Geiger Gibson Program in Community Health
Policy Issue Brief #73
November 2025
Leighton Ku, PhD, MPH
Maddie Krips, MPP
Kristine Namhee Kwon, MPH
Feygele Jacobs, DrPH, MS, MPH
- Executive Summary
Community health centers (CHCs), the nation’s primary care safety net, are under pressure. As recent policy changes take effect, conditions are likely to worsen, making it even more difficult for CHCs to meet the needs of the patients and communities they serve.
The number of patients served by health centers grew from 28.6 million in 2020, when the COVID-19 pandemic began, to 32.4 million in calendar year 2024, the last year for which data are available. However, the centers’ finances became more precarious.[1] In 2020, nationwide health center operating margins (revenues minus costs) were $1.4 billion (+4.1 percent). By 2024 health centers were operating in the red, with total losses of -$1.1 billion (-2.1 percent). Centers in the majority of states had net losses in 2024 and seven (Texas, Wyoming, Minnesota, Arizona Vermont, Virginia and Rhode Island) had losses exceeding 10 percent. While data for 2025 are not yet available, the situation may have deteriorated further this year, leading to site closures and possible reductions in the number of patients served.
If Affordable Care Act (ACA) enhanced premium tax credits expire at the end of December, millions of patients could lose health insurance marketplace coverage, causing health centers to have even deeper losses in 2026.[2] In addition, recent policy changes, such as restrictions on care for immigrants or on Medicaid coverage of family planning, create additional challenges for health centers. Finally, beginning in 2027, when Medicaid work requirements must be implemented under the One Big Beautiful Bill Act (H.R. 1 or the OBBBA), health centers will sustain even greater losses.
Health centers provide high-quality primary and preventive care that helps reduce the need for more expensive emergency and inpatient care in Medicaid and Medicare.[3][4] But the levels of mandatory and appropriations funding for community health centers for Fiscal Year 2026 have not yet been determined and need to be extended and strengthened during the critical period. Investing in primary care at community health centers can help protect vulnerable rural and urban communities and help contain other federal health costs.
- Introduction
Community health centers (sometimes also called federally qualified health centers or FQHCs), are non-profit comprehensive primary care centers that serve low-income and vulnerable populations in medically underserved areas, including rural, suburban and Community health centers (sometimes also called federally qualified health centers or FQHCs), are non-profit comprehensive primary care centers that serve low-income and vulnerable populations in medically underserved areas, including rural, suburban and urban communities.[5] CHCs receive funding from multiple sources, and while Medicaid is the largest source of revenue, their core support is from federal Section 330 grants distributed by Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC).[6] Under the terms of those grants, CHCs must serve patients without regard to their source of insurance coverage or ability to pay; they offer sliding fee scales to help patients afford care. In addition to offering preventive and primary medical care, CHCs generally provide behavioral health and dental care, as well as supportive enabling or social services. Many health centers also offer related programs like Title X family planning, Ryan White HIV/AIDS care, and Women Infants and Children (WIC) nutrition services.
- Findings
More Patients Receive Care at Health Centers, For Now Anyway
Evidence of their effectiveness[1][2] coupled with historic bipartisan support, have enabled health centers to grow. The number of patients receiving CHC care more than tripled from 9.6 million in 2000[7] to 32.4 million in 2024.
But 2024 may be a turning point. As seen in Exhibit 1, although 1.1 million more patients received care in 2024 than in 2023, the number covered by Medicaid declined. The number of Medicaid and CHIP patients surged by 2.4 million between 2020 and 2023, but declined by 48,000 (-0.3%) in 2024. The rapid growth in Medicaid enrollment from 2020 to 2023 was largely related to Medicaid continuous enrollment during the public health emergency period spurred by the COVID-19 pandemic, while the decline in 2024 was related to Medicaid “unwinding” that began after continuous enrollment ended and Medicaid shed millions of enrollees as eligibility was redetermined.[8][9]
Conversely, the number of uninsured health center patients, which declined from 2020 to 2023, rose by 256,000 (+4.6%) in 2024, for the first time in many years. Thus, uncompensated care burdens at CHCs rose again.
The loss of Medicaid in 2024 was offset by the increase in the number of patients with private and other insurance, which rose by 722,000 (11%) largely due to growth in the number of privately-insured patients. While UDS data does not distinguish between ACA marketplace enrollees and other privately-insured patients, the growth in privately-insured patients may be largely attributable to growth in health insurance marketplace enrollment. Unfortunately, the number covered by the ACA marketplace is expected to fall in 2026 if the ACA enhanced premium tax credits expire.[4]
More Health Centers Are Operating in the Red[10]
Community health centers receive funds from multiple sources, including insurance payments and grants. Grants from the Bureau of Primary Health Care (BPHC) provide core funding for infrastructure and care for the uninsured, but Medicaid is the largest source of CHC revenue, as seen in Exhibit 2.
Community health centers operate on a non-profit basis and, as such, do not seek profits for owners or investors. Nonetheless, CHCs generally seek to have higher revenue than costs, in order to support growth and sustain their operations. But this has become more challenging. Revenue growth was 10% to 13% per year in the 2020-22 period, but slowed to 6% by 2024, while costs – primarily to support patient care -- continued to rise. In 2024, costs increased by 10%, which while slightly less than in earlier years, still led to losses. The total annual health center operating margin (revenues minus costs) was $1.4 billion in 2020 (+4.1% of revenue) and grew to $2.1 billion (+5.3%) in 2021, but CHCs experienced a loss of $1.1 billion (-2.1%) in 2024. By 2024, 56 percent of health centers were operating in the red; their costs exceeding their revenues.
Three key factors explain the weakened financial status of health centers in 2024:
- The number of Medicaid patients fell due to unwinding, so Medicaid became a smaller share of patient revenue. (Note: Since Medicaid payments are received after patient care is delivered, revenue changes lag behind enrollment changes.) Since patients who lose Medicaid often continue to seek care at health centers as uninsured self-pay patients, the costs of care for uninsured patients increases.
- Supplemental grants awarded during the COVID years fell sharply in 2024 and balances were depleted.
- Core Section 330 grants were essentially flat and did not account for inflation or increased demand for care by the uninsured.
An underlying factor in cost growth is the continued need to pay competitive salaries for clinicians and other health center personnel. As of 2025, health centers reported vacancies for 4,300 physician positions, 2,800 nurse practitioners and physician assistants and 5,300 behavioral staff.[11] Salaries for physicians and advanced practice clinicians continue to rise and health centers often must offer market rate salaries and signing bonuses to remain competitive.[12] Without enough clinicians, health centers are unable to maintain high quality patient care.
Factors Affecting Differences in Financial Status
The national data described above obscures some important variations across different types of health centers and different states. We examined a number of factors that might explain differences in financial health. Exhibit 3 examines differences in CHC operating margins by urban/rural status and location in a Medicaid expansion or non-expansion state.[13]
Medicaid Expansions. Expanded Medicaid eligibility increases the total number of patients that health centers can serve[14] and enhances their revenues. In 2023 and 2024, centers located in Medicaid expansion states tended to have better margins than those in states that did not expand Medicaid. In 2024, centers in non-expansion states lost an average of -6.7%, compared to an average loss of -1.4% in expansion states. Despite Medicaid unwinding, Medicaid expansion was still associated with stronger financial status in 2024.
Urban/Rural Status. Rural health centers generally had stronger financial margins than urban centers from 2020 through 2024. In 2024, urban centers lost an average of -3.0%, while rural centers fared much better with only a -0.4% average loss. The data in Exhibit 3 show the rural/urban gap existed in each year from 2019 to 2024. Multivariate analysis (not shown) found this persisted, even after controlling for Medicaid expansion. Possible reasons are that rural centers have more diversified revenue sources (e.g., more Medicare or privately insured patients and fewer uninsured)[15] or may have lower operating costs (e.g., lower average salaries or rents) than urban centers.
Medicaid Unwinding. Multivariate analyses demonstrate the influence of Medicaid unwinding on 2024 margins. We measured unwinding based on changes in states’ combined Medicaid and CHIP enrollment in June 2024 versus June 2023.[16] After controlling for urban/rural status and location in a Medicaid expansion state, every 1% change in a state’s Medicaid/CHIP enrollment was associated with a 0.19% lower margin for health centers.
In 2024, average Medicaid enrollment fell about 14.8%, which suggests that Medicaid unwinding was associated with a 2.8 percentage point reduction in operating margins on average. We note that North Carolina, which implemented Medicaid expansion in December 2023, had higher Medicaid enrollment in 2024 and its health center margin rose from -0.5% in 2023 to +2.5% in 2024.
Differences Across States. There were substantial differences in health center’s financial status across states. For example, several states experienced losses greater than 10% in 2024: Texas -19.3%, Wyoming -17.1%, Minnesota -12.6%, Arizona -11.5%, Vermont – 11.0%, Virginia – 10.4% and Rhode Island -10.2%. Exhibit 4 shows state level average health center financial margins in 2023 and 2024. (Note: In this table, as in Exhibit 3, average margins, expressed as a percentage of revenues, are weighted based on the level of each health center's revenue. Rather than counting each health center equally, larger centers are counted more heavily in proportion with their larger sizes.) Because of the small number of health centers in some states, these figures may be strongly influenced by the performance of one or two centers.
Financial Status in 2025
Calendar year 2025 is not yet complete and UDS data for 2025 will not be reported until August or September 2026. However, while it seems likely the turbulence experienced in 2024 will persist in 2025, it is not yet clear if the total number of patients served will rise or fall.
Many of the underlying factors described above, such as reduced Medicaid enrollment, flat Section 330 grants, and rising salary costs continued in 2025. But some new factors also could affect this year’s performance. Early in 2025, many health centers experienced delays in accessing their federal grants due to a temporary freeze on grant funding by the new Administration.[17] In October, the federal government shutdown created additional risks for health centers, although health centers continue to provide patient care. HRSA has advised that centers can continue to draw down their grants on a short-term basis, although that might not be sustained if the shutdown persists. Delays in receipt of reimbursements from Medicaid, Medicare or other sources could create revenue and cash flow problems.[18] On the other hand, financial losses experienced in 2024 may have forced many health centers to limit their costs by reducing personnel or services to avoid further losses.
Problems Affecting Patients from Immigrant Families
Because of health centers’ mission and location in disadvantaged communities, CHCs are likely to serve large numbers of patients from immigrant families, including US-born citizen children whose parents are immigrants. Health centers do not collect data about the immigrant status of their patients. While roughly one-quarter are described as having “limited English proficiency,” that number includes US-born children whose immigrant parents have limited English skills.
Recent policies have hindered immigrants’ access to care at community health centers. Until recently, health care settings were considered “sensitive locations,” which immigration enforcement agents would avoid. But in January 2025, the Trump administration rescinded these protections,[19] allowing immigration agents to check immigration status of patients (or those accompanying them) in public spaces, such as health center or hospital waiting rooms or parking lots, placing them at risk of detention and deportation. Though health centers may seek to offer “safe spaces” for their clientele, immigration agents may conduct searches in public areas without their consent. This has created widespread fear and many immigrants – including those with legal status – are avoiding health centers or similar facilities, even when they need care.[20]
In July, HHS issued a notice declaring that community health centers and grantees of many other HHS programs, including Head Start and community behavioral health clinics, could no longer serve undocumented or other “non-qualified” immigrants, effective immediately upon publication.[21] This was based on a sudden reinterpretation of longstanding policy based on the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. This new policy appears to be contrary to the statute that governs community health centers.[22] In response to injunctions ordered by two federal courts in September in response to lawsuits, this policy has been temporarily paused and is not being enforced by HHS,[23] although the ultimate legal outcome is unresolved. While the notice did not change funding levels for health centers, it could affect thousands of immigrant patients who historically have been able to get primary care at health centers.[24]
Although most CHCs serve members of immigrant families, these policies are particularly harmful for health centers that receive funding as Migrant Health Centers, which are legislatively mandated to care for migrant workers and their families.
- citations
- Looking Ahead
The Effects of Future Policies
Additional federal policy changes are expected to increase the number of uninsured, which will simultaneously lower Medicaid revenue and increase uncompensated care costs for the health centers. Ultimately, these will further damage the bottom lines of health centers across the country, forcing them to reduce staffing and services and cut the number of service sites, despite the documented high quality and cost-effectiveness of CHC care.
First, enhanced premium tax credits for the ACA health insurance marketplaces (Obamacare) are currently scheduled to expire at the end of December 2025. If the subsidies expire, premiums would rise sharply and many privately insured health center patients would lose their coverage and become uninsured beginning in 2026. Analyses indicate that almost 2 million health center patients insured by ACA marketplaces could lose coverage if the tax credits expire; triggering a revenue loss to health centers of roughly $2 billion.[4] The losses will be particularly serious in non-expansion states like Texas, Florida and Georgia, where more people get insurance from the ACA marketplaces.[25] Whether the ACA tax credits will be extended is at the center of the Congressional dispute about a Continuing Resolution for Fiscal Year 2026, which began on October 1. This has resulted in a stalemate that has left much of the federal government shut down since October 1.
The One Big Beautiful Bill Act (OBBBA or H.R. 1) enacted in July includes very large Medicaid cuts which will have even larger impacts. Beginning in January 2027, states must require that Medicaid enrollees 19 to 64 years old in expansion categories meet work (or community engagement) requirements for at least 20 hours per week, unless they are exempt. In principle, those who are too frail to work, parents with children under 13 and full-time students, should be exempt from the work requirements. Data show that most adult Medicaid beneficiaries already work or meet one of the exemption categories.[26] But past experiences strongly indicate that a far greater number of beneficiaries lose Medicaid coverage because of the paperwork burdens and poor communication surrounding implementation of work requirements.
These policies create particular challenges for CHCs.[27] Because the new law requires that applicants’ exemption or work status be determined before a person can receive Medicaid benefits, health center clinicians will need to help diagnose and document the medical conditions that render a person unable to work, while health center eligibility and enrollment staff help patients navigate the increased paperwork. However, this effort and associated costs will be incurred before Medicaid coverage is determined; in some cases, applicants may be rejected, so health centers may not be paid for services rendered. And again, patients previously covered by Medicaid are likely to continue to seek care at health centers after they lose their coverage, so health centers will lose Medicaid revenue while incurring additional uncompensated care costs.
Finally, other recent policies may increase the demand for care at health centers. For example, OBBBA effectively prohibits Medicaid funding for family planning offered by Planned Parenthood affiliates. Although this has been challenged in court, a federal appeals court has allowed the prohibition to continue.[28] If patients are unable to receive care at those facilities, demand for care at community health centers will rise.
- Conclusion
Community health centers are at a tipping point. After years of growth and positive financial margins, CHCs began to lose money in 2024 and, unless steps are taken to reverse this trend, conditions will deteriorate further. Because of financial losses health centers must reduce personnel and other operating expenses, which in turn means that they must cut back patient care and services, including potentially closing sites of care. Since health centers are required to provide care regardless of patients’ insurance status, they cannot simply refuse to care for uninsured patients, unlike other health care providers. While health centers can (and do) sustain losses for a brief period, they cannot do so on a protracted basis. As non-profit safety net providers, health centers have neither extensive reserves nor deep-pocketed investors to help them sustain losses. As a result, communities across the country could lose access to high-quality low-cost primary and preventive health services, including medical, behavioral and dental health care.
In the very near future, unless the ACA enhanced premium tax credits are extended, the expected drops in marketplace insurance coverage could cause millions of CHC patients to lose their government-subsidized private insurance. This could be followed by implementation of harsh Medicaid work requirements beginning in 2027, which will lower the number of Americans covered by Medicaid and increase the number who are uninsured.
Federal funding for Section 330 health center grants – both mandatory and appropriated – is expiring and needs to be extended. Increasing federal grant levels would strengthen health centers and help them through this critical period. The Congressional Budget Office has confirmed that health centers are cost-effective and increasing mandatory CHC funding levels could lower overall federal Medicaid and Medicare costs.[29][30][31] Recent analyses also show the critical role that health centers play in filling primary care gaps in the most vulnerable parts of the nation.[32] Even if the policies of the One Big Beautiful Bill Act reduce the number of insured Americans, bolstering funding for community health centers can help maintain access to low-cost, high-quality primary and preventive care for America’s medically underserved communities.
- Footnotes
[1] Much of the data in this report is based on analyses of Uniform Data System (UDS) reports filed by health centers annually with the Health Resources and Services Administration (HRSA). In general, this report describes the status of community center grantees, and does not include “lookalikes” which are similar but do not receive Sec. 330 grant funding. National and other UDS data are available at https://data.hrsa.gov/topics/healthcenters/uds/overview/national.
[2] Jacobs F, Johnson K, Rosenbaum S. Millions of Community Health Center Patients to Lose Coverage When Tax Credits Expire. Commonwealth Fund. Oct. 23, 2025. https://www.commonwealthfund.org/blog/2025/millions-community-health-center-patients-lose-coverage-when-tax-credits-expire#:~:text=As%20a%20result%2C%20nearly%202,the%20ACA%20marketplaces%20and%20Medicaid.
[3] Ku L, Sharac J, Morris R, et all. The Value Proposition: Evidence of the Health and Economic Contributions of Community Health Centers. Geiger Gibson/RCHN Community Health Foundation Research Collaborative Policy Brief #68. August 2022. https://geigergibson.publichealth.gwu.edu/sites/g/files/zaxdzs4421/files/2022-08/the-value-proposition-gg-ib-68_final-new-82222-rem-by-tc.pdf
[4] Nocon R. Testimony to the Senate Health, Education, Labor and Pensions Committee. Mar. 2, 2023. https://www.help.senate.gov/imo/media/doc/Testimony-Nocon-CHCs%202023-0228_Final.pdf
[5] Shin P, Dunn J. Commentary: Sustaining the Community Health Center Model. Journal of Ambulatory Care Management. 2025 Oct-Dec; 48(4): 240–243
[6] In March, the Department of Health and Human Services proposed a reorganization in which HRSA and some other agencies would become part of a larger Administration for Healthy America (AHA), but this has not yet been approved by Congress. In this report, we use the traditional agency names.
[7] Rosenbaum S, Tolbert J, Sharac J, et al. Community Health Centers: Growing Importance in a Changing Health Care System. Kaiser Family Foundation. Mar. 2018. https://files.kff.org/attachment/Issue-Brief-Community-Health-Centers-Growing-Importance-in-a-Changing-Health-Care-System
[8] KFF. Medicaid Enrollment and Unwinding Tracker. https://www.kff.org/medicaid/medicaid-enrollment-and-unwinding-tracker/ [Accessed Oct. 20, 2025}
[9] UDS data span the whole year, the number of Medicaid patients served at the end of 2024 was likely smaller than at the beginning of the year.
[10] The financial data in this report are based on our analysis of UDS data reported by health centers. These reports are not audited and do not include data often available in financial reports, such as assets, cash on hand, etc.
[11] Shin P. Investing in the Primary Care Front Line: Why CHCs Need Workforce Investment Now. National Association of Community Health Centers. July 2025. https://www.nachc.org/investing-in-the-primary-care-front-line-why-chcs-need-workforce-investment-now/
[12] Smith T. Physician employers offer big signing bonuses—but there’s a catch. AMA News. Aug. 2025. https://www.ama-assn.org/medical-residents/transition-resident-attending/physician-employers-offer-big-signing-bonuses-there
[13] These analyses are confined to health centers in the 50 states or District of Columbia and exclude those in the U.S. territories. Urban/rural status is self-reported by the health center grantees. Since health center grantees typically operate in multiple sites, some health centers that are described as urban may have some rural sites and vice versa.
[14] Han X, Luo Q, Ku L. Medicaid Expansions and Increases in Grant Funding Increased the Capacity of Community Health Centers. Health Affairs. 2017 Jan.; 36 (1):49-56.
[15] National Association of Community Health Centers. 2025 Uniform Data System Chartbook: Analysis of the 2023 UDS Data. Fig. 1-9. May 2025. https://www.nachc.org/wp-content/uploads/2025/05/2025-UDS-Chartbook_Final-05.13.25.pdf
[16] KFF. Total Monthly Medicaid & CHIP Enrollment and Pre-ACA Enrollment, using data for June 2024 and June 2023. https://www.kff.org/affordable-care-act/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
[17] Rogin A. Community health centers face funding delays after Trump administration freeze. PBS News. Feb. 7, 2025. https://www.pbs.org/newshour/nation/community-health-centers-face-funding-delays-after-trump-administration-freeze
[18] Andala P. Health Centers Face Risks as Government Funding Lapses. KFF Health News. Oct. 2, 2025. https://kffhealthnews.org/news/article/community-health-centers-government-shutdown-state-cuts-funding-risks/
[19] Linton J, Rejeske J, Lessard G. Health Care Institutions And Immigration Enforcement: An Ethical Imperative. Health Affairs Forefront. Feb. 12, 2025. https://www.healthaffairs.org/content/forefront/health-care-institutions-and-immigration-enforcement-ethical-imperative
[20] Schumacher S, et al. KFF Survey of Immigrants: Views and Experiences in the Early Days of President Trump’s Second Term. KFF. May 8. 2025. https://www.kff.org/racial-equity-and-health-policy/kff-survey-of-immigrants-views-and-experiences-in-the-early-days-of-president-trumps-second-term/
[21] Office of the Secretary of Health and Human Services. Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA); Interpretation of “Federal Public Benefit”. Federal Register. 2025-13118 (90 FR 31232) Jul 14, 2025.
[22] Somodevilla A, Margulies R, Rosenbaum S, Jacobs F, Johnson K. Trump Administration Reverses Decades-Old Policy on Immigrant Eligibility for Federal Programs: Implications for Health Centers. Geiger Gibson Program in Community Health. July 2025. https://geigergibson.publichealth.gwu.edu/trump-administration-reverses-decades-old-policy-immigrant-eligibility-federal-programs
[23] See notices posted by HHS about the ban on enforcing the July policy because of the injunctions ordered by two federal courts at https://www.hhs.gov/press-room/prwora-hhs-bans-illegal-aliens-accessing-taxpayer-funded-programs.html. Accessed November 6, 2025.
[24] Pillai D, Artiga S. New Policy Bars Many Lawfully Present and Undocumented Immigrants from a Broad Range of Federal Health and Social Supports. KFF. July 21, 2025. https://www.kff.org/racial-equity-and-health-policy/new-policy-bars-many-lawfully-present-and-undocumented-immigrants-from-a-broad-range-of-federal-health-and-social-supports/
[25] Ku L, Gorak T, Orgera K, Kwon K, Krips M, Cordes J. Expiring ACA Premium Tax Credits Could Lead to Nearly 340,000 Jobs Lost Across the U.S. in 2026. Commonwealth Fund. Oct. 16, 2025. https://www.commonwealthfund.org/publications/issue-briefs/2025/oct/expiring-premium-tax-credits-lead-340000-jobs-lost-2026
[26] Hinton E, Rudowitz R. 5 Key Facts About Medicaid Work Requirements. KFF. Feb. 2025. https://www.kff.org/medicaid/5-key-facts-about-medicaid-work-requirements/
[27] Rosenbaum S, Jacobs F, Johnson K. Nearly 5.6 Million Community Health Center Patients Could Lose Medicaid Coverage Under New Work Requirements, with Revenue Losses Up to $32 Billion. Commonwealth Fund. May 30, 2025. https://www.commonwealthfund.org/blog/2025/community-health-center-patients-medicaid-coverage-work-requirements
[28] Associated Press. Appeals court allows Trump administration to block Medicaid funds to Planned Parenthood. PBS News. Sept. 11, 2025. https://www.pbs.org/newshour/politics/appeals-court-allows-trump-administration-to-block-medicaid-funds-to-planned-parenthood
[29] Congressional Budget Office. Cost Estimate for S. 2840, Bipartisan Primary Care and Health Workforce Act. Feb. 6, 2024. https://www.cbo.gov/publication/59945
[30] Ku L, Rosenbaum S. CBO’s Score for the Bipartisan Primary Care and Health Workforce Act Recognizes the Value of Primary Care Health Investments. Health Affairs Forefront, Mar. 21, 2024. https://www.healthaffairs.org/content/forefront/cbo-score-bipartisan-primary-care-and-health-workforce-act-recognizes-value-primary
[31] Ku L, Kwon K, Jacobs F, Rosenbaum S. Eligibility Assistance Increases Insurance Enrollment Within Community Health Centers But Not at the State Level. Health Affairs. May 2025. 44(5): 606-13. 2025.
[32] Herring J, Park YH, Luo Q, et al. Medicaid Primary Care Utilization and Area-Level Social Vulnerability. JAMA Health Forum. Sept. 5, 2025. 2025;6;(9):e253020.