold as pure heroin.

“Drug traffickers involved in the wholesale distribution of those products can yield close to $1.5 million off that one kilogram,” says Baer.

The DEA has six agents who operate out of Beijing and work closely with China’s Ministry of Public Security, Baer says. Chinese officials established controls on 116 new chemicals last year, including 19 that have much the same molecular structure as fentanyl. Baer says that helped reduce the supply of some of these designer analogs of the drug. (Though each analog drug has a slightly different chemical structure from fentanyl, they work much the same way in the body.)

And in September, the DEA moved to declare another fentanyl analog called U-47700 illegal. But the producers always seem to be one step ahead of enforcement agencies, Baer says.

“Once we control a substance, whether here in the U.S. or in China, for example,” he says, “the drug manufacturers simply change a molecule, tweak a molecule, in an attempt to circumvent the law.”

Keeping up with the inventive chemists sounds nearly impossible.

“We’re identifying one to two new synthetic substances every week,” Baer says.

If a drug compound is similar to fentanyl, or if it produces the same physiological effect, the DEA can file trafficking charges here in the U.S. But these variations are not illegal in many countries. McDonald says the State Department is working, through the United Nations and with individual nations, to make sure police everywhere can identify new drugs and prosecute dealers.

The international control system is only able to detect, process and outlaw about 10 new psychoactive substances a year, McDonald says. “It doesn’t take a mathematician to identify that we have a real challenge here.”

To get in front of production, the State Department and a group of U.S. senators asked the United Nations in October to add to the list of tightly controlled substances two key ingredients used to make fentanyl. A decision is expected next year.

McDonald and Baer at the DEA say slowing demand for illicit uses of fentanyl and other opioids has become an urgent priority. The office of the U.S. Surgeon General this week also issued a report on the growing problem of substance abuse and the need for more widespread implementation of well-recognized, evidence-based treatment programs to address the problem.

In an interview with NPR’s Steve Inskeep on Morning Edition Thursday, Surgeon General Vivek Murthy called addiction “a chronic disease of the brain.”

“We need to treat it with the same urgency and compassion that we do any other illness,” Murthy told Inskeep.

But some lawmakers, physicians and families who’ve lost loved ones say the Obama administration has done too little too late to tackle the epidemic.

U.S. Sen. Ed Markey, a Democrat from Massachusetts, says it’s time to make the illegal production and trafficking of fentanyl the top policy issue in relations with China and Mexico.

“Many more people are going to die from this than [from] any threat from nuclear weapons or any devastation that’s caused by an imbalance in trade,” Markey says.

Baer says trying to stop the supply of opioids is part of the solution, but so is tackling demand by addressing addiction as a disease.

“The community needs to embrace these folks, create treatment opportunity,” Baer says. “We need to educate the public. It’s the No. 1 priority and it represents a public health crisis that all of us must work together to try to resolve.”

The CDC offers a sobering perspective. While about 78 Americans will die today after an overdose, another 580 will try heroin — or what they think is heroin — for the first time.

This story is part of NPR’s reporting partnership with WBUR and Kaiser Health News.

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Georgia Moore was diagnosed with leukemia the day after her 10th birthday. The fourth-grader began an intense chemotherapy regimen, which left her immune system vulnerable and kept her from attending her small, private Montessori school in Austin, Texas.

But her younger sister Ivy was in kindergarten at the same school, where a handful of families opted out of vaccinating their children. That meant 6-year-old Ivy might bring home germs that could pose a risk to Georgia.

“She would go to school, come home and immediately we’d put clothes in the washer to keep a healthy environment,” the girls’ mother, Courtney Moore, said of the family’s after-school routine.

Georgia, now 16, had very few hospitalizations during the course of her treatment and is now cancer-free, five years out from treatment. But Georgia’s battle against cancer made Courtney Moore a vocal advocate for immunizations in Texas — where an increasing number of parents are opting against vaccinating their children.

Texas is one of 18 states that allow nonmedical exemptions to the vaccines required for school attendance. California had a similar law allowing nonmedical exemptions, until last year when it enacted a law that has one of the strictest requirements in the country after a 2014 outbreak of measles traced to the Disneyland theme park infected more than 100 people around the country.

Many of the parents opting out of the immunizations, which are widely recommended by doctors, say they fear a link between the vaccines and health problems such as autism. But studies that they cite have been widely debunked by public health officials.

“Year after year we’ve seen a steady increase in the number of students with a conscientious exemption from vaccination in Texas,” said Christine Mann, a spokeswoman for the Texas Department of State Health Services. “But overall, the numbers are small.”

Even though statewide levels of vaccinations remain high, at over 98 percent, what concerns public health officials are the growing geographic clusters of geographic areas with high rates of unvaccinated children. Texas went from just 2,314 “conscientious exemptions” in 2003 to 44,716 this year, according to the Texas Department of State Health Services.

Data about the number of unvaccinated kids in individual public schools aren’t available. Currently, exemption rates are available for individual private and charter schools, but only districtwide for public schools.

Some parents are pressing state officials to let them know how many of their children’s peers are unvaccinated.

Jinny Suh, who has a 4-year-old son, is helping spearhead a petition drive asking legislators to change state law so that the number of school exemptions is public. As a parent, there are lots of things that people get very passionate about,” Suh said. “But for some reason, in my experience, vaccinations remain an almost taboo topic besides a few passionate people.”

At least two bills were introduced during the past legislative session that would require Texas schools to notify parents about vaccination rates at the school level, but none were approved.

As is the case across the country, areas where kids aren’t receiving vaccinations in Texas tend to be places with more highly educated and higher-income residents. The school with the highest percentage exemption rate in the state is the Austin Waldorf School, where more than 40 percent of students are unvaccinated and tuition exceeds $13,000 a year. Regents Academy, a private school in east Texas, was the second-highest exemption rate, at almost 38 percent of the school.

“If one of those kids is incubating an infectious disease and the other kids aren’t vaccinated, then it’s going to spread like wildfire,” said Catherine Troisi, an infectious disease epidemiologist at the University of Texas Health Science Center at Houston.

Troisi explains that for a disease like measles, you want “herd immunity” to be at 95 percent to prevent an outbreak. If healthy children aren’t receiving vaccines, they are putting children who are too young to receive the vaccine and people with compromised immune systems at a much greater risk of infection.

Dr. Peter Hotez, a professor in the department of pediatrics and molecular virology and microbiology at the Baylor College of Medicine in Houston, called the growing numbers “extremely troubling” in a commentary last month in the PLOS Medicine, an online journal. He noted that some counties were getting close to that 95 percent marker, such as Gaines County in the western part of the state where the exemptions are now at 4.83 percent and Briscoe County in the Texas Panhandle with 3.55 percent. And Hotez, who has an adult daughter with autism, highlighted the situation in Austin, where the public school rate for exemptions is 2 percent but many of the private schools exceed 20 percent.

The American Academy of Pediatrics in September issued a policy statement encouraging pediatricians to be more vocal about the importance of vaccines for children healthy enough to receive them.

But some parents are leery of the public health efforts on vaccinations. “We believe parents should make medical decisions for their children, not the state,” said Jackie Schlegel, director of Texans for Vaccine Choice, a political action committee that was formed partially in opposition to 2015 legislation to do away with the state’s nonmedical vaccine exemptions.

“We campaigned, we block-walked and we’ll do it again for anyone else who would like to trample on our parental rights,” said Schlegel. When asked if she supported a parent’s right to know the number of unvaccinated children at a given public school, Schlegel said “informed consent and privacy are very big concerns and need to be evaluated on both sides of the coin.”

As a mother who has seen the issue up close, Moore says she hopes parents understand how their decision not to vaccinate their children could have far-reaching consequences.

“It’s a very personal decision …” Moore said. “But you have to recognize that if you choose not to [vaccinate], there’s a good possibility that that personal decision will impact a lot of people.”

An earlier version of this story ran on Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, and The Texas Tribune.

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How do you get people to discuss diarrhea? Ask them to write poetry about it.

That’s the idea behind Poo Haiku, a competition created by Defeat DD, a campaign dedicated to the eradication of diarrheal disease.

Although everybody’s had the runs, it’s not something most folks talk about, says Hope Randall, digital communications officer for PATH’s Center for Vaccine Innovation and Access, which created DefeatDD to bring together resources on vaccines, nutrition, oral rehydration therapy, sanitation and more.

Silence is a problem because diarrheal disease is a problem. It’s the second-leading cause of death for children under the age of five. And it disproportionately affects kids in the developing world, where it’s tougher to access safe water and medical care.

Attention translates into more resources, Randall says, which is why Defeat DD wants to get people comfortable with words like “poo.” Hence, the call for “poo-ets” to write “poo-ems.”

Turns out there are plenty of potty mouths eager to show off their creativity. For the third Poo Haiku contest, which wrapped up on Nov. 4, Twitter was flush with submissions — a record 146 poo-ems, Randall boasts. The prize? Social media fame and the chance to be featured in DefeatDD’s 2017 calendar, which will be shaped like a toilet.

Most contributions came from the global health world. Take, for example, this winning entry from Kat Kelley of the Global Health Technologies Coalition, which references a recent study published in The Lancet:

Just six pathogens
But eighty percent of kids’
Diarrheal deaths.

Currently, there’s only a vaccine for one of these six pathogens — rotavirus, Randall notes. So DefeatDD is pushing for investment in vaccines to fight two more, ETEC, a type of E. coli bacteria, and Shigella.

The other pressing item on the DefeatDD agenda, Randall says, is the need to address the fact that even kids who survive diarrhea often deal with long-term consequences. Randall herself penned an entry on that topic:

A vicious cycle,
Gut damage, malnutrition
We can halt the churn.

Some Poo Haiku are more emotional than informational. Alanna Imbach, media relations manager for WaterAid, offers a good reminder that behind the stats, there are individual children out there facing hurdles to hygiene:

She is just a girl
Out looking for a toilet
Trying not to fear.

Other “poo-ems” will put a smile on your face, promises Randall, who’s partial to this one from a fifth grader who learned about Poo Haiku at school:

Go now, Mister Poo
Hurry, quick to the toilet,
When done wash your hands.

The ultimate winner, of course, is the fight against diarrheal disease. “As simple as it sounds, these kinds of words are so rarely used in polite discourse,” Randall says, noting that anything that helps poo become public makes the campaign a success.

Although the contest is now over, Randall would love to see people continue to share poo-ems through Saturday, which is World Toilet Day — the annual reminder that 2.4 billion people don’t have access to a toilet. Check out all of the poo-ems, including some videos, by searching for the hashtag #poohaiku on Twitter.

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Repeal of the Affordable Care Act is politically dangerous for Republicans unless they can pass a replacement that covers many of the people who benefit from the health care law.

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Before Donald Trump takes the oath of office in January, there are a lot of questions about how he will decide key policy issues.

We’ve identified the top 10 issues voters care about most according to a 2016 survey from the Pew Research Center and charted what Trump has said about each of them. The issues are, in order: the economy, terrorism, foreign policy, health care, gun policy, immigration, Social Security, education, Supreme Court appointments and the treatment of racial and ethnic minorities.

Where we could, we gave Trump’s stances a simple “Yes” or “No,” but also used the rating “It’s Complicated” in cases where his stance is more nuanced or has changed.

(Trump has given clues on what he’ll prioritize in his first 100 days, which we’ve posted here and fact checked here.)

The Economy

Trump hopes to grow the economy by significantly lowering taxes. Under his plan, he says a middle-class family with two children would get a 35 percent income tax cut. He will also reduce the number of tax brackets from seven down to three, which would largely benefit the wealthiest Americans. When it comes to business tax rates, Trump wants to go from a 35 percent rate to 15 percent.

Trump is also big on infrastructure as a way to create jobs. He says he would grant the permit needed for the Keystone Pipeline despite opposition from environmental activists, as NPR’s Scott Horsley outlined. He also plans to cancel all payments to U.N. climate change programs and put that money toward “water and environmental infrastructure,” as he wrote in his 100-day action plan. Trump would also lift restrictions on the oil, coal, shale and natural gas industries. In addition, he plans to impose tariffs to discourage companies from relocating to other countries.

Relevant stories

• Who Benefits From Donald Trump’s Tax Plan?
• In Economy As In Business, Trumponomics May Mean Building Big Things
• Here Is What Donald Trump Wants To Do In His First 100 Days

Terrorism

Trump made fighting terrorism a central pillar of his campaign and strengthened his hard-line stances with each high-profile terror attack, from the shooting in San Bernardino, Calif., last December to the Pulse nightclub shooting in Orlando, Fla., in June.

In his 100-day action plan, Trump promised to “suspend immigration from terror-prone regions where vetting cannot safely occur. All vetting of people coming into our country will be considered extreme vetting.” During his campaign, he also condoned other extreme counter-terrorism tactics, like waterboarding.

Relevant stories

• Here Is What Donald Trump Wants To Do In His First 100 Days
• Trump Calls To Ban Immigration From Countries With ‘Proven History Of Terrorism’

Foreign Policy

When it comes to foreign policy, Trump’s main focus has been to upend U.S. trade policy. He has promised to renegotiate or withdraw from NAFTA, the United States’ free trade agreement with Canada and Mexico. According to NPR’s Marilyn Geewax, actually doing away with NAFTA might not actually be feasible, but Trump could undermine it. He also wants to label China a currency manipulator and, per his 100-day plan, “identify all foreign trading abuses that unfairly impact American workers and direct them to use every tool under American and international law to end those abuses immediately.”

Relevant stories

• 3 Ways President-Elect Trump May Shake Up Trade Policy
• Trump Has A Chance To Pull U.S. Out Of Climate Accord
• Trump’s Election Gives Hope To Europe’s Far Right
• A Wary World Looks For Clues To Donald Trump’s Foreign Policy
• What Will A Trump Presidency Mean For China?
• From Cairo To Manila, Hardline Leaders Welcome Trump’s Victory
• For Trump, Pakistan And Afghanistan Pose Challenges Without Easy Solutions

Health

Trump’s main goal for health care policy is to repeal the Affordable Care Act. That feat will be harder than Trump seems to think, as we reported. To completely repeal and replace the act, he would need 60 votes in the Senate, which is the number needed to overcome a filibuster. Though they’ll make up a majority, there will be only 51 Republican senators come January. He recently signaled in an interview that he may be open to keeping provisions of Obamacare that expand insurance to people with pre-existing conditions and to young people.

Trump has also promised to allow tax deductions for child care and elder care and to create tax-free dependent care savings accounts, with matching contributions for low-income families. As we reported earlier this year, that would cost the government $25 billion annually.

Relevant stories

• Trump Can Kill Obamacare With Or Without Help From Congress
• From AIDS To Zika: Trump On Global Health And Humanitarian Aid
• Access To Abortion Could Be Curtailed Under Trump Administration

Gun Policy

Donald Trump aligned himself strongly with the National Rifle Association, which endorsed him, and also with Second Amendment protectionists (though no major candidate claimed to want to take away gun rights outright). Trump has said states should be more diligent about putting criminal and mental health records into existing background check systems.

Relevant stories

• Guns Strike Emotional Chords For People On Both Sides Of The Political Debate
• Here’s Where Gun Laws Stand In Your State

Immigration

Restricting immigration appears to be top-of-mind for Trump’s presidency, at least initially. In his 100-day plan, Trump promised to cancel federal funding to “sanctuary cities,” though he hasn’t specified which funds he would cut. There’s no legal definition for this type of city; it’s used to describe places with policies limiting how much local authorities can collaborate with federal authorities on immigration issues, such as detention requests from Immigration and Customs Enforcement, according to CNN.

Trump has also promised to undo all of President Obama’s executive actions, which include two on immigration (only one of which is in effect). Deferred Action for Childhood Arrivals allows certain people brought to the country illegally as children to apply for protection against deportation for two-year periods. That protection would go away, it seems.

Trump has also promised to deport immigrants in the country illegally who have committed crimes, stop immigration from “terror-prone” regions and begin “extreme vetting” of people entering the U.S. He has also mostly stood by his vow to build a wall on the country’s southern border, and make Mexico pay for it. Trump and some surrogates have said recently they would be OK with certain areas of the border having fence, rather than wall.

Relevant stories

• Immigrants In The U.S. Illegally Say ‘We’re Not Hypothetical’
• 6 Things You Might Not Have Known About Trump’s Border Enforcement Plan

Social Security

Trump does not want to privatize Social Security, nor does he want to raise the retirement age or increase taxes. He told AARP he plans to fund the entitlement program through “an economy that is robust and growing,” and he specifically highlighted his tax and immigration plans as key players in that growth.

Relevant stories

• The Issues: Hillary Clinton And Donald Trump On Social Security And Medicare

Education

Trump has been vocal about school choice, which allows parents to choose to send their child to any type of school: traditional public, private or charter. Critics say school choice leads to a gap in equitable school investment. Proponents say it increases competition between schools. In addition to school choice, Trump wants to end the Common Core standards, which are the federal guidelines created for K-12 education across the country. States were able to choose to opt in (some didn’t) — and the federal government encouraged it.

Relevant stories

• Can A President Trump Get Rid Of Common Core?
• Here’s What Students Are Saying About The Election Results

Supreme Court Appointments

Trump has released two lists, adding up to 21 judges, to fill the Supreme Court vacancy resulting from Antonin Scalia’s death last February. According to NPR’s Nina Totenberg, the lists are very conservative and a lot is unknown about who is helping Trump make this selection. With two other justices over 80 years old, it’s possible Trump will be able to nominate more than one justice during his presidency.

Relevant stories

• Republicans’ Senate Tactics Leave Trump Wide Sway Over Nation’s Courts
• Donald Trump Unveils New, More Diverse Supreme Court Short List
• Trump’s Supreme Court List Might Reassure Conservatives, But Leaves Off Big Names
• LGBT Rights Activists Fear Trump Will Undo Protections Created Under Obama

The Treatment of Racial and Ethnic Minorities

The relationship between police and their treatment of African-Americans was a common topic this election year. Trump ran as the “law and order” candidate and he’s sticking to it: He plans on increasing funding for federal law enforcement “to dismantle criminal gangs and put violent offenders behind bars.” He also wants to provide more funding and training to local police departments.

Trump has been criticized for his own rhetoric on minorities, most notably referring to Mexican immigrants as rapists in his June 2015 announcement speech and calling for a ban on Muslims entering the United States.

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• The Outlook On Race After Trump Victory: Fear, Resignation And Deja Vu

Stephan Bisaha, Alyson Hurt, Clinton King and Lisa Charlotte Rost designed the charts for this post. A version of this story, breaking down where all the major candidiates stood, was published ahead of Election Day.

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The number of doctors who each prescribe millions of dollars of medications annually in Medicare’s drug program has soared, driven by expensive hepatitis C treatments and rising drug prices overall, federal data obtained by ProPublica show.

The number of providers who topped the $5 million mark for prescriptions increased more than tenfold, from 41 in 2011 to 514 in 2015. The number of prescribers — mostly physicians but also nurse practitioners — exceeding $10 million in drug costs jumped from two to 70 over the same time period, according to the data.

Most of the doctors atop the spending list prescribed Harvoni or Sovaldi, relatively new drugs that cure hepatitis C. Other providers on the list prescribed pricey drugs to treat cancer, multiple sclerosis and rheumatoid arthritis.

Medicare’s drug program, known as Part D, covers more than 41 million seniors and disabled people. In 2015, it accounted for $137.4 billion in drug spending, before factoring in rebates from drug companies. That was up from $121.5 billion a year earlier.

“The trends in this space are troubling and don’t show any signs of abating,” said Tim Gronniger, deputy chief of staff at the Centers for Medicare and Medicaid Services, the federal agency that runs Medicare. “It’s going to be a pressure point for patients and the program for the foreseeable future.”

During the recent presidential campaign, both Hillary Clinton and Donald Trump pledged to tackle the rising costs of prescription drugs. Since his election, however, President-elect Trump’s transition agenda for health care hasn’t featured the topic, a shift The Los Angeles Times reported.

Medicare has released top-level data on drug spending for 2015, including the number of doctors who prescribed medications worth more than $1 million. But the agency has only published data on individual doctors up to 2014.

Dr. Ben Thrower, medical director of the Multiple Sclerosis Institute at the Shepherd Center in Atlanta, was near the top of the list in 2014. He prescribed medications costing $11.5 million that year, mostly for multiple sclerosis drugs. “We get that it’s very expensive,” Thrower said. “I think all the MS providers working in the U.S. would like to see the costs go down.”

But prices have climbed steadily in recent years for drugs used to treat the neurological condition, including medicines that have been on the market for quite a while.

Most of the spending on Thrower’s prescriptions — $8.5 million — was for MS drugs Tecfidera and Copaxone, which can slow progression of the neurological disease and reduce the chance of relapse. Thrower has received payments from the makers of those and other MS drugs, but said he cut ties with the companies in January of this year.

“It was kind of exciting when the first one came out,” Thrower said. “The problem we’ve seen is the cost for these drugs has just gone up and up and up.”

Thrower said he no longer prescribes Tecfidera to new patients because it can lower white blood cell counts, putting them at risk for infections.

Just because a doctor prescribes costly drugs doesn’t mean he or she has done anything wrong, Gronniger said. “It’s much more about drug pricing … than it is about the behavior of any individual physician, many of whom are equally concerned about the price of these products as we are.”

Today, ProPublica is updating its Prescriber Checkup online tool, which allows you to look up your doctor and see how his or her prescribing in Medicare Part D compares to others in the same specialty and state. Our tool covers the year 2014. You can compare the percentage of each doctor’s prescriptions that were for brand-name medications, the average cost per prescription and the average number of prescriptions per patient, among other things.

Allyson Funk, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, an industry trade group, said Medicare’s figures leave out important context.

“It is important to note physicians’ prescribing patterns are dynamic and based on individual patient needs,” she said in a statement. “When looking at Medicare Part D, government data on spending at the point of sale does not include the substantial rebates for brand name medicines negotiated between manufacturers and plans and therefore does not accurately reflect actual prescribing dollars or program spending.”

These rebates are confidential by law, but Medicare said this week that the average rebate for brand-name drugs in 2014 was 17.5 percent.

The new data on high-spending prescribers is the latest indication of the burden of drug prices on government health programs.

In the past couple years, Medicare’s drug tab has surged, in large part because it picks up the vast majority of the cost of drugs once enrollees exceed a certain threshold each year. In 2015, beneficiaries over the limit, which was $4,700, spent $51.3 billion on drugs. In 2013, the figure was $27.7 billion, government data shows. (Taxpayers, through Medicare, pick up 80 percent of the cost of this so-called catastrophic benefit.) The Associated Press first reported the ballooning cost in July.

Another sign could be seen in a drug dashboard released by Medicare this week. It showed that 1 percent of drugs prescribed in the Part D program accounted for more than one-third of the program’s cost in 2015 (before rebates). Some drugs were incredibly expensive. The drug H.P. Acthar Gel, used to treat several conditions, such as multiple sclerosis relapses and a rare kidney disease, cost an average of $162,371 for each of its 3,104 users—a higher per-user cost than any other drug in the program. That’s up significantly from several years ago, when ProPublica flagged the drug’s expense.

Harvoni, used by more than 75,000 people, cost an average of $92,847 per person, for a total cost of $7 billion (also before any rebates).

Michael Chernew, a professor of health care policy and director of the Healthcare Markets and Regulation Lab at Harvard Medical School, said the number of high-dollar prescribers in Medicare doesn’t surprise him. Given the increased cost of prescription drugs and the latest treatment advances, “the entire distribution is shifting to the right.”

Chernew said that, in the long term, Medicare and insurance companies have to examine the total cost of caring for patients with certain diseases, taking into account drugs, hospital visits, medical tests and more. Only then can anyone tell if certain expenses, such as a pricey new drug, are justified.

For now, he said, “How do we know what’s good or bad?”

Physicians say their top priority must be the patients in front of them, not the costs to the system.

Dr. Bruce Bacon, a liver specialist at St. Louis University, had the highest total Part D drug costs in 2014, $22.7 million. He was a frequent prescriber of Sovaldi and Olysio, another expensive hepatitis C medication.

Bacon didn’t return a call for comment for this story. In a 2015 interview, he said he did not realize his prescriptions were so costly to Medicare.

“I really don’t think about the cost,” he said. “I think about taking care of the patients. Should I not take care of the patients because the cost is expensive?”

Thrower, the multiple sclerosis specialist, said the high cost of drugs frustrates him and his colleagues, but ultimately the successful treatment of patients comes first.

“On one hand, we get that,” he said. “On the other hand, when you’re sitting in the exam room and looking someone in the eye, you can’t say, ‘I’m not going to treat you because of the cost.’ “

ProPublica is a nonprofit investigative reporting newsroom based in New York.

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When he was growing up in New York, All Things Considered host Robert Siegel always knew that Bellevue Hospital was a city institution.

But it wasn’t until he read David Oshinsky’s book Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, that he realized the hospital was a pioneering institution for all of American medicine.

The hospital, which grew out of an almshouse founded in 1736, has been in the forefront of many innovations in medicine in the U.S. Advances that started at Bellevue included ambulances, a maternity ward, nursing school, a children’s clinic and forensic pathology.

Siegal talked with Oshinsky, a professor of history at New York University, about the hospital and how it reflects the advances and failures of medicine. The interview has been edited for length and clarity.

On Bellevue’s origins in colonial New York

Bellevue in the 18^th century was really both a poorhouse and a pest house. It was a place you came to die. It really began with the great yellow fever epidemics of the 1790s. At that time the Bel-Vue estate, which became the hospital, was located on the East River, about two miles away from where most of New York was located down by the Battery. And you would send people who really had no chance of recovering.

On hospitals not being very good at saving lives in the first half of Bellevue’s history

Most physicians at Bellevue and elsewhere believed in the miasma theory — that clouds of bad air caused all kinds of disease. They had no concept that an invisible organism could cause so much damage, and that was what germ theory was about. Belluevue physicians were really on the forefront, particiularly the younger physicians, in pushing germ theory forward.

You also had a hospital where there was no anesthesia until the 1840s, and once anesthesia comes, postoperative infections are still extraordinarily high. It’s only when you have professional nursing and germ care and the coming of X-ray machines and the kind of pathology where you can actually do lab work within a hospital that makes a hospital better at saving a person’s life.

On Bellevue doctors treated two presidents — James Garfield and Grover Cleveland — with very different outcomes

Garfield was hit by two bullets, neither of which was fatal, but the lead surgeon was Frank Hamilton from Bellevue. And Hamilton came down to Washington and he put his finger into Garfield’s wound, and put dirty probes into Garfield’s wound. He didn’t die from the bullets, he died of the kind of infection was brought about by physicians who didn’t believe in germ theory.

About 15 or 20 years later, Grover Cleveland had a mass in his mouth which turned out to be cancerous. It was during the Great Panic of 1893, a serious economic depression. Cleveland did not want to alert his critics. So they hired a yacht with a number of Bellevue surgeons and physicians. They sailed up the East River to a very, very calm piece of water and they removed this mass from Cleveland’s mouth in a one and a half hour operation using every imaginable antiseptic technique available. Cleveland survived the operation and died of a heart attack many, many years later.

How Bellevue’s response to AIDS epitomizes its ethos

Because it was the place that turned no one away, it dealt with anything that came through New York City: cholera with the Irish in the 1930s, tuberculosis with the Jews and the Italians about the turn of the century, the great influenza epidemics. Bellevue treated more AIDS patients than any hospital in the country, and more AIDS patients died at Bellevue than at any hospital in the country. Bellevue was really in crisis mode at that time.

AIDS was one of the big issues at Bellevue and hospitals across the country. Doctors were wary. There were studies done where even a percentage of young interns thought they had the right to determine whether they would treat these patients or not. In the end, and this is the important point, Bellevue prevailed. The Bellevue message prevailed. The ethos that we treat everybody, regardless of their disease, regardless of their social standing. And they did. And I think that people look back at that era with great pride.

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For 22 years, Nick Fugate washed dishes at a local hotel near his home in Olathe, Kan.

“There was nothing easy,” he says, and chuckles. “I just constantly had to scrape the dishes off to get them clean.”

Fugate recalls minor annoyances like the long days and the hot kitchen. The work did sometimes get tedious, he says, but he didn’t really mind.

“Just as long as I got the job done, it was fine,” he says.

Nick’s father, Ron Fugate, says the job was the key to the self-reliance he’s wanted for his son ever since Nick was born with an intellectual disability 42 years ago.

“From our perspective,” Ron says, “having a job, being independent, participating in the community, paying taxes, being a good citizen — that’s a dream parents have for their children in general.”

But things got tough last year when Nick lost his job and his health insurance. For the first time, he enrolled in Medicaid. He got his basic medical care covered right away, but in Kansas, there’s now a long waitlist — a 7-year wait — for people with intellectual disabilities to get the services they need. Decades ago, Fugate might have been institutionalized, but Medicaid now provides services to help people remain independent — including job coaching, help buying groceries, food preparation and transportation. These are the services Nick is eligible for but must wait to receive through Medicaid.

In the months since losing his employment, Nick has had to pay around $1,000 a month out of pocket for help buying groceries, career coaching and transportation. Those expenses are quickly burning through his life savings.

This year, families like the Fugates have been speaking out about that long waitlist and about other Medicaid problems at public forums like one held at the Jack Reardon Convention Center, in Kansas City, Kan., in May.

In a basement meeting room hundreds of people with disabilities, their families and caseworkers railed against KanCare — the state Medicaid program. Some even heckled the moderator. The state has been gathering feedback because it needs the federal government’s permission to continue running KanCare.

In 2013 Republican Gov. Sam Brownback put KanCare under the management of three private companies that promised to improve services, cut waste and save enough money to end the long waits for the kind of services Nick needs.

Two-and-a-half years later, many families say they’ve seen few signs of improvement, especially in terms of shortening the waitlist. In fact, it’s actually grown by a few hundred names to about 3,500. And, except in emergency situations, the wait to get treatment averages seven years.

But an end is in view, insists Brandt Haehn, commissioner for Home and Community Based Services, part of the agency that oversees KanCare.

“I think everybody in the system is doing the best job they can do to provide the people services,” Haehn says.

In August, the department announced it had eliminated a different waiting list — the one for getting physical disability services. That claim has been challenged by advocates, who say many people were dropped from the list without notice.

But state officials say the progress that’s been made in speeding up the start of services for KanCare applicants who have physical disabilities demonstrates that the agency can get results.

Haehn does acknowledge that cases like Nick Fugate’s, of developmental disability, are more expensive and complicated than physical disability cases. It will take time, he says, to come up with $1.5 billion — the state’s share of a $2.6 billion program — that’s needed to make sure that, at least through 2025, everyone qualified for these important services can get them without having to wait.

“Nothing would make me happier than to write a check and give all these people services, but that’s just not reality,” Haehn says. “So I have to deal with what reality is and try to use the money that I have to effect positive change in the most people.”

But Ron Fugate says KanCare had its chance. “We’re not treading water, we’re drowning,” he says. Families like his are quickly losing lifelong savings, he says, and their life situations are getting worse while they wait for the state to provide services.

“It’s not getting any better,” he says. “We’ve got to start taking some serious action on this and get it addressed. We’ve kicked the can down the road too long.”

The U.S. Department of Justice is investigating the waiting lists, although it declined to comment for this story.

The ability of the state of Kansas to act may be limited. Gov. Brownback’s tax cuts, which he initiated to boost the economy, have instead blown a hole in the state’s budget, leaving little money to apply to something like reducing the length of the KanCare waitlist.

Meanwhile, Ron Fugate and other advocates have been studying the ways Missouri recently eliminated its waiting list for similar services, in hopes of persuading Kansas legislators to adopt the same strategy.

Ron and his wife are both in their 70s, and say they’re now watching their carefully laid plans for their son’s future slip away.

“After 22 years, it looked like he was going to be able to complete a career,” Ron says, “and it didn’t happen that way. All of this comes at a time in our lives where we’re in the waning seasons. We did not anticipate this kind of a challenge at this point.”

Kansas submits its application the federal government to reauthorize KanCare this month.

This story is part of NPR’s reporting partnership with KCUR and Kaiser Health News.

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