ProPublica
March 27, 2025
Southern Illinois University includes the 2,000-acre University Farms, part of the School of Agricultural Sciences. Students in its equine science program learn about the animals’ physiology, reproduction, genetics and nutrition, as well as how to train and care for them. Credit:Julia Rendleman for ProPublica
ProPublica is a Pulitzer Prize-winning investigative newsroom.
CARBONDALE, Ill. — I grew up off a gravel road near a town of 60 people, a place where cows outnumber people.
Southern Illinois University, just 40 miles north, opened up my world. I saw my first concerts here, debated big ideas in giant lecture halls and shared dorms with people who looked like no one I’d ever met. Two of my most influential professors came from opposite ends of the political spectrum.
SIU was the only four-year college within reach when I enrolled here in the fall of 2000 — both in miles and cost. And it set me on the path to who I would become. That’s why I accepted a job here teaching journalism two years ago. It is still a place of opportunity, but I was struck by how fragile it had become — a fraction of its former size, grappling with relentless enrollment and budget concerns.
Now, it faces new threats. The Trump administration has proposed cuts to research and labs across the country; targeted certain schools with diversity, equity and inclusion programs; and signed an executive order to eliminate the U.S. Department of Education, which manages student loans. State officials estimate that proposed funding reductions from the National Institutes of Health alone would cost SIU about $4.5 million.
In addition, conservative activists are on the lookout for what they deem “woke” depravity at universities. This is true at SIU as well, where students received emails from at least one conservative group offering to pay them to act as informants or write articles to help “expose the liberal bias that occurs on college campuses across the nation.”
Schools like SIU, located in a region that overwhelmingly voted for President Donald Trump, may not be the primary targets of his threatened funding cuts, but they — along with the communities they serve — stand to lose the most.
There are nearly 500 regional public universities across the U.S., serving around 5 million students — about half of all undergraduates enrolled in public universities, according to the Alliance for Research on Regional Colleges at Appalachian State University. These institutions of higher learning span nearly every state, with many rooted in rural areas and communities facing high unemployment, childhood poverty and limited access to medical care. They play a vital role in lifting up struggling individuals — and in some cases, entire communities that could very easily die out without them.
While Trump’s actions have primarily targeted high-profile institutions like Columbia University and the University of Pennsylvania, some regional schools are also under investigation for alleged racial discrimination tied to DEI programs. (So far, SIU hasn’t been named in any federal probes.)
“This is definitely one of those baby-in-the-bathwater moments,” said Cecilia Orphan, an associate professor of higher education at the University of Denver, who is a lead researcher with the regional colleges alliance. While the administration has “a bone to pick with a particular type of institution,” she said, “there are all these other institutions that serve your community, your constituents.”
Regional schools like SIU tend to operate with fewer resources than their counterparts, relying on federal and state money to support both the students and the school. Greater shares of students rely on need-based federal financial aid like Pell Grants, low-cost student loans and subsidized student work programs.
And in terms of research, while attention goes to large, elite schools, hundreds of the schools spending at least $2.5 million on scientific studies — the threshold for qualifying as a research school — are regional public universities. SIU pumps $60 million annually into research. About a quarter of that money comes from the federal government.
At SIU, as at other regional universities, many research projects focus on overlooked issues in their own backyards. Here that means studying ways to help farmers yield stronger crops, to deal with invasive species in the waterways, and to deliver mental health care to remote schools.
“We are at a crossroads and facing a national crisis. It is going to have far-reaching consequences for higher education,” said Mary Louise Cashel, a clinical psychology professor at SIU whose research, which focuses on youth violence prevention among diverse populations, relies on federal funding.
Supporters of Trump’s proposed research funding cuts say schools should dip into their endowment funds to offset the recent cuts. But SIU’s $210 million endowment, almost all of it earmarked for specific purposes, is pocket change compared with Ivy League schools like Yale, which has a similar student population size but a roughly $41 billion endowment. At present, SIU faces a $9.4 million deficit, the result of declining enrollments and years of state budget cuts; there is no cushion for it to fall back on.
Intertwined with SIU’s fate is that of Carbondale, a town of 21,500 about 50 miles from the borders of Kentucky and Missouri. Since its founding in 1869, the university has turned Carbondale into a tiny cultural mecca and a powerful economic engine in an otherwise vast, rural region that has been battered by the decline of manufacturing and coal mining. Three decades ago, SIU and Carbondale felt electric: Lecture halls overflowed; local businesses thrived on the fall surge of students; The Strip, a longstanding student hangout, spilled over every weekend, music rattling windows into the early morning hours.
The “Dirty Dale,” as the town is affectionately known, still carries traces of its college-town energy, and SIU remains the largest employer in the region. But there’s an undeniable fade as the student population is now half the size it was in the 1990s. Some of the local anchor establishments along The Strip have vanished. Now, more cuts threaten to push the university, and the town that depends on it, to a breaking point.
Jeff Vaughn, a retired police officer who has owned Tres Hombres restaurant and bar in the heart of town for the past 10 years, says the school, though smaller, still has a huge impact on businesses’ bottom lines.
“It’s dollar bills coming into the city” that wouldn’t be here otherwise, he said. “It’s the people who work there, the people going to school there — every part of it brings money into the city. A basketball game happens, people come into town and they usually go out to eat before the game.”
Even before the Trump administration began its cuts in academia, it was clear to regional leaders that the school and the community needed to do more. A 2020 report by a regional economic development agency issued a warning: “The region can no longer sit idle and let SIU tackle these issues on their own.”
DEI, a Survival Strategy?
The Rev. Joseph A. Brown, a professor of Africana studies at Southern Illinois University, calls federal orders on higher education “epistolary drones.”
“Bomb, bomb, bomb, bomb,” Brown said, “and everybody’s running and ducking.”
Brown spoke by phone in late February, his oxygen tank humming in the background after a bout of pneumonia. While he was in the hospital, his inbox and phone were blowing up with panicked messages about the federal directive that schools eliminate all diversity, equity and inclusion programs.
That’s because diversity also means something more in regional public universities: Many students at SIU come from families that are poor, or barely middle class, and depend on scholarships and mentorship to succeed. Paul Frazier, SIU’s vice chancellor for anti-racism, diversity, equity and inclusion, said the way DEI has been politicized ignores what it actually does: “Poor doesn’t have a color.”
But beyond helping students, DEI is also about the school’s survival.
In 2021, SIU Chancellor Austin Lane rolled out Imagine 2030 — an ambitious blueprint for rebuilding SIU Carbondale. It called for doubling down on research, expanding student success programs and, at its core, embedding diversity into how the university operates, including in the recruitment of students, hiring and training of faculty and staff, and creation of programs that offer extra help to students struggling to keep up in their classes. It also called for growing SIU’s enrollment to 15,000.
SIU won’t reach that goal without targeted recruitment. “You can’t do that without bringing more of the largest-growing population, which is Latinx and Hispanic students,” Frazier said. “It’ll be like an old Western,” Frazier said of the risks of further eroding SIU. “It’ll be a ghost town.
SIU is offering marketing materials in Spanish for the first time in years. Similar efforts are going into reigniting passion for SIU throughout Cook County, home to Chicago; near St. Louis, and in high schools close by.
While the plan was new, the desire to bring in students from a wide range of backgrounds was not. From the start, SIU grew against the grain by embracing diversity in a region that often didn’t.
In 1874, two Black women enrolled in the school’s first class. A few years later, Alexander Lane became SIU’s first Black male student and then its first Black graduate, according to research by an SIU history professor. Born to an enslaved mother in Mississippi, Lane graduated and became a teacher, then a doctor, then a lawmaker in the state Capitol. Today, a scholarship in his name helps students gain internships in state government.
During World War II, SIU expanded to accommodate returning soldiers on the GI Bill. It designed parts of campus with accessibility in mind for wounded veterans in hopes of drawing students and boosting enrollment.
By 1991, the student body peaked at nearly 25,000. And even amid significant changes that hurt enrollment, by 2010 it still had 20,000.
In the decade that followed, SIU lost nearly 9,000 students—a nearly 45% drop. A lot happened, but one decision proved fateful: Concerns had surfaced that SIU was enrolling underprepared Black students from inner-city Chicago and failing to support them. At the same time, the university wanted to reshape its image, positioning itself as a world-class research institution. Officials targeted a different type of student and stopped recruiting as heavily in Cook County.
This era also saw a state budget crisis, and high-level leadership churned amid constant drama. (The university had seven chancellors between 2010 and 2020.) Eventually, it wasn’t about pulling away from Cook County — it was about having no direction at all. And by the end of the decade, SIU had fewer than 12,000 students. By the time the chancellor unfurled Imagine 2030, it was clear that diversity — in all its forms — was the only path forward.
Clawing Its Way Back
It’s easy to destabilize a school. But restoring it? That’s a much harder challenge.
Still, recently, it has felt like SIU has been clawing its way back. There have been two straight years of enrollment gains, driven in part by an influx of students coming from Southern Illinois and again from Cook County, as well as by growing online programs. And in late February, the Carnegie Classification of Institutions of Higher Education, which ranks universities by research spending, elevated SIU to its “very high” Research 1 status. In academic circles, it’s a big deal — putting SIU on the academic research map and bestowing it a status symbol that helps recruit top faculty and students.
“It’s a great day to be a Saluki,” SIU President Dan Mahony said, referencing SIU’s canine mascot, at a February celebration of that promotion. Then there was a pop, and confetti rained down.
But the federal financial directives and cultural wars roiling higher education are, once again, unsettling the campus and wider community. Things escalated earlier this month when SIU became a new target for the right: A social media account known for targeting LGBTQ+ people and DEI initiatives, Libs of TikTok, posted about an SIU professor who had uploaded explicit photos of himself online. The post, about an openly gay School of Medicine professor who has been publicly critical of Trump, took off, racking up more than 3 million views and hundreds of shares and comments.
“LoTT INVESTIGATION: LGBTQ professor at a Public University posts extreme p*rnographic videos of himself m*sturbating ON CAMPUS,” it read.
His employee profile quickly disappeared from the school’s website, and within days, SIU officials announced he was no longer employed by the university; he was subsequently charged with two misdemeanor counts of public indecency, and an arraignment hearing is scheduled for late April. But the controversy made SIU, not just the professor, a target. The post also took SIU to task for promoting itself on a hiring website as an “anti-racist” community. “SIU receives tens of millions of dollars from the federal government. SIU is violating Trump’s EO and should be stripped of their federal funding,” it read, tagging Elon Musk’s cost-cutting federal Department of Government Efficiency.
The irony is high: While Carbondale, where the school is located, is a solidly blue island, it is surrounded by a conservative rural region hanging in the balance.
Across the nation, universities are eliminating or rebranding DEI offices to avoid federal scrutiny. SIU isn’t backing down.
“As a university, we need to stay the course,” Phil Gilbert, chair of SIU’s Board of Trustees and a longtime federal judge appointed by George H.W. Bush, said at a recent board meeting.“I can’t think of an institution more important to diversity, equity and inclusion than an educational institution, because education is the bridge to tomorrow for everyone.
'Just a fact': Rural America readies for scourge of tooth decay under Trump policies
Brett Kelman,
David Potts is treated by James Flanagin, the only dentist in Leslie, Arkansas. About 25 million Americans live in dentist shortage areas, according to new research from Harvard University. (Katie Adkins for KFF Health News)
In the wooded highlands of northern Arkansas, where small towns have few dentists, water officials who serve more than 20,000 people have for more than a decade openly defied state law by refusing to add fluoride to the drinking water.
For its refusal, the Ozark Mountain Regional Public Water Authority has received hundreds of state fines amounting to about $130,000, which are stuffed in a cardboard box and left unpaid, said Andy Anderson, who is opposed to fluoridation and has led the water system for nearly two decades.
This Ozark region is among hundreds of rural American communities that face a one-two punch to oral health: a dire shortage of dentists and a lack of fluoridated drinking water, which is widely viewed among dentists as one of the most effective tools to prevent tooth decay. But as the anti-fluoride movement builds unprecedented momentum, it may turn out that the Ozarks were not behind the times after all.
“We will eventually win,” Anderson said. “We will be vindicated.”
Fluoride, a naturally occurring mineral, keeps teeth strong when added to drinking water, according to the Centers for Disease Control and Prevention and the American Dental Association. But the anti-fluoride movement has been energized since a government report last summer found a possible link between lower IQ in children and consuming amounts of fluoride that are higher than what is recommended in American drinking water. Dozens of communities have decided to stop fluoridating in recent months, and state officials in Florida and Texas have urged their water systems to do the same. Utah is poised to become the first state to ban it in tap water.
Health and Human Services Secretary Robert F. Kennedy Jr., who has long espoused fringe health theories, has called fluoride an “industrial waste” and “dangerous neurotoxin” and said the Trump administration will recommend it be removed from all public drinking water.
Separately, Republican efforts to extend tax cuts and shrink federal spending may squeeze Medicaid, which could deepen existing shortages of dentists in rural areas where many residents depend on the federal insurance program for whatever dental care they can find.
Dental experts warn that the simultaneous erosion of Medicaid and fluoridation could exacerbate a crisis of rural oral health and reverse decades of progress against tooth decay, particularly for children and those who rarely see a dentist.
“If you have folks with little access to professional care and no access to water fluoridation,” said Steven Levy, a dentist and leading fluoride researcher at the University of Iowa, “then they are missing two of the big pillars of how to keep healthy for a lifetime.”
Many already are.
Overlapping ‘Dental Deserts’ and Fluoride-Free Zones
Nearly 25 million Americans live in areas without enough dentists — more than twice as many as prior estimates by the federal government — according to a recent study from Harvard University that measured U.S. “dental deserts” with more depth and precision than before.
Hawazin Elani, a Harvard dentist and epidemiologist who co-authored the study, found that many shortage areas are rural and poor, and depend heavily on Medicaid. But many dentists do not accept Medicaid because payments can be low, Elani said.
The ADA has estimated that only a third of dentists treat patients on Medicaid.
“I suspect this situation is much worse for Medicaid beneficiaries,” Elani said. “If you have Medicaid and your nearest dentists do not accept it, then you will likely have to go to the third, or fourth, or the fifth.”
The Harvard study identified over 780 counties where more than half of the residents live in a shortage area. Of those counties, at least 230 also have mostly or completely unfluoridated public drinking water, according to a KFF analysis of fluoride data published by the CDC. That means people in these areas who can’t find a dentist also do not get protection for their teeth from their tap water.
The KFF Health News analysis does not cover the entire nation because it does not include private wells and 13 states do not submit fluoride data to the CDC. But among those that do, most counties with a shortage of dentists and unfluoridated water are in the south-central U.S., in a cluster that stretches from Texas to the Florida Panhandle and up into Kansas, Missouri, and Oklahoma.
In the center of that cluster is the Ozark Mountain Regional Public Water Authority, which serves the Arkansas counties of Boone, Marion, Newton, and Searcy. It has refused to add fluoride ever since Arkansas enacted a statewide mandate in 2011. After weekly fines began in 2016, the water system unsuccessfully challenged the fluoride mandate in state court, then lost again on appeal.
Anderson, who has chaired the water system’s board since 2007, said he would like to challenge the fluoride mandate in court again and would argue the case himself if necessary. In a phone interview, Anderson said he believes that fluoride can hamper the brain and body to the point of making people “get fat and lazy.”
“So if you go out in the streets these days, walk down the streets, you’ll see lots of fat people wearing their pajamas out in public,” he said.
Nearby in the tiny, no-stoplight community of Leslie, Arkansas, which gets water from the Ozark system, the only dentist in town operates out of a one-man clinic tucked in the back of an antique store. Hand-painted lettering on the store window advertises a “pretty good dentist.”
James Flanagin, a third-generation dentist who opened this clinic three years ago, said he was drawn to Leslie by the quaint charms and friendly smiles of small-town life. But those same smiles also reveal the unmistakable consequences of refusing to fluoridate, he said.
“There is no doubt that there is more dental decay here than there would otherwise be,” he said. “You are going to have more decay if your water is not fluoridated. That’s just a fact.”
Fluoride Seen as a Great Public Health Achievement
Fluoride was first added to public water in an American city in 1945 and spread to half of the U.S. population by 1980, according to the CDC. Because of “the dramatic decline” in cavities that followed, in 1999 the CDC dubbed fluoridation as one of 10 great public health achievements of the 20th century.
Currently more than 70% of the U.S. population on public water systems get fluoridated water, with a recommended concentration of 0.7 milligrams per liter, or about three drops in a 55-gallon barrel, according to the CDC.
Fluoride is also present in modern toothpaste, mouthwash, dental varnish, and some food and drinks — like raisins, potatoes, oatmeal, coffee, and black tea. But several dental experts said these products do not reliably reach as many low-income families as drinking water, which has an additional benefit over toothpaste of strengthening children’s teeth from within as they grow.
Two recent polls have found that the largest share of Americans support fluoridation, but a sizable minority does not. Polls from Axios/Ipsos and AP-NORC found that 48% and 40% of respondents wanted to keep fluoride in public water supplies, while 29% and 26% supported its removal.
Chelsea Fosse, an expert on oral health policy at the American Academy of Pediatric Dentistry, said she worried that misguided fears of fluoride would cause many people to stop using fluoridated toothpaste and varnish just as Medicaid cuts made it harder to see a dentist.
The combination, she said, could be “devastating.”
“It will be visibly apparent what this does to the prevalence of tooth decay,” Fosse said. “If we get rid of water fluoridation, if we make Medicaid cuts, and if we don’t support providers in locating and serving the highest-need populations, I truly don’t know what we will do.”
Multiple peer-reviewed studies have shown what ending water fluoridation could look like. In the past few years, studies of cities in Alaska and Canada have shown that communities that stopped fluoridation saw significant increases in children’s cavities when compared with similar cities that did not. A 2024 study from Israel reported a “two-fold increase” in dental treatments for kids within five years after the country stopped fluoridating in 2014.
Despite the benefits of fluoridation, it has been fiercely opposed by some since its inception, said Catherine Hayes, a Harvard dental expert who advises the American Dental Association on fluoride and has studied its use for three decades.
Fluoridation was initially smeared as a communist plot against America, Hayes said, and then later fears arose of possible links to cancer, which were refuted through extensive scientific research. In the ’80s, hysteria fueled fears of fluoride causing AIDS, which was “ludicrous,” Hayes said.
More recently, the anti-fluoride movement seized on international research that suggests high levels of fluoride can hinder children’s brain development and has been boosted by high-profile legal and political victories.
Last August, a hotly debated report from the National Institutes of Health’s National Toxicology Program found “with moderate confidence” that exposure to levels of fluoride that are higher than what is present in American drinking water is associated with lower IQ in children. The report was based on an analysis of 74 studies conducted in other countries, most of which were considered “low quality” and involved exposure of at least 1.5 milligrams of fluoride per liter of water — or more than twice the U.S. recommendation — according to the program.
The following month, in a long-simmering lawsuit filed by fluoride opponents, a federal judge in California said the possible link between fluoride and lowered IQ was too risky to ignore, then ordered the federal Environmental Protection Agency to take nonspecified steps to lower that risk. The EPA started to appeal this ruling in the final days of the Biden administration, but the Trump administration could reverse course.
The EPA and Department of Justice declined to comment. The White House and Department of Health and Human Services did not respond to questions about fluoride.
Despite the National Toxicology Program’s report, Hayes said, no association has been shown to date between lowered IQ and the amount of fluoride actually present in most Americans’ water. The court ruling may prompt additional research conducted in the U.S., Hayes said, which she hoped would finally put the campaign against fluoride to rest.
“It’s one of the great mysteries of my career, what sustains it,” Hayes said. “What concerns me is that there’s some belief amongst some members of the public — and some of our policymakers — that there is some truth to this.”
Not all experts were so dismissive of the toxicology program’s report. Bruce Lanphear, a children’s health researcher at Simon Fraser University in British Columbia, published an editorial in January that said the findings should prompt health organizations “to reassess the risks and benefits of fluoride, particularly for pregnant women and infants.”
“The people who are proposing fluoridation need to now prove it’s safe,” Lanphear told NPR in January. “That’s what this study does. It shifts the burden of proof — or it should.”
Cities and States Rethink Fluoride
At least 14 states so far this year have considered or are considering bills that would lift fluoride mandates or prohibit fluoride in drinking water altogether. In February, Utah lawmakers passed the nation’s first ban, which Republican Gov. Spencer Cox told ABC4 Utah he intends to sign. And both Florida Surgeon General Joseph Ladapo and Texas Agriculture Commissioner Sid Miller have called for their respective states to end fluoridation.
“I don’t want Big Brother telling me what to do,” Miller told The Dallas Morning News in February. “Government has forced this on us for too long.”
Additionally, dozens of cities and counties have decided to stop fluoridation in the past six months — including at least 16 communities in Florida with a combined population of more than 1.6 million — according to news reports and the Fluoride Action Network, an anti-fluoride group.
Stuart Cooper, executive director of that group, said the movement’s unprecedented momentum would be further supercharged if Kennedy and the Trump administration follow through on a recommendation against fluoride.
Cooper predicted that most U.S. communities will have stopped fluoridating within years.
“I think what you are seeing in Florida, where every community is falling like dominoes, is going to now happen in the United States,” he said. “I think we’re seeing the absolute end of it.”
If Cooper’s prediction is right, Hayes said, widespread decay would be visible within years. Kids’ teeth will rot in their mouths, she said, even though “we know how to completely prevent it.”
“It’s unnecessary pain and suffering,” Hayes said. “If you go into any children’s hospital across this country, you’ll see a waiting list of kids to get into the operating room to get their teeth fixed because they have severe decay because they haven’t had access to either fluoridated water or other types of fluoride. Unfortunately, that’s just going to get worse.”
Methodology: How We Counted
This KFF Health News article identifies communities with an elevated risk of tooth decay by combining data on areas with dentist shortages and unfluoridated drinking water. Our analysis merged Harvard University research on dentist-shortage areas with large datasets on public water systems published by the U.S. Centers for Disease Control and Prevention.The Harvard research determined that nearly 25 million Americans live in dentist-shortage areas that span much of rural America. The CDC data details the populations served and fluoridation status of more than 38,000 public water systems in 37 states. We classified counties as having elevated risk of tooth decay if they met three criteria:More than half of the residents live in a dentist-shortage area identified by Harvard.The number of people receiving unfluoridated water from water systems based in that county amounts to more than half of the county’s population.The number of people receiving unfluoridated water from water systems based in that county amounts to at least half of the total population of all water systems based in that county, even if those systems reached beyond the county borders, which many do.
Our analysis identified approximately 230 counties that meet these criteria, meaning they have both a dire shortage of dentists and largely unfluoridated drinking water.
But this total is certainly an undercount. Thirteen states do not report water system data to the CDC, and the agency data does not include private wells, most of which are unfluoridated.
KFF Health News data editor Holly K. Hacker contributed to this article.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News' free Morning Briefing.
This article first appeared on KFF Health News and is republished here under a Creative Commons license.
Brett Kelman,
KFF Health News
March 27, 2025
March 27, 2025
David Potts is treated by James Flanagin, the only dentist in Leslie, Arkansas. About 25 million Americans live in dentist shortage areas, according to new research from Harvard University. (Katie Adkins for KFF Health News)
In the wooded highlands of northern Arkansas, where small towns have few dentists, water officials who serve more than 20,000 people have for more than a decade openly defied state law by refusing to add fluoride to the drinking water.
For its refusal, the Ozark Mountain Regional Public Water Authority has received hundreds of state fines amounting to about $130,000, which are stuffed in a cardboard box and left unpaid, said Andy Anderson, who is opposed to fluoridation and has led the water system for nearly two decades.
This Ozark region is among hundreds of rural American communities that face a one-two punch to oral health: a dire shortage of dentists and a lack of fluoridated drinking water, which is widely viewed among dentists as one of the most effective tools to prevent tooth decay. But as the anti-fluoride movement builds unprecedented momentum, it may turn out that the Ozarks were not behind the times after all.
“We will eventually win,” Anderson said. “We will be vindicated.”
Fluoride, a naturally occurring mineral, keeps teeth strong when added to drinking water, according to the Centers for Disease Control and Prevention and the American Dental Association. But the anti-fluoride movement has been energized since a government report last summer found a possible link between lower IQ in children and consuming amounts of fluoride that are higher than what is recommended in American drinking water. Dozens of communities have decided to stop fluoridating in recent months, and state officials in Florida and Texas have urged their water systems to do the same. Utah is poised to become the first state to ban it in tap water.
Health and Human Services Secretary Robert F. Kennedy Jr., who has long espoused fringe health theories, has called fluoride an “industrial waste” and “dangerous neurotoxin” and said the Trump administration will recommend it be removed from all public drinking water.
Separately, Republican efforts to extend tax cuts and shrink federal spending may squeeze Medicaid, which could deepen existing shortages of dentists in rural areas where many residents depend on the federal insurance program for whatever dental care they can find.
Dental experts warn that the simultaneous erosion of Medicaid and fluoridation could exacerbate a crisis of rural oral health and reverse decades of progress against tooth decay, particularly for children and those who rarely see a dentist.
“If you have folks with little access to professional care and no access to water fluoridation,” said Steven Levy, a dentist and leading fluoride researcher at the University of Iowa, “then they are missing two of the big pillars of how to keep healthy for a lifetime.”
Many already are.
Overlapping ‘Dental Deserts’ and Fluoride-Free Zones
Nearly 25 million Americans live in areas without enough dentists — more than twice as many as prior estimates by the federal government — according to a recent study from Harvard University that measured U.S. “dental deserts” with more depth and precision than before.
Hawazin Elani, a Harvard dentist and epidemiologist who co-authored the study, found that many shortage areas are rural and poor, and depend heavily on Medicaid. But many dentists do not accept Medicaid because payments can be low, Elani said.
The ADA has estimated that only a third of dentists treat patients on Medicaid.
“I suspect this situation is much worse for Medicaid beneficiaries,” Elani said. “If you have Medicaid and your nearest dentists do not accept it, then you will likely have to go to the third, or fourth, or the fifth.”
The Harvard study identified over 780 counties where more than half of the residents live in a shortage area. Of those counties, at least 230 also have mostly or completely unfluoridated public drinking water, according to a KFF analysis of fluoride data published by the CDC. That means people in these areas who can’t find a dentist also do not get protection for their teeth from their tap water.
The KFF Health News analysis does not cover the entire nation because it does not include private wells and 13 states do not submit fluoride data to the CDC. But among those that do, most counties with a shortage of dentists and unfluoridated water are in the south-central U.S., in a cluster that stretches from Texas to the Florida Panhandle and up into Kansas, Missouri, and Oklahoma.
In the center of that cluster is the Ozark Mountain Regional Public Water Authority, which serves the Arkansas counties of Boone, Marion, Newton, and Searcy. It has refused to add fluoride ever since Arkansas enacted a statewide mandate in 2011. After weekly fines began in 2016, the water system unsuccessfully challenged the fluoride mandate in state court, then lost again on appeal.
Anderson, who has chaired the water system’s board since 2007, said he would like to challenge the fluoride mandate in court again and would argue the case himself if necessary. In a phone interview, Anderson said he believes that fluoride can hamper the brain and body to the point of making people “get fat and lazy.”
“So if you go out in the streets these days, walk down the streets, you’ll see lots of fat people wearing their pajamas out in public,” he said.
Nearby in the tiny, no-stoplight community of Leslie, Arkansas, which gets water from the Ozark system, the only dentist in town operates out of a one-man clinic tucked in the back of an antique store. Hand-painted lettering on the store window advertises a “pretty good dentist.”
James Flanagin, a third-generation dentist who opened this clinic three years ago, said he was drawn to Leslie by the quaint charms and friendly smiles of small-town life. But those same smiles also reveal the unmistakable consequences of refusing to fluoridate, he said.
“There is no doubt that there is more dental decay here than there would otherwise be,” he said. “You are going to have more decay if your water is not fluoridated. That’s just a fact.”
Fluoride Seen as a Great Public Health Achievement
Fluoride was first added to public water in an American city in 1945 and spread to half of the U.S. population by 1980, according to the CDC. Because of “the dramatic decline” in cavities that followed, in 1999 the CDC dubbed fluoridation as one of 10 great public health achievements of the 20th century.
Currently more than 70% of the U.S. population on public water systems get fluoridated water, with a recommended concentration of 0.7 milligrams per liter, or about three drops in a 55-gallon barrel, according to the CDC.
Fluoride is also present in modern toothpaste, mouthwash, dental varnish, and some food and drinks — like raisins, potatoes, oatmeal, coffee, and black tea. But several dental experts said these products do not reliably reach as many low-income families as drinking water, which has an additional benefit over toothpaste of strengthening children’s teeth from within as they grow.
Two recent polls have found that the largest share of Americans support fluoridation, but a sizable minority does not. Polls from Axios/Ipsos and AP-NORC found that 48% and 40% of respondents wanted to keep fluoride in public water supplies, while 29% and 26% supported its removal.
Chelsea Fosse, an expert on oral health policy at the American Academy of Pediatric Dentistry, said she worried that misguided fears of fluoride would cause many people to stop using fluoridated toothpaste and varnish just as Medicaid cuts made it harder to see a dentist.
The combination, she said, could be “devastating.”
“It will be visibly apparent what this does to the prevalence of tooth decay,” Fosse said. “If we get rid of water fluoridation, if we make Medicaid cuts, and if we don’t support providers in locating and serving the highest-need populations, I truly don’t know what we will do.”
Multiple peer-reviewed studies have shown what ending water fluoridation could look like. In the past few years, studies of cities in Alaska and Canada have shown that communities that stopped fluoridation saw significant increases in children’s cavities when compared with similar cities that did not. A 2024 study from Israel reported a “two-fold increase” in dental treatments for kids within five years after the country stopped fluoridating in 2014.
Despite the benefits of fluoridation, it has been fiercely opposed by some since its inception, said Catherine Hayes, a Harvard dental expert who advises the American Dental Association on fluoride and has studied its use for three decades.
Fluoridation was initially smeared as a communist plot against America, Hayes said, and then later fears arose of possible links to cancer, which were refuted through extensive scientific research. In the ’80s, hysteria fueled fears of fluoride causing AIDS, which was “ludicrous,” Hayes said.
More recently, the anti-fluoride movement seized on international research that suggests high levels of fluoride can hinder children’s brain development and has been boosted by high-profile legal and political victories.
Last August, a hotly debated report from the National Institutes of Health’s National Toxicology Program found “with moderate confidence” that exposure to levels of fluoride that are higher than what is present in American drinking water is associated with lower IQ in children. The report was based on an analysis of 74 studies conducted in other countries, most of which were considered “low quality” and involved exposure of at least 1.5 milligrams of fluoride per liter of water — or more than twice the U.S. recommendation — according to the program.
The following month, in a long-simmering lawsuit filed by fluoride opponents, a federal judge in California said the possible link between fluoride and lowered IQ was too risky to ignore, then ordered the federal Environmental Protection Agency to take nonspecified steps to lower that risk. The EPA started to appeal this ruling in the final days of the Biden administration, but the Trump administration could reverse course.
The EPA and Department of Justice declined to comment. The White House and Department of Health and Human Services did not respond to questions about fluoride.
Despite the National Toxicology Program’s report, Hayes said, no association has been shown to date between lowered IQ and the amount of fluoride actually present in most Americans’ water. The court ruling may prompt additional research conducted in the U.S., Hayes said, which she hoped would finally put the campaign against fluoride to rest.
“It’s one of the great mysteries of my career, what sustains it,” Hayes said. “What concerns me is that there’s some belief amongst some members of the public — and some of our policymakers — that there is some truth to this.”
Not all experts were so dismissive of the toxicology program’s report. Bruce Lanphear, a children’s health researcher at Simon Fraser University in British Columbia, published an editorial in January that said the findings should prompt health organizations “to reassess the risks and benefits of fluoride, particularly for pregnant women and infants.”
“The people who are proposing fluoridation need to now prove it’s safe,” Lanphear told NPR in January. “That’s what this study does. It shifts the burden of proof — or it should.”
Cities and States Rethink Fluoride
At least 14 states so far this year have considered or are considering bills that would lift fluoride mandates or prohibit fluoride in drinking water altogether. In February, Utah lawmakers passed the nation’s first ban, which Republican Gov. Spencer Cox told ABC4 Utah he intends to sign. And both Florida Surgeon General Joseph Ladapo and Texas Agriculture Commissioner Sid Miller have called for their respective states to end fluoridation.
“I don’t want Big Brother telling me what to do,” Miller told The Dallas Morning News in February. “Government has forced this on us for too long.”
Additionally, dozens of cities and counties have decided to stop fluoridation in the past six months — including at least 16 communities in Florida with a combined population of more than 1.6 million — according to news reports and the Fluoride Action Network, an anti-fluoride group.
Stuart Cooper, executive director of that group, said the movement’s unprecedented momentum would be further supercharged if Kennedy and the Trump administration follow through on a recommendation against fluoride.
Cooper predicted that most U.S. communities will have stopped fluoridating within years.
“I think what you are seeing in Florida, where every community is falling like dominoes, is going to now happen in the United States,” he said. “I think we’re seeing the absolute end of it.”
If Cooper’s prediction is right, Hayes said, widespread decay would be visible within years. Kids’ teeth will rot in their mouths, she said, even though “we know how to completely prevent it.”
“It’s unnecessary pain and suffering,” Hayes said. “If you go into any children’s hospital across this country, you’ll see a waiting list of kids to get into the operating room to get their teeth fixed because they have severe decay because they haven’t had access to either fluoridated water or other types of fluoride. Unfortunately, that’s just going to get worse.”
Methodology: How We Counted
This KFF Health News article identifies communities with an elevated risk of tooth decay by combining data on areas with dentist shortages and unfluoridated drinking water. Our analysis merged Harvard University research on dentist-shortage areas with large datasets on public water systems published by the U.S. Centers for Disease Control and Prevention.The Harvard research determined that nearly 25 million Americans live in dentist-shortage areas that span much of rural America. The CDC data details the populations served and fluoridation status of more than 38,000 public water systems in 37 states. We classified counties as having elevated risk of tooth decay if they met three criteria:More than half of the residents live in a dentist-shortage area identified by Harvard.The number of people receiving unfluoridated water from water systems based in that county amounts to more than half of the county’s population.The number of people receiving unfluoridated water from water systems based in that county amounts to at least half of the total population of all water systems based in that county, even if those systems reached beyond the county borders, which many do.
Our analysis identified approximately 230 counties that meet these criteria, meaning they have both a dire shortage of dentists and largely unfluoridated drinking water.
But this total is certainly an undercount. Thirteen states do not report water system data to the CDC, and the agency data does not include private wells, most of which are unfluoridated.
KFF Health News data editor Holly K. Hacker contributed to this article.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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This article first appeared on KFF Health News and is republished here under a Creative Commons license.
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