By MICHAEL CASEY, AMANDA SWINHART and DEVI SHASTRI

FRANCONIA, N.H. (AP) — For more than two decades, Susan Bushby, a 70-year-old housekeeper from a rural ski town in New Hampshire’s White Mountains, took comfort in knowing she only had a short drive to reach the community health center.

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The lodge-like medical building, which sits on a hill overlooking town, was like a second home for Bushby and many other patients. The front desk staff knew their names and never missed a chance to celebrate a birthday or anniversary. Staff photos of the wilderness that makes the place such a draw hung on the walls, and bumping into a neighbor in the waiting room was routine.

But last month, the Ammonoosuc Community Health Services location in Franconia, a town of around 1,000 people, closed for good.

Closure raises concerns

Officials blamed cuts in Medicaid, the federal program that millions of low-income Americans rely on for health care. The 1,400 patients, almost half of them older and some facing serious health challenges like cancer and early-stage dementia, must now drive at least 10 miles (16 kilometers) along rural roads to reach the nearest health center, which also is near a regional hospital. A second center is twice as far.

“I was very disturbed. I was downright angry,” said Bushby, who was brought to tears as she discussed the challenges of starting over at a new health center. “I just really like it there. I don’t know, I’m just really going to miss it. It’s really hard for me to explain, but it’s going to be sad.”

The closure of the Franconia center reflects the financial struggles facing community health centers and rural health care systems more broadly amid Medicaid cuts and a feared spike in health insurance rates. The government shutdown, which ended last week, was driven by a Democratic demand to extend tax credits, which ensure low- and middle-income people can afford health insurance through the Affordable Care Act, or ACA.

Patients rattled by closure

Marsha Luce, whose family moved from the Washington, D.C., area in 2000, is especially concerned about the impact on her 72-year-old husband, a former volunteer firefighter who has had his left ear and part of his jaw removed due to cancer. He also has heart and memory issues.

She worries about longer waits to see his doctor and the loss of relationships built up over decades in Franconia.

“It’s going to be hard,” she said. “But it’s a relationship that’s going to be missed. It’s a relationship that you can talk to people and you tell them something and you go, yeah, well, I’ve had cancer. Oh, let’s see. Oh, yeah. There it is in your chart. Do you know what I mean?”

Demise of rural health care

More than 100 hospitals closed over the past decade, according to the Center for Healthcare Quality and Payment Reform, a policy and advocacy group, and more than 700 more hospitals are at risk of closure. A branch of the HealthFirst Family Care Center, a facility in Canaan, New Hampshire, also announced it was closing at the end of October due in part to “changes in Medicaid reimbursement and federal funding” for these facilities.

“Because of these Medicaid cuts, we’re going to see rural hospitals, in particular, hit hard,” New Hampshire Sen. Maggie Hassan, a Democrat, told The Associated Press. “And obviously, the failure to extend the ACA tax credits right now is going to compound the problem. … These providers are going to see more and more uninsured patients. And that means they’re going to have to make really difficult decisions.”

The sustainability of the centers is critical because they serve as the nation’s primary care safety net, treating patients regardless of insurance coverage or ability to pay.

Though federally-funded community health centers like the one in Franconia have expanded their reach in recent years, treating 1 in 10 Americans and 1 in 5 rural Americans, they’ve often done so in the face of major financial constraints, according to data from the National Association of Community Health Centers.

On average, the centers are losing money — relying heavily on cash reserves, making service changes and sometimes closing locations to stay afloat, NACHC found. Nearly half have less than 90 days’ cash on hand, according to the association. The future is even more bleak, with at least 2 million community health center patients expected to lose Medicaid coverage by 2034 and 2 million more who are newly uninsured turning to the centers for care.

“There’s nothing left to trim without cutting into care itself,” said Peter Shin, the chief science officer at the association.

Tough choices for Ammonoosuc

When President Donald Trump’s bill passed this summer, Ed Shanshala, the CEO of Ammonoosuc, knew he was in trouble.

A meticulous planner and strategist, Shanshala projected that his network of five New Hampshire health centers — which relies on more than $2 million in federal funding out of a $12 million budget — would face a $500,000 shortfall partly due to Medicaid funding cuts. He also expected work requirements in the bill and spikes in health insurance premiums to have an impact.

Shanshala knew he needed to make cuts to save his centers and zeroed in on Franconia because the building was leased, whereas Ammonoosuc owns the other facilities.

“We’re really left with no choice,” Shanshala said, adding the closure would save $250,000. Finding additional cuts is hard, given that the centers provide services to anyone under 200% of the federal poverty line, he said. If he cuts additional services, Shanshala fears some patients will end up in a hospital emergency room or “stop engaging in health care period.”

“To have to pull out of a community is devastating on a relational level,” he said. “People still have access to health care. We’ll help them with transportation, but it’s clearly a grieving process. Whenever a business leaves a community, regardless if it’s health care or something else, there’s an emotional fabric tear.”

Sense of loss

The closure has brought little controversy. Just a lot of grief.

Most of the patients come from the small towns of Franconia, Easton, Lincoln and Sugar Hill, communities whose economies rely on hikers, skiers and leaf peepers. Many are older, sicker and more spread out than the rest of the state.

Luce, who volunteers at the local Head Start program and delivers food to schools in Franconia, said the closure has her mostly frustrated with politicians, adding that she wished lawmakers in Washington could “just live the way regular people live” for a few months.

“They would have a much different idea of what goes on in the real world,” she added.

More closures coming?

Patients like Jill Brewer, the chair of the Franconia Board of Selectmen whose family has been going there for decades, worry about the future and whether the closure signals the gradual collapse of the health care system in this part of the state.

“Is this kind of the first domino to fall?” said Brewer, noting how disbanding the town’s volunteer ambulance service in 2023 angered many residents.

“It definitely leaves you feeling pretty anxious that this is going to continue to kind of snowball and become an even bigger issue,” she added.

On the clinic’s last day, it was business as usual — no balloons, no cakes, no farewell speeches. The staff were stoic as they tended to patients, three of whom came in for their physicals and four for checkups. Bushby, who had come to have her blood pressure checked, hugged a staffer as crews dismantled the clinic and wheeled out exam tables.

“I’ll come see you, honey. I will,” Bushby said, hugging Diane LaDuke, a patient access specialist. “It’s been such a joy coming here.”

Shastri reported from Milwaukee, Wisconsin.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

By MIKE SCHNEIDER, Associated Press

ORLANDO, Fla. (AP) — A federal judge in Florida is pushing for a resolution in a lawsuit over whether detainees at an immigration center in the Florida Everglades are getting adequate access to attorneys.

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U.S. District Judge Sheri Polster Chappell last Friday ordered a two-day conference to be held next month in her Fort Myers courtroom, with attorneys present who have the authority to settle. The judge asked for an update at a hearing next Monday.

“The court will not entertain excuses regarding leaving early for flights or other meetings,” the judge wrote about next month’s conference.

The lawsuit filed by detainees against the federal and state governments over legal access is one of three federal cases challenging practices at the immigration detention center that was built this summer at a remote airstrip in the Florida Everglades by the administration of Republican Gov. Ron DeSantis.

In a separate environmental lawsuit, a federal appellate court panel in September allowed the center to continue operating by putting on hold a lower court’s preliminary injunction ordering the facility to wind down by the end of October. The appeal was put on hold during the government shutdown but resumed last week.

A third lawsuit claims immigration is a federal issue and Florida agencies and private contractors hired by the state have no authority to operate the facility.

President Donald Trump toured the facility in July and suggested it could be a model for future lockups nationwide as his administration pushes to expand the infrastructure needed to increase deportations. While the facility was built and operated by the state and its private contractors, federal officials have approved reimbursing Florida for $608 million.

In the legal access case, attorneys representing detainees at the Everglades facility are seeking a preliminary injunction that will make it easier for their clients to meet and communicate with their individual attorneys.

They claim that detainees’ attorneys must make an appointment to visit three days in advance, unlike at other detention facilities where the lawyers can just show up during visiting hours; that detainees often are transferred to other facilities after their attorneys have made an appointment to see them; and that scheduling delays have been so lengthy that detainees are unable to meet with attorneys before key deadlines.

Florida officials said in a motion to dismiss that the case is now moot since the concerns initially raised by the detainees and their attorneys have been addressed. Any delays were due to trying to construct a facility for thousands of detainees in a remote area with little infrastructure, they said.

“In other words, there is no longer a live controversy,” Florida officials said in their court filing.

Follow Mike Schneider on the social platform Bluesky: @mikeysid.bsky.social.

By COLLIN BINKLEY and ANNIE MA, AP Education Writers

WASHINGTON (AP) — The Education Department is breaking off several of its main offices and giving their responsibilities to other federal agencies, an early look at how President Donald Trump could fulfill his campaign pledge to close the department entirely.

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Offices that serve the nation’s schools and colleges would go to departments ranging from Labor to Interior. Education officials say the moves won’t affect the money Congress gives states, schools and colleges. They didn’t say whether current department staff would keep their jobs.

Since he took office, Trump has called for the dismantling of the Education Department, saying it has been overrun by liberal thinking. Agency leaders have been making plans to parcel out its operations to other departments, and in July the Supreme Court upheld mass layoffs that halved the department’s staff.

In recent days, Education Secretary Linda McMahon has started a public campaign for the end of her department, making the case on social media that Education’s grantmaking and question-answering functions could be better handled by states and other federal agencies.

While the necessity of the department is up for debate, it’s also unclear how well-equipped other state and federal departments are to take over the Education Department’s responsibilities. The department sends billions of dollars to schools and colleges and helps decipher complex federal laws. It will be a test for the administration: Can the department be shut down smoothly, or will rural and low-income kids and students with disabilities — the populations that most rely on federal education support — be impacted?

Here’s what the Education Department currently handles, where its responsibilities will go to other federal agencies and what will stay the same.

Money for schools and colleges

While American schools are funded primarily by state and local money, the Education Department serves as a conduit for billions of dollars of federal aid going to state and local education agencies.

Education officials say that money will continue to be awarded as allocated by Congress, but much of it will flow from another federal agency. Most notably, the Department of Labor will oversee some of the largest federal funding streams for schools and colleges, including Title I money for schools serving low-income communities. Adult education programs already were moved to Labor in June.

Another deal will put Health and Human Services in charge of a grant program for parents who are attending college. The State Department will take on money to fund foreign language programs. Interior will oversee programs supporting Native American education.

Federal student loans

One of the department’s major roles is management of the $1.6 trillion federal student loan portfolio. Student aid so far will be largely unaffected, although McMahon and Trump have suggested it could be better handled by a different federal department.

Pell Grants and federal loans will continue to be disbursed, and student loan borrowers must continue making payments on their debts.

The website for the Free Application for Student Aid, or FAFSA, remains open — a key piece of how colleges and universities provide aid packages to incoming students. The Education Department will continue to handle support for people navigating the complicated form.

The Education Department also will continue to oversee another major part of higher education: accreditation, which allows colleges to accept students’ federal financial aid.

Students with disabilities

For now, the department will continue to distribute money to schools to provide educational support for students with disabilities, though McMahon has suggested this function could move to the Department of Health and Human Services.

The Education Department also oversees investigations into schools and universities alleged to have violated disability rights law, along with other civil rights violations such as discrimination involving sex, race and shared ancestry.

Those responsibilities will remain with the department for now, although McMahon has suggested sending them to the Department of Justice.

In any case, since the mass layoffs in March, the Office for Civil Rights has operated under a significantly reduced footprint. The department’s civil rights branch lost about half of its staff. The cuts raised questions about whether the office would be able to shrink a backlog of complaints from students who allege they have experienced discrimination on the basis of race, sex or disability status.

The department’s own data has shown a decline in resolving civil rights cases, while new complaints from families have increased.

The Associated Press’ education coverage receives financial support from multiple private foundations. AP is solely responsible for all content. Find AP’s standards for working with philanthropies, a list of supporters and funded coverage areas at AP.org.

By ERIC TUCKER and MICHAEL KUNZELMAN, Associated Press

ALEXANDRIA, Va. (AP) — The Justice Department acknowledged in court Wednesday the grand jury that charged former FBI Director James Comey was not presented with a copy of the final indictment, a concession that may further imperil a prosecution already subject to multiple challenges and demands for its dismissal.

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The revelation is the latest indication of a troubled presentation of the case to the grand jury by an inexperienced and hastily appointed U.S. attorney named to the job just days earlier by President Donald Trump.

Concerns about the process surfaced earlier in the week when a different judge in the case said there was no record in the transcript he had reviewed of the grand jury reviewing the indictment that was actually presented against Comey.

Lindsey Halligan, the interim U.S. attorney in charge of the case, said under questioning that only the foreperson of the grand jury and a second grand juror were present for the returning of the indictment.

Comey has pleaded not guilty to charges accusing him of making a false statement and obstructing Congress and has denied any wrongdoing.

The Justice Department has denied that the prosecution was vindictive or selective and insists that the allegations support the indictment.

Trump fired Comey as FBI director in May 2017 as Comey was overseeing an FBI investigation into potential ties between Russia and Trump’s 2016 campaign. The two have been publicly at odds ever since, with Trump deriding Comey as “a weak and untruthful slime ball” and calling for his prosecution.