by Anna Clark

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Just 15 months after receiving an award from the Centers for Disease Control and Prevention for excellence in community water fluoridation, the city of Grayling, Michigan, changed course.

With little notice or fanfare, council members voted unanimously in May to end Grayling’s decadeslong treatment program. The city shut down the equipment used to deliver the drinking water additive less than two weeks later.

Although it already paid for them, the town returned six unopened barrels of the fluoride treatment to the supplier.

Personal choice was the issue, said City Manager Erich Podjaske. “Why are we forcing something on residents and business owners, some of which don’t want fluoride in their water?” he said. He saw arguments for and against treatment in his research, he said, and figured that those who want fluoride can still get it at the dentist or in their toothpaste.

Drinking water fluoridation is widely heralded as a public health triumph, but it’s had critics since it was pioneered 80 years ago in Grand Rapids, about 150 miles southwest of Grayling. While once largely on the fringes, fluoridation skeptics now hold sway in federal, state and local government, and their arguments have seeped into the mainstream.

Even in the state where the treatment began, communities are backpedaling. And because customer notice requirements are patchy, people may not even know about it when their fluoridation stops.

Robert F. Kennedy Jr., secretary of the Department of Health and Human Services, has called fluoride “industrial waste” and supports an end to community water fluoridation. The head of the Food and Drug Administration said on a newscast that the CDC’s online description of water fluoridation as one of the greatest public health achievements is “misinformation.”

The CDC, which is in the midst of a leadership exodus and staff revolt, and the Environmental Protection Agency are reviewing their respective approaches to fluoride in drinking water. At the same time, President Donald Trump’s administration dismantled the CDC’s Division of Oral Health, which, among other initiatives, provided research and technical assistance on fluoridation. That’s the office that helped present awards for well-run programs like the one in Grayling.

Since Kennedy was elevated to the nation’s top health post, Utah and Florida became the first states to ban communities from adding fluoride to public drinking water. The Utah ban included measures to make prescription fluoride supplements more accessible — but now, the FDA is moving to remove certain types of those supplements for children from the market.

Altogether, legislation was introduced this year in at least 21 states to prohibit or roll back provisions related to adding fluoride to public water systems, according to Abby Francl, policy analyst at the National Conference of State Legislatures. In addition, citing Kennedy’s “Make America Healthy Again” initiative, Oklahoma’s governor issued an executive order instructing state agencies to cease promotion of fluoridation in the public water supply while it reviews the practice.

Some local communities across the country opted to stop treatment this year, including at least four in Alabama, the state with the second-lowest number of dentists per resident. Others are debating it. On Michigan’s east side, the medical director of St. Clair County’s health department urged the agency to take steps to “prohibit the addition of fluoride” to public water systems. Two Upper Peninsula cities with a shared water system had special council meetings this summer on fluoridation. In Hillsdale, the acting mayor has said that ending fluoridation is a top priority.

“I want to reform the water system now that we have RFK in Health and Human Services,” Joshua Paladino told a local paper in November. Paladino added in an email to ProPublica that he sees public water fluoridation as an imprecise tool because it gives a standard dose across the population.

According to Michigan’s environmental agency, some communities had temporarily stopped fluoridation and were “hesitant to restart because of uncertainty.” That prompted it to issue a five-page statement with the state health department in March, stressing that the levels recommended for water suppliers — 0.7 milligrams per liter of water — have no adverse health effects and that fluoridation benefits everyone.

“Local anti-fluoride movements can be vocal and persistent, but do not necessarily represent the viewpoints of the greater community,” the statement said.

Communities that end fluoridation will see more decaying teeth, according to Margherita Fontana, a professor at the University of Michigan School of Dentistry. Young children, older adults, people with disabilities and people who are poor are especially at risk, she said, but everyone will be vulnerable. Excessive tooth decay in children can require treatment in hospitals, under anesthesia. In rare but extreme cases, it can lead to death.

“It’s unfortunate, because we know how to prevent the disease,” Fontana said. “So it just seems like we’re going backwards in time rather than forward.”

A handful of states require customer notification when fluoridation ends. New York mandates such notice, yet fluoridation in Buffalo lapsed for years before it was widely known. Outside Detroit, the city of Wyandotte suspended treatment about a decade ago, despite saying on its website until early this summer that it used fluoride. The claim was removed only after a local reporter raised the issue.

Michigan doesn’t have a statewide protocol for notifying residents when fluoridation stops. The environmental agency’s spokesperson said in an email that while it strongly recommends that communities inform customers, it doesn’t have the authority to compel them.

Grayling’s water operator, Josh Carlson, said a district engineer at the agency told him he just needed to tell the state if the town decided to stop fluoridating the water.

“It was almost like she was caught off guard that we actually did it,” Carlson said.

From Fringe to Mainstream

Water fluoridation began in 1945 in Grand Rapids, Michigan’s second-largest city, as part of a planned trial intended to last 15 years. Muskegon, on the Lake Michigan shore, served as the control, meaning its water was not treated with a fluoride additive. An Illinois city with naturally occurring fluoride in its water was another point of comparison.

Six years in, Muskegon officials withdrew from the trial after determining that the health benefits were so significant, they couldn’t deny treatment any longer to Muskegon’s children. Similar studies elsewhere continued for years, showing positive outcomes.

“It was very usual to have dentures at a very young age” at the time, Fontana said. Fluoride treatment “was such a fantastic discovery, something so easy that nature already provided. It was already there. It was the greatest discovery, really, for oral health.”

Grand Rapids celebrates its role in public health history with plaques and a totemic sculpture. But the treatment has been criticized since the early days as, variously, a Communist plot, forced mass medication and an industrial byproduct that causes more harm than good. (Fluoride additives are commonly derived from the processing of phosphate fertilizer.)

Even as fluoridation became widespread, opposition persisted. Today’s critics note that fluoride is now available in toothpaste, as well as in ingestible drops and tablets like the ones for children that the FDA is working to remove from the marketplace. Dental care is also more accessible than it was in the 1940s. The need that fluoridated water was meant to address, critics say, isn’t as urgent.

While progress has made fluoridation’s effects less dramatic, they’re still significant. It was initially credited with a 65% reduction in tooth decay; now, it’s about 25%. No other fluoride source compares to the cost-effectiveness of drinking water, proponents say, especially for those least able to access dental care, either because of cost or because they live in areas with a shortage of dental providers.

“Steel Water,” a sculpture by artist Cyril Lixenberg, was erected in 2007 in Grand Rapids to celebrate the community’s role in advancing water fluoridation. (Joel Seewald, HMdb.org)

Community water fluoridation is supported by the American Academy of Pediatrics, the American Dental Association and the American Medical Association. The CDC, at least for the moment, still recommends it.

Advocates say that its benefits are so pervasive, they’ve become invisible to many.

“Known benefits that are not visible, they take it for granted, whereas unknown risks are what they are always worried about,” said Jayanth Kumar, lead researcher on a systematic review of community water fluoridation and IQ. “Florida didn’t ban alcohol. Florida didn’t ban cigarettes. But they banned fluoride.”

Critics say the National Toxicology Program’s “state of the science” report from last year shows an association between fluoridated drinking water and a lowered IQ in children. But that assessment — which is both contested and much-cited — involves fluoride levels that are more than twice what the federal government recommends for drinking water, and it’s based on limited studies conducted outside the U.S., with different water conditions.

A post made on Gov. Ron DeSantis’ X account, celebrating Florida’s ban on local governments adding fluoride to public drinking water, was sent to ProPublica in response to a query to the governor’s office about the state’s policy. (Obtained by ProPublica)

Even the report’s abstract says that “more studies are needed to fully understand the potential for lower fluoride exposure to affect children’s IQ.”

In a lawsuit brought against the EPA by groups opposed to water fluoridation, a district judge relied in part on the NTP analysis in ruling that fluoridation presents such an “unreasonable risk” that the agency must take action. Even as it appeals the decision, the EPA said its review of new science on fluoride in drinking water “is being done in coordination with Secretary Kennedy and HHS.”

The court ruling, the NTP report and the wavering stance of federal agencies have empowered a backlash to fluoridation in state and local governments.

Stuart Cooper, executive director of the Fluoride Action Network, said he’s seen momentum shift over the last two decades as his group sought to eliminate fluoride treatment, not least as a plaintiff in the EPA lawsuit. Kennedy has given a jolt to the movement, he said. Now, “we have allies at every level.”

“Legislators and city councilors are calling us instead of me having to do vice versa,” he said.

Tooth Decay and Regrets

In Grayling, questions about fluoridation were brewing for at least a year before the town changed course. Podjaske, the city manager, said he discussed it off and on with Carlson, the city’s water operator. When it came time to reorder the fluoride additive, Podjaske wondered: Is this really necessary?

Carlson asked the state’s environmental agency about the protocol for discontinuing treatment and was told to keep the state posted. In April, Podjaske suggested adding the fluoridation question to the City Council’s agenda. At the May meeting, the council voted 4-0 to end treatment.

“I figured the best option was don’t push it on people,’’ council member Jack Pettyjohn said about his vote. “Don’t force them to have it in their water.”

There wasn’t any outreach to the public or health experts ahead of the vote. Meeting minutes say that Podjaske and Carlson discussed the removal of the fluoride additive after the water operator received “additional education and training.”

But both men say that isn’t right. Fluoridation was already on the agenda when Carlson attended a training that wasn’t about the treatment, but where he had an informal conversation with an instructor that made him worry about fluoride’s safety.

The vote would’ve occurred even without Kennedy’s activism, Podjaske and Pettyjohn said. Carlson, though, noted how Grayling’s pivot played out in context of “some of the new narratives coming out of Washington.”

“There’s a lot of mixed feelings about RFK Jr., but he seems to be anti-fluoride,” Carlson said. “I don’t know if that’s driving people’s complaints about fluoride.” With the proliferation of social media, he said, “I could see that being a factor, in the fact there’s more people with an opinion now.”

At the same time, he said, locals are more tuned in to water issues following the Flint water crisis and the contamination of waterways with PFAS chemicals linked to a nearby military base. PFAS are a group of “forever chemicals” that can carry a cancer risk.

Carlson said that in the occasional feedback he’s gotten on fluoridation over the last couple of decades, “the negatives were more than the positives in recent years.”

Following input from the state environmental agency, Grayling posted a notice about the change online in August, 10 weeks after treatment stopped. Some people didn’t see it. Mary Bobenmoyer, owner and general manager of Our Town Coffee & Treats, didn’t know until a reporter asked her about it in late August. “They did it?” she said.

Bobenmoyer spent seven years as a dental assistant. She encourages children especially to get fluoride treatment at the dentist. But, she said, “I personally don’t think it should be filtered in our water. We should have free and clear water.”

Over in Grand Rapids, there’s sporadic pushback on fluoridation, said water system manager Wayne Jernberg. But he hasn’t noticed any recent escalation. And he doesn’t see why there would be.

“We rely on the science of us,” Jernberg said. “We’ve been adding it for 80 years, OK? And we don’t see any issues in our community.”

Meanwhile, reports on dental health have caused some communities that dropped fluoridation to reconsider.

In Canada, just across the river from Detroit, the City Council of Windsor, Ontario, voted to stop fluoridation in 2013 after lengthy public debate. Less than six years later, the county health agency reported troubling outcomes from oral health screenings at area schools. It found that the percentage of children with decay or requiring urgent care increased 51% in five years, while the percentage of children that didn’t require any care decreased by 43%. The Windsor council soon decided to reintroduce water fluoridation, citing it as “a key prevention strategy.”

In the province of Alberta, Calgary’s council voted in 2011 to stop fluoridation in part because of community skepticism and because expensive repairs to the equipment were needed, according to Councillor Gian-Carlo Carrà. But in time, researchers found that local children developed significantly more cavities than their peers in Edmonton, where water is fluoridated.

“We saved ourselves some money,” said Carrà. “Fast-forward 10 years, and the results are clear that dental outcomes for Calgarians are worse after 10 years of not having fluoride in the water.”

When fluoridation was put on the ballot in 2021, 62% of voters supported its reintroduction. It took more than 28 million Canadian dollars and several years to start treatment again.

But, Carrà said, those costs — and the money to run the system — seem worthwhile. “I’m just much more interested in doing as much good as I possibly can,” Carrà said.

In Grayling, speaking more than two months after voting to end the treatment, Pettyjohn said he has an open mind about the future of fluoridation. “I would totally look at readdressing it, especially if the people of Grayling really wanted us to,” he said.

For now, though, he said he’s heard nothing negative from residents.

This post was originally published on ProPublica.

by David Armstrong, Eric Umansky and Vernal Coleman

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Veterans hospitals are struggling to replace hundreds of doctors and nurses who have left the health care system this year as the Trump administration pursues its pledge to simultaneously slash Department of Veterans Affairs staff and improve care.

Many job applicants are turning down offers, worried that the positions are not stable and uneasy with the overall direction of the agency, according to internal documents examined by ProPublica. The records show nearly 4 in 10 of the roughly 2,000 doctors offered jobs from January through March of this year turned them down. That is quadruple the rate of doctors rejecting offers during the same time period last year.

The VA in March said it intended to cut its workforce by at least 70,000 people. The news sparked alarm that the cuts would hurt patient care, prompting public reassurances from VA Secretary Doug Collins that front-line health care staff would be immune from the proposed layoffs.

Last month, department officials updated their plans and said they would reduce the workforce by 30,000 by the end of the fiscal year, which is Sept. 30. So many staffers had left voluntarily, the agency said in a press release, that mass layoffs would not be necessary.

“VA is headed in the right direction,” Collins said in a statement.

But a review of hundreds of internal staffing records, along with interviews with veterans and employees, reveal a far less rosy picture of how staffing is affecting veterans’ care.

After six years of adding medical staff, the VA this year is down more than 600 doctors and about 1,900 nurses. The number of doctors on staff has declined each month since President Donald Trump took office. The agency also lost twice as many nurses as it hired between January and June, records viewed by ProPublica show.

In response to questions, a VA spokesperson did not dispute numbers about staff losses at centers across the country but accused ProPublica of bias and of “cherry-picking issues that are mostly routine.”

Agency spokesperson Peter Kasperowicz said that the department is “working to address” the number of doctors declining job offers by speeding up the hiring process and that the agency “has several strategies to navigate shortages,” including referring veterans to private providers and telehealth appointments. A nationwide shortage of health care workers has made hiring and retention difficult, he said.

Kasperowicz said that the recent changes at the agency have not compromised care and that wait times are getting better after worsening under President Joe Biden.

While wait times for primary, mental health and specialty care for existing patients did increase during Biden’s presidency, the VA’s statistics show only slight reductions since Trump took office in January.

However, appointment wait times for new patients seeking primary and specialty care have slightly increased, according to a report obtained by ProPublica.

As of early July, the average wait time nationally to schedule outpatient surgery appointments for new patients was 41 days, which is 13 days higher than the goal set by the VA and nearly two days longer than a year ago.

In some locations, the waits for appointments are even longer.

At the Togus VA Medical Center in Augusta, Maine, internal records show that there is a two-month wait for primary care appointments, which is triple the VA’s goal and 38 days longer than it was at this time last year. The wife of a disabled Marine veteran who receives care at the facility told ProPublica that it has become harder in recent months to schedule appointments and to get timely care.

Her husband, she said, served in Somalia and is completely disabled. He has not had a primary care doctor assigned to him for months after his previous doctor left over the winter, she said.

“He has no person who is in charge of his health care,” said the woman, who did not want to be named because of fears her comments might affect benefits for her husband. “It was never like this before. There’s a lack of staff, empty rooms, locked doors. It feels like something that’s not healthy.”

Kasperowicz said the VA is taking “aggressive action” to recruit primary care doctors in Maine and anticipates hiring two new doctors by the end of the year.

Nationwide, records reviewed by ProPublica show, the vacancy rate for doctors at the VA was 13.7% in May, up from 12% in May of 2024. Kasperowicz said those rates are in line with historical averages for the agency. But while the vacancy rate decreased over the first five months of 2024, it has risen in 2025.

Sen. Richard Blumenthal, D-Conn., who has been critical of Collins’ stewardship, has argued that the VA is heading in a dangerous new direction. He said that ProPublica’s findings reinforce his concerns about “damaging and dangerous impacts” from cuts and staffing reductions.

“Dedicated professionals are fleeing — and recruitment is flagging — because of toxic work conditions and draconian funding cuts and firings,” he told ProPublica. “We’ve warned repeatedly about these results — shocking, but not surprising.”

In the VA’s Texas region, which covers most of the state, officials reported in an internal presentation in June that approximately 90 people had turned down job offers “due to the uncertainty of reorganization” and noted that low morale was causing existing employees to not recommend working at the medical centers.

Anthony Martinez, a retired Army captain who did tours of duty in Iraq and Afghanistan, said he has witnessed a downgrade in care at the Temple, Texas, VA facility. He said that the hospital has lost records of his recent allergy shots, which he now has to repeat, and he has to wait longer for appointments.

“Problems have always existed but not to this degree,” Martinez said.

Martinez, who runs a local nonprofit for veterans, said he’s heard similar frustrations from many of them. “It’s not just me. Many vets are having bad experiences,” he said.

Kasperowicz said the agency couldn’t discuss Martinez’s case without a patient privacy waiver, which Martinez declined to sign. He said wait times for primary care appointments for existing patients at Temple are unchanged over the past fiscal year. But internal records show an increase in wait times for new patients in specialties such as cardiology, gastroenterology and oncology.

Administrators there have expressed concern about the impact of staff losses, warning in their June internal presentation about “institutional knowledge leaving the Agency due to the increase of supervisors departing.”

It is not just the loss of doctors and nurses impacting care. Shortages in support staff, who have not been protected from cuts, are also adding to delays.

In Dayton, Ohio, vacant positions for purchasing agents resulted in delays in acquiring hundreds of prosthetics, according to an internal VA report from May. Kasperowicz said the hospital has recently cut processing time for such orders by more than half.

Some facilities are experiencing trouble hiring and keeping mental health staff.

In February, a human resources official in the VA region covering much of Florida reported in an internal warning system that the area was having trouble hiring mental health professionals to treat patients in rural areas. The jobs had previously been entirely remote but now require providers to be on site at a clinic.

When the region offered jobs to three mental health providers, all of them declined. The expected impact, according to the warning document, was longer delays for appointments. Kasperowicz said the VA is working to address the shortages.

Yet even as the agency faces these challenges, the Trump administration has dramatically scaled back the use of a key tool designed to help the VA attract applicants and plug gaps in critical front-line care.

The VA in recent years has used incentive payments to help recruit and keep doctors and other health care workers. In fiscal 2024, the agency paid nearly 20,000 staffers retention bonuses and over 6,000 new hires got signing bonuses. In the first nine months of this fiscal year, which started Oct. 1, only about 8,000 VA employees got retention bonuses and just over 1,000 received recruitment incentives. The VA has told lawmakers it has been able to fill jobs without using the incentive programs.

Rep. Delia Ramirez, D-Ill., said during a congressional oversight hearing in July that the Trump administration is withholding the bonuses because it “wants them to leave” as part of a plan to privatize services.

“It’s not that VA employees are less meritorious than they were under Biden,” she said. “They want every employee to be pushed out so they can decimate the VA’s workforce.”

Do you have information about the VA that we should know about? Contact reporters David Armstrong on Signal, DavidArmstrong.55, or via email, david.armstrong@propublica.org; Eric Umansky on Signal, Ericumansky.04, or via email, eric.umansky@propublica.org; and Vernal Coleman on Signal, vcoleman91.99, or via email, vernal.coleman@propublica.org.

Joel Jacobs contributed reporting.

This post was originally published on ProPublica.

by Cassandra Jaramillo

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Seven years ago, when President Donald Trump signed the Preventing Maternal Deaths Act into law, it was hailed as a crucial step toward addressing the nation’s maternal mortality crisis.

The law pumped tens of millions of dollars a year into a program to help fund state committees that review maternal deaths and identify their causes. The committees’ findings have led to new protocols to prevent hemorrhage, sepsis and suicide. Federal money has allowed some states to establish panels for the first time.

The committees’ work only became more urgent after the Supreme Court overturned the constitutional right to abortion. Last year, Georgia’s committee determined the state’s abortion ban contributed to the preventable death of 41-year-old Candi Miller.

But now the program that enabled this progress — known as Enhancing Reviews and Surveillance to Eliminate Maternal Mortality, or ERASE MM — is in danger, maternal health advocates say.

The program’s funding expires on Sept. 30, and efforts to renew it have thus far not succeeded. Congress included money to extend ERASE MM in a broader stopgap funding measure that almost passed in December 2024 before being scuttled by Republican opposition. The program isn’t paid for in the Trump administration’s budget proposal for 2026. Late last week, the Senate Appropriations Committee introduced a bill to fund the Department of Health and Human Services for the next fiscal year that includes money for ERASE MM, but the measure hasn’t moved forward yet.

Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance, said she fears how little attention the program’s fraught future has drawn amid waves of layoffs at federal health agencies and ferocious debate over impending Medicaid cuts.

“We were concerned when the president’s budget did not include these programs,” Griffen said. “While we are happy with the progress, there is still a lot that needs to happen.”

The Centers for Disease Control and Prevention, which is responsible for awarding ERASE MM grants and guiding the work of state maternal mortality committees, didn’t answer specific questions from ProPublica about the future of the program. Andrew Nixon, communications director for HHS, the CDC’s parent agency, said in a statement that HHS “is committed to improving maternal and infant health outcomes.”

“We are currently reviewing the maternal and infant health portfolio to identify the most effective ways to collect and analyze data and improve the health and safety of mothers and infants,” the statement said.

HHS Secretary Robert F. Kennedy Jr. didn’t respond to requests for comment on whether advocates’ concerns are warranted.

The Trump administration’s budget proposal jettisons not only ERASE MM but a slate of programs known as the Safe Motherhood initiative, which aims to reduce risks such as premature births and infections that affect mothers and infants. All previously had bipartisan support. That’s left some members of Congress mystified about why their funding is in jeopardy.

At a June budget hearing, Rep. Greg Landsman, D-Ohio, pressed Kennedy on why the administration had proposed eliminating the programs, including ERASE MM.

“I genuinely believed this was zeroed out either accidentally or by some sort of oversight,” Landsman said, asking Kennedy to work with members of the House Committee on Energy and Commerce to restore funding.

After their exchange at the hearing, Landsman told ProPublica that Kennedy had agreed to meet to discuss restoring the funding.

“We want to save this investment,” he said. “It’s critical for expecting moms.”

ERASE MM came about in 2019 after reporting by ProPublica and others showed that hundreds of American women were dying each year from preventable causes related to pregnancy. U.S. maternal mortality rates had risen sharply over two decades as rates in other affluent nations had dropped.

Other countries, particularly the United Kingdom, had reliable national data on maternal mortality, as well as robust case-review systems designed to turn information into improvements in care. In the U.S., by contrast, only two-thirds of states had review processes at all and even those sometimes went years between reports or operated inconsistently.

ERASE MM was designed to plug these holes, ensuring that lessons from maternal deaths didn’t go unlearned.

Over the last five years, the CDC has distributed nearly $90 million to fund the work of state review committees. At least by federal standards, the program is relatively inexpensive; it divvied up a total of about $40 million last year between 46 states, an average of $870,000 apiece.

The members of maternal mortality review committees — usually a mix of physicians, nurses, mental health professionals and advocates — volunteer their time. ERASE MM grants typically pay to hire the staffers who gather records from hospitals, medical examiners, police and other agencies and abstractors who redact private information from case summaries.

Committees are advisory in nature, but their findings have made a difference, advocates say. In recent years, many states have developed mental health initiatives for pregnant people and new mothers based on maternal mortality reviews. Recommendations by New Hampshire’s committee, for example, led to a program in which OB-GYNs collaborate with psychiatrists on treatments for post-partum depression or substance use disorder.

In Indiana, which used ERASE MM funds to establish a maternal mortality review committee in 2018, the panel’s work spurred state officials to expand an initiative to have nurses make post-partum home visits to new mothers.

Indiana is one of at least five states that rely entirely on federal dollars to pay for their maternal mortality reviews (the others are South Carolina, Iowa, Missouri and Utah). Committee members in several states expressed alarm that this money may evaporate.

Before ERASE MM, Utah had a joint committee that reviewed both infant and maternal deaths, said Dr. Marcela Smid, a maternal-fetal health specialist. Utah set up a maternal mortality review committee for the first time in 2019 using funds from ERASE MM, which Smid chairs. It found increasing numbers of maternal deaths by suicide, leading to programs for better mental heath and substance use disorder screening and treatment. Since 2021, the committee has received about $1.7 million from the CDC.

“If we get defunded, I suspect it would be devastating,” Smid said.

As part of reviews, committee members consider the legal and socioeconomic context in which a woman dies. Those steps were critical in Georgia when the committee reviewed deaths that had occurred after Roe v. Wade was overturned in 2022 and the state prohibited abortion. The CDC hasn’t directed committees to ask explicitly about such laws, but committee members say the process has provided a window that could be lost if ERASE MM ends.

Case reviews are typically confidential, but ProPublica reported last year that Georgia’s committee had concluded the abortion-related deaths of Miller and Amber Thurman, 28, had been preventable.

Reviewers found both women had taken abortion pills and suffered a rare complication when they failed to expel all the fetal tissue from their bodies. Miller decided not to go to the doctor when she began having symptoms of sepsis because she feared repercussions related to the state’s abortion ban, the review committee found. Thurman went to the hospital but died after doctors waited 20 hours to perform a dilation and curettage to clear her uterus; the procedure, also used to perform abortions, had become entangled in restrictions subjecting doctors to criminal penalties if they violated the law.

Even before the threat to ERASE MM’s funding emerged, four states, including Florida and Texas, had opted out of accepting money from the program. The Florida Department of Health didn’t respond to questions from ProPublica about why it had done this. The Texas Department of Health said the state Legislature had instructed it not to take the funds and instead allocated funding to create its own system. Texas, which accounts for about 10% of U.S. maternal deaths, also stopped sharing data collected by its maternal mortality review committee with the CDC shortly after restricting abortion access.

Officials at the Texas Department of Health also have chosen not to have the state’s maternal mortality review committee examine cases from 2022 and 2023, a period that includes two preventable deaths ProPublica reported on last year. The panel was nearly four years behind on case reviews, and state officials said skipping two years would help it catch up. The state also forbids its panel from investigating deaths related to abortion.

Dr. Thomas Westover, a maternal-fetal medicine specialist who also sits on the maternal mortality review committee in New Jersey, said he worries that if ERASE MM goes away, there will be no consistency from state to state in how maternal deaths are reviewed or what data is collected on them.

“You’ll have states that pick and choose what to review,” Westover said. He noted that some states likely would ignore accidental deaths to manage their caseloads, while others, like Texas, choose to exclude deaths related to abortions, making data less comparable nationally. “That’s a bad decision.”

As part of ERASE MM, the CDC gives state review committees detailed guidance on what contributing factors to consider when assessing maternal deaths, including obesity, mental health issues, substance abuse and homicide.

This information fuels analysis that goes well beyond what’s in death certificates, said Amy Raines-Milenkov, an associate professor at the University of North Texas Health Science Center and longtime maternal health scholar-practitioner. Based on this information, Texas expanded nurse home visits to post-partum mothers that’s similar to Indiana’s initiative.

“What we choose to measure is what we value in society,” Raines-Milenkov said.

Maternal health advocates say they’re working together to bring national attention to the potential funding threat to ERASE MM. Griffen, the executive director of the Maternal Mental Health Leadership Alliance, said she’s hopeful with more meetings on Capitol Hill that a solution can secure the program.

Women’s lives depend on it, she said.

Kavitha Surana contributed reporting. Mariam Elba contributed research.

This post was originally published on ProPublica.