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Congress’ Tight Timetable Complicates Renewal Of Children’s Health Plan

Kaiser Health News:HealthReform - September 07, 2017

A popular federal-state program that provides health coverage to millions of children in lower- and middle-class families is up for renewal Sept. 30.

But in a deeply divided Congress facing such pressing concerns as extending the nation’s debt ceiling, finding money for the Hurricane Harvey cleanup and keeping the government open, some health advocates fear that the program for children could be in jeopardy or that conservative lawmakers will seek changes to limit the program’s reach.

“With all that is on Congress’ plate, I am very worried that a strong, wildly successful program with strong public support will get lost in the shuffle and force states to begin the process of winding down CHIP,” said Bruce Lesley, president of the advocacy group First Focus.

This KHN story also ran on NPR. It can be republished for free (details).

The Children’s Health Insurance Program covers more than 9 million kids — children typically from families not poor enough to qualify for Medicaid, the state-federal program that covers low-income people.

Income eligibility levels for CHIP vary widely among states, though most set thresholds at or below 200 percent of the poverty level, about $49,000 for a family of four. Unlike Medicaid, CHIP is usually not free. Enrolled families pay an average premium of about $127 a year.

Since CHIP’s enactment, the share of uninsured children fell from 13.9 percent in 1997 to 4.5 percent in 2015, according to the Medicaid and CHIP Payment and Access Commission.

The 20-year-old program has bipartisan support — and one of its original sponsors is Sen. Orrin Hatch (R-Utah), chairman of the Finance Committee, which has scheduled a hearing on reauthorization Thursday.

It’s possible in the jampacked legislative calendar this month that other health-related provisions could be attached to a CHIP reauthorization bill — such as Republican-sponsored changes to the Affordable Care Act. Those changes could keep a bill from getting enough support from Democrats and some Republicans in the Senate for passage.

“It’s the only vehicle in health care policy other than the federal budget that’s going to be moving, so it’s likely extraneous items are likely to be added to it,” said Christopher Pope, senior fellow at the conservative Manhattan Institute.

Supporters of CHIP also worry about changes in eligibility that could dampen enrollment.

Without a reauthorization from Congress, Arizona, Minnesota, North Carolina and the District of Columbia will run out of their federal funding for the Children’s Health Insurance Plan by the end of this year. By next March, 27 other states would exhaust their funds. (Courtesy of the Kaiser Family Foundation. Kaiser Health News is an editorially independent project of the foundation.)

The Affordable Care Act bumped up federal funding of CHIP by 23 percentage points and forbid states from restricting eligibility rules that were in place in 2010. Both of those requirements continue through September 2019.

The added funding means a dozen states have their entire CHIP programs paid for by the federal government. In the fiscal year that ended last September, states spent less than $2 billion of the total $15.6 billion in CHIP spending, according to the conservative Heritage Foundation, which says states should pay a higher share of the program’s costs.

President Donald Trump’s budget request this spring called for immediately eliminating the ACA bump in funding and ending the restriction on states curtailing eligibility — often referred to as the “maintenance of effort” provision.

But that provision has kept CHIP stable at a time when the individual insurance market faces uncertainty, said Joan Alker, director of Georgetown University’s Center for Children and Families in Washington, D.C.

Advocates note that if children have to leave CHIP and move to marketplace coverage, their families may be forced to pay higher out-of-pocket costs for their kids’ health care.

Without the maintenance of effort requirement, advocates fear that states would be more likely to do what Arizona did during the last economic downturn: It froze enrollment from December 2009 until last June. The move was allowed because it took effect before the ACA’s restriction began in March 2010.

Meanwhile, Republicans are not united in their views of the maintenance of effort requirement. Some favor it because they say it shifts more authority of the program to states. Others say it would likely lead some states to move many CHIP enrollees either into Medicaid or private insurance policies sold on the Obamacare exchanges — both areas where the federal government may pay an even higher share of the costs, Pope said.

“It’s not a simple win for anything, but you can see why some governors would like it,” he said.

At a House subcommittee hearing in June, some Republicans lawmakers expressed concerns about extending the enhanced federal funding for CHIP.

“This increase in funding has challenged the program by both shifting the nature of shared responsibility of the state Children’s Health Insurance Program to the federal government and making states more dependent on federal dollars,” said Rep. Michael Burgess (R-Texas), who heads the Energy and Commerce subcommittee on health.

A committee staff memo prepared for the hearing said taking away the extra funding — but leaving the maintenance of effort requirement in place — would not result in fewer children having coverage.

Without renewal of the program, Arizona, Minnesota, North Carolina and the District of Columbia would run out of their federal CHIP funding by the end of this year. By March 2018, an additional 27 states would exhaust their funds.

Minnesota and D.C. officials said all children covered by CHIP will transition to Medicaid if funding is cut.

Alker said the enhanced funding has helped several states, including Nevada and Utah, expand coverage to legal immigrant children instead of having to face a five-year wait.  

Given the complexity of making major changes and the tight congressional timeline, some experts say Congress may opt to pass a clean CHIP bill — without major changes to the program.

“Congress is in this month so few days that I can easily see CHIP simply being reauthorized without strings attached,” said Joe Antos, a health economist with the conservative American Enterprise Institute, because lawmakers’ attention is more likely to focus on the debt-limit deadline, the budget resolution and tax reform.

Shedding New Light On Hospice Care: No Need To Wait For The ‘Brink Of Death’

Kaiser Health News:Marketplace - September 07, 2017

A few weeks ago, Kathy Brandt’s 86-year-old mother was hospitalized in Florida after a fall. After rushing to her side, Brandt asked for a consult with a palliative care nurse.

“I wanted someone to make sure my mother was on the right medications,” Brandt said.

For all her expertise — Brandt advises end-of-life organizations across the country — she was taken aback when the nurse suggested hospice care for her mother, who has advanced chronic obstructive pulmonary disease, kidney disease and a rapid, irregular heartbeat.

“I was like — really?” Brandt remembered saying, struggling with shock.

It’s a common reaction. Although hospices now serve more than 1.4 million people a year, this specialized type of care, meant for people with six months or less to live, continues to evoke resistance, fear and misunderstanding.

“The biggest misperception about hospice is that it’s ‘brink-of-death care,’” said Patricia Mehnert, a longtime hospice nurse and interim chief executive officer of TRU Community Care, the first hospice in Colorado.

NAVIGATING AGING

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

To contact Judith with a question or comment, click here.

For more KHN coverage of aging, click here.

In fact, hospice care often makes a considerable difference for those with months to live. “When someone is further out from death, we can really focus on enhancing their quality of life,” said Rachel Behrendt, senior vice president of Hospice of the Valley, which serves the Phoenix metropolitan area.

New research confirms that hospice patients report better pain control, more satisfaction with their care and fewer deaths in the hospital or intensive care units than other people with similarly short life expectancies.

What should seniors and their families, the largest users of hospice care, expect? It’s fairly well understood that patients forgo curative therapies in favor of comfort care when they enter hospice. Here are additional features:

Four Levels Of Care

Hospice providers are required to offer routine care in patients’ homes (this includes seniors who reside in assisted living or nursing homes); continuous care at home for people with out-of-control symptoms such as pain or breathing problems; inpatient respite for families that need a break from caring for a loved one; and general inpatient care for medical crises that can’t be handled in any other setting.

With continuous care, a nurse must be on-site in the home for at least eight hours a day, helping to bring symptoms under control. Usually, this will happen in one to three days. Respite care has a maximum limit of five days.

Some hospices have their own general inpatient facilities and “it’s a common misconception that patients are sent to inpatient hospice to die,” said Jean Cohn, clinical manager at Montgomery Hospice’s inpatient facility, Casey House. “In fact, we’re frequently fine-tuning patients’ regimens in inpatient hospice and sending them back home.”

Intermittent Care At Home

Routine care at home is by far the most common service, accounting for about 94 percent of hospice care, according to the latest report from the National Hospice and Palliative Care Organization.

While services vary depending on a patient’s needs, home care typically involves at least one weekly visit from a nurse and a couple of visits from aides for up to 90 minutes. Also, a volunteer may visit, if a patient and family so choose, and social workers and chaplains are available to address practical and spiritual concerns.

Hospices will provide all medications needed to address the underlying illness that is expected to cause the patient’s death, as well as medical equipment such as hospital beds, commodes, wheelchairs, walkers and oxygen. Typically, there is no charge for such gear, although a copay of up to $5 per prescription is allowed.

What families and patients often don’t realize: Hospice staff will not be in the home every day, around the clock. “Many people think that hospice will be there all the time, but it doesn’t work that way,” Brandt said. “The family is still the front line for providing day-to-day care.”

In assisted living, patients or their families may have to hire nursing assistants or companions to provide supplemental care, since hands-on help is limited. In nursing homes, aides may visit less often, since more hands-on help is available on-site.

Self-Referrals Are Allowed

Anyone can ask for a consultation with a hospice. “We get many self-referrals, as well as referrals from family and friends,” said Behrendt of Hospice of the Valley. Usually, a nurse will go out and do a preliminary assessment to determine if a person would qualify for hospice services.

To be admitted, two physicians — the patient’s primary care physician and the hospice physician — need to certify that the person’s life expectancy is six months or less, based on the anticipated trajectory of the patient’s underlying illness. And recertification will be required at regular intervals.

You Choose Your Physician

You have a right to keep your primary care physician or you can choose to have a hospice physician be in charge of your medical care.

At JourneyCare, the largest hospice in Illinois, “we prefer that the patient keeps their primary care physician because that physician knows them best,” said Dr. Mark Grzeskowiak, vice president of medical services.

These arrangements require close collaboration. For instance, if a nurse observes that a patient with heart failure is experiencing increased shortness of breath, JourneyCare staff will get in touch with that patient’s primary care physician. The physician is responsible for altering the treatment plan; the hospice is responsible for implementing that plan and giving clear instructions to the patient and family.

Concerns About Medications

“There’s a misconception that you’re going to be medicated to a highly sedated state in hospice,” said Dr. Christopher Kerr, chief executive officer and chief medical officer for Hospice Buffalo Inc. in upstate New York. “The reality is our primary goal is to increase quality wakefulness. Managing these medications is an art and we’re good at it.”

Use Our ContentThis KHN story can be republished for free (details).

Family caregivers are on the front line since they’re responsible for administering pain medications such as morphine. “Absolutely, there’s a great deal of fear and anxiety around all the issues associated with giving medications,” said Cohn of Montgomery Hospice. “We try to reassure caregivers that the doses we start with are very small and we’ll see how the patient reacts and go slowly and deliberately from there.”

Because most hospice stays are short — the median length is only 17 days — and because the diversion of painkillers from people’s homes is a risk, doctors have begun writing prescriptions for a week or two at a time, said Judi Lund Person, vice president of regulatory and compliance for the National Hospice and Palliative Care Organization. If concerns exist, hospices can have a lockbox for medications sent to the home.

Discharges Are Possible

Estimating when someone is going to die is an art, not a science, and each year hundreds of thousands of hospice patients end up living longer than doctors anticipated.

If physicians can document continued decline in these patients — for instance, worsening pain or a noticeable advance in their underlying illness — they might be able to recertify them for ongoing hospice care. But if the patient is considered stable, they’ll be discharged, various experts said.

In 2015, nearly 17 percent of hospice patients were so-called live discharges, according to a report from the Medicare Payment Advisory Commission. Two days before a discharge, hospices are required to give the patient or family members a Notice of Medicare Non-Coverage. Expedited appeals of discharge decisions can be lodged with a Medicare quality improvement organization.

There are no regulatory requirements governing what hospices should do to facilitate live discharges. Some hospices will spend weeks helping patients make arrangements to receive medications, medical equipment and ongoing care from other sources. Others offer minimal help.

At The Very End

Almost 1 in 8 hospice patients don’t get visits from professional staff during their last two days of life, according to a study published in JAMA Internal Medicine last year. And this can leave families without needed support.

Some hospices have responded by creating programs specifically for people who have a very short time left to live. “We’ve put together a special team for people who are expected to live 10 days or less because that requires a different kind of management,” said Ann Mitchell, chief executive officer of Montgomery Hospice. “Instead of a nurse for every 15 patients, a nurse on this team will have five to six patients and a social worker is available seven days a week.”

“One-third of our patients are here for less than seven days and often we get them in a crisis,” said Kerr of Hospice Buffalo. “We’ve had to repurpose our services to address the urgency and complexity of these patients’ needs and that means we have to be ever more present.” Across the board, Hospice Buffalo requires that patients be seen within 24 hours of an expected death.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation and coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Insurance Commissioners Say Help Offered By Congress Is Not Enough To Save Market

Kaiser Health News:HealthReform - September 06, 2017

A key Senate committee Wednesday launched a set of hearings intended to lead to a short-term, bipartisan bill to shore up the troubled individual health insurance market, but a diverse group of state insurance commissioners united around some solutions that were not necessarily on the table.

Sen. Lamar Alexander (R-Tenn.), the chairman of the Health, Education, Labor and Pensions Committee, said at the outset of the hearing he hoped to reach consensus on “a small, bipartisan, stabilization bill” by the end of next week. But the five state officials who testified seemed to have ideas other than those Alexander has touted for the past couple of weeks.

Related: Vital Health Officials You’ve Never Heard Of: Insurance Commissioners In The Hot Seat

Alexander has been floating the notion of guaranteeing insurance companies that they would be reimbursed for at least one more year for the “cost-sharing reduction” discounts they provide to enrollees with incomes under 250 percent of the federal poverty level. Insurers must make those payments under the Affordable Care Act, but the Trump administration has threatened to withhold the money owed insurers.

Use Our ContentThis KHN story can be republished for free (details).

Commissioners said insurers in their states plan sharp rate hikes next year unless Congress removes that uncertainty by appropriating money to pay the discounts, estimated at $10 billion in 2018.

In exchange for guaranteeing the cost-sharing payments, which Democrats have sought, Alexander suggested Democrats would need to give states more flexibility to seek waivers from the rules of the federal health law to experiment with different ways to provide health insurance coverage. “Democrats will have to agree to something they may be reluctant to support,” he said. “That is called a compromise.”

But the state insurance officials — Democrats and Republicans from Tennessee, Alaska, Washington, Oklahoma and Pennsylvania — agreed that the guarantee for funding cost-sharing payments needs to go for more than a year.

“Insurers right now are already planning for 2019,” said Washington Insurance Commissioner Mike Kreidler, a former Democratic member of Congress. “In order to give them predictability, you would have to give them more certainty in the market” than a one-year extension.

Added Alaska Insurance Commissioner Lori Wing-Heier, “Insurers have to have more than a one-year commitment” to persuade them to stay in the market and not raise premiums high enough to make up for the potentially lost payments from the federal government.

Alexander also pushed his idea to make it easier for states to use the federal health law waivers to create their own “reinsurance” programs that would keep premiums down by paying for the most expensive patients. But the insurance officials suggested they would rather have Congress reinstate a federal reinsurance program that expired this year.

Wing-Heier, whose state is so far the only one to have its own reinsurance plan approved by the federal government, noted that Alaska funded its own program for the first year, “and the states I’ve talked to said they can’t afford to do that.”

“Allowing states to do that is great, but if we could have a federal backstop in the meantime and to help with 2018, I think that’s going to be important,” said Pennsylvania acting Human Services Secretary Teresa Miller. She was formerly the state’s insurance commissioner.

A federal reinsurance program, said Tennessee Insurance Commissioner Julie Mix McPeak, “would help states that don’t have the wherewithal to get their own programs up and running.”

States, agreed Miller, “are not going to be able to fix this completely on our own.”

The state officials concurred that the current process for seeking a federal waiver is too cumbersome and could definitely use streamlining.

“The part that is stifling states is the six-month waiting period before they receive final approval,” Wing-Heier said. “… [Federal officials were] very helpful to us, but it still was a very lengthy process.”

State officials also expressed concerns about the Trump administration’s cutbacks in programs this fall to help people sign up for coverage starting in 2018 and to promote the open enrollment period from Nov. 1 to Dec. 15, which is 45 days shorter than last year’s.

“I worry that these decisions will result in fewer people enrolling and relatively fewer healthy people enrolling, exacerbating the issues that already exist in the risk pool,” Miller said.

Some senators also suggested ideas that have not been on the table.

For example, Sen. Lisa Murkowski (R-Alaska) asked whether individuals in places with few or no insurers might instead be allowed to purchase coverage through the federal employee health plan.

The committee has three more hearings scheduled on the health issue this week and next. On Thursday, senators will hear from a bipartisan panel of governors on what they think would best stabilize the individual insurance market and better control health care costs over the long term. One major concern is rising drug prices — a point that insurance commissioners made Wednesday and which some governors will reinforce, according to their prepared testimony.

Survivor Health and Safety a Federal Family Focus after Hurricane Harvey

HHS Gov News - September 06, 2017

Washington, D.C. – More than a week after Hurricane Harvey made landfall in Texas, all levels of government remain committed to life saving and safety needs across the affected areas. Priorities remain focused on the health and well-being of survivors as they begin the road to recovery.

The Department of Health and Human Services (HHS) is the lead federal coordinating agency to coordinate federal support activities of public health, health care facilities and coalitions, environmental health, behavioral health, and essential social service needs. HHS is working closely with the state of Texas as well as other federal, state, local, tribal and voluntary agencies to support local efforts to recover health care, public health, and social services functions in areas affected by Hurricane Harvey.

To support health and social services recovery, HHS and its partners will begin recovery impact assessments and will assist the state in finding solutions to meet the needs of impacted communities and survivors. Common areas include persistent environmental health risks, such as mold and safety issues that can emerge in cleaning up debris; healthcare infrastructure needs such as long-term repair of healthcare facilities, clinics, and nursing homes; impacts on children and families, such as repair of child care centers and schools, and behavioral health in coping with personal and economic effects of disasters.

These efforts will build on work underway in the disaster response, including:

The U.S. Department of Health and Human Services continues to assist hospitals and other healthcare facilities, such as dialysis centers, and FDA regulated businesses, in reopening or in meeting the surge in demand for healthcare and social services.

  • Secretary Tom Price, M.D., declared a public health emergency for Texas to provide flexibility and authority to help those who have been impacted by the storm.
  • Centers for Medicare and Medicaid Services temporarily waived or modified certain Medicare, Medicaid and Children’s Health Insurance Program (CHIP) requirements to provide immediate relief to those affected by the hurricane and flooding.
  • HHS set up temporary care sites at the George R. Brown Convention Center in Houston and surrounding communities.
  • The more than 1,000 HHS personnel from the National Disaster Medical System and the U.S. Public Health Service deployed with more than 460,000 pounds of medical equipment and supplies to provide medical care for Texans in affected areas.
  • More than 1,000 local members of the HHS-sponsored Medical Reserve Corps (MRC) Program are volunteering in shelters, evacuation centers, call centers, and donation sites.
  • HHS activated its Disaster Distress Helpline, a toll-free call center, available 24/7 at 1-800-985-5990. Since August 26, more than 1,100 people in Texas have called the helpline for assistance in coping with the behavioral health effects of the storm and to connect with local behavioral health professionals.
  • Staff from the Centers for Disease Control and Prevention are widely distributing public health information related to carbon monoxide poisoning, flood water safety, generator safety, mental health, chemical hazards, evacuations & shelter safety, food and water safety, pet safety, injury prevention, and power outages. More information can be found at https://emergency.cdc.gov/han/han00406.asp.

The U.S. Department of Agriculture (USDA) is providing assistance through their Supplemental Nutrition Assistance Program (SNAP) and waiving some regulations to make food more accessible, especially to school children and seniors. The USDA has also made food available to the Salvation Army to prepare and serve 100,000 meals to disaster survivors.

  • In addition, the USDA approved the state of Texas to designate schools not directly impacted by the Hurricane to serve as disaster organizations and shelters so that USDA foods can be used for congregate feeding, providing critical food assistance to those in need. All disaster affected schools are now able to provide meals to all students at no charge and be reimbursed at the free reimbursement rate through September 30.
  • The Animal and Plant Health Inspection Service’s (APHIS’) Animal Care Program is  supporting animal safety and well-being during disasters which is helping to ensure the safety and well-being of people affected by the disaster. APHIS currently has staff deployed to emergency operations centers in both Texas and Louisiana and has already helped make available 25 tons of pet food to meet needs in affected areas and ensure additional food is available as necessary.

The U.S. Department of Education activated its emergency response contact center and is supporting their K-12 and higher education stakeholders affected by Hurricane Harvey. The Department of Education has made informational resources available to impacted schools and school districts online at rems.ed.gov. Those seeking relief from department-based administrative requirements can contact the department toll-free at 1-844-348-4082 or by email at HarveyRelief@ed.gov

The Environmental Protection Agency is working closely with local, state and federal responders, and is monitoring public water systems, securing waste sites, and supporting emergency response activities throughout the affected region.

  • With many drinking water and wastewater facilities affected by the impacts of Harvey, EPA is providing resources for those seeking information about their drinking water. During an emergency, citizens under a boil water notice should follow the directions of their local water utility. Drinking water emergency response resources can be found at www.epa.gov/ground-water-and-drinking-water/drinking-water-emergency-response.

The Occupational Safety and Health Administration (OSHA) is helping employers keep their workers safe during cleanup and recovery operations by providing a number of resources.

  • OSHA is actively engaged with the National Response Team and the interagency response to the hurricane and flooding. They are working with FEMA, the EPA, the Department of Homeland Security, and other federal agencies to coordinate strategies for the recovery.

The U.S. Department of Veteran’s Affairs has activated a hotline through its Health Resource Center (HRC) to assist veterans impacted by Hurricane Harvey. HRC assists veterans in updating temporary or permanent addresses or phone numbers; providing facility's operational status; providing information on how to reschedule appointments or receive medical advice; and, offers veterans information on emergency prescription refills and additional emergency resources. The VA has also deployed mobile assets to assist veterans affected by the storm. This includes:

  • Mobile Medical Units providing primary care, mental health, social work and benefits services to Veterans affected by Hurricane Harvey. VA has five units currently located in Houston, Crosby, Silsbee, and Corpus Christi and is open to any veteran and family members.
  • Mobile Vet Centers providing counseling services to veterans and the affected community.
  • Mobile Pharmacies located in the Houston metropolitan area capable of delivering life-saving pharmaceuticals to veterans.
  • Additionally, VA is using its telehealth capabilities with 170 iPads distributed throughout greater Houston and more than 65 staff devoted to current telehealth efforts focused on primary care, mental health and clinical pharmacist support.

For additional information about recovery resources in states affected by Hurricane Harvey, visit www.fema.gov/hurricane-harvey.

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Follow HHS on @HHSgov and HHS Secretary Tom Price on @SecPriceMD. Find HHS emergency response and recovery tips and activities on @PHEgov.

Follow efforts across the federal government with FEMA online at www.fema.gov/blog, www.twitter.com/fema, www.facebook.com/fema and www.youtube.com/fema. Also, follow Administrator Brock Long’s activities at http://www.twitter.com/fema_brock.

Move To End DACA Leaves Some Young Immigrants Fearing For Their Health

Kaiser Health News:Insurance - September 06, 2017

LOS ANGELES — For 26-year-old Paulina Ruiz, having legal immigration status is about more than going to school or holding a job. It’s about staying healthy.

The University of California-Los Angeles graduate, whose parents brought her from Mexico to the U.S. illegally two decades ago, has cerebral palsy, a neurological condition diagnosed shortly after birth.

In the past, Ruiz said, she relied on emergency rooms for her health care and rarely could see specialists. She developed kidney and back problems after years of inconsistent medical care and using an inappropriate wheelchair.

Paulina Ruiz, who has cerebral palsy, said losing her legal immigration status could mean losing her health coverage and access to doctors. Ruiz is on Medi-Cal, which helps cover some of the costs of her medical care. (Courtesy of Paulina Ruiz)

But in 2012, she qualified for the federal Deferred Action for Childhood Arrivals (DACA) program, which temporarily protected her from deportation. In California, that meant she could get Medi-Cal, California’s version of the Medicaid insurance program for low-income Americans, and regularly see a doctor.

The Trump administration’s controversial decision on Tuesday to scrap the DACA program does more than put nearly 800,000 “Dreamers” in fear of deportation and losing their jobs. It threatens the health care of thousands of young adults like Ruiz, who either have job-based insurance or whose incomes qualify them for Medicaid in California and several other states.

“I am very upset,” said Ruiz, who organizes for the Coalition for Humane Immigrant Rights of Los Angeles and lives near the city. “I don’t know what’s going to happen to my health.”

The decision is set to take effect in six months, unless Congress comes up with an alternative plan. Trump has said the program, started under President Obama in 2012, rewards lawbreakers who hurt Americans by taking their jobs and depressing wages, a claim some economists dispute. Attorney General Jeff Sessions said Tuesday that the program was unconstitutional because it was a unilateral executive action on a proposal that had been repeatedly rejected by Congress.

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Trump, who has suggested he has conflicting sentiments about the program, left open the door for Congress to change it. “I have a love for these people, and hopefully now Congress will be able to help them and do it properly,” he said, according to The New York Times. But the newspaper noted that he did not call for bipartisan legislation to restore its protections.

The program allows immigrants between the ages of 16 and 31 who were brought to the United States illegally as children to receive work permits and temporary protection from deportation. Those who qualified were explicitly barred from receiving federal health benefits through Medicaid, Obamacare exchanges or other programs.

Many DACA recipients now have jobs with health insurance. In addition, California, New York, Massachusetts, Minnesota and the District of Columbia have used their own money to cover low-income Dreamers through Medicaid, according to Tanya Broder, a Berkeley, Calif.-based senior staff attorney for the National Immigration Law Center.

Maria Garcia, 22, said she was able to get a job as a receptionist at a Los Angeles hotel because of the DACA program. The job also came with health insurance, which helped cover physical therapy from a knee injury. She fears getting fired and being unable to pay for her own health insurance and medical care. (Anna Gorman/KHN)

An estimated 367,000 people qualify for DACA in California. There are an estimated 220,000 DACA recipients in California, the largest number in the country. Those who meet income requirements — 138 percent of the federal poverty level or $33,534 for a family of four — can qualify for coverage under the state’s “Permanently Residing in the United States under Color of Law” eligibility category.

That coverage is now in question. In California, those at risk of losing Medicaid are 19 and older, because the state under a separate law decided to cover all low-income children, regardless of immigration status, through age 18. That decision was not connected to the DACA program.

With the federal government’s action, “nobody will lose coverage in the Medi-Cal program immediately,” said Ronald Coleman, director of government affairs for the California Immigrant Policy Center, an immigrant advocacy group. But Coleman worries about what happens after March 5, when DACA’s protections will end — unless Congress takes action to protect the program.

The Department of Health Care Services, which oversees Medi-Cal, could not provide a comment on Tuesday, a spokeswoman said.

Marielena Hincapié, executive director of the National Immigration Law Center, told reporters in a conference call on Tuesday that she expects DACA recipients to start losing their job-based health insurance. Hincapié said she is particularly concerned about the effect of the president’s decision on the mental health of DACA recipients.

“The need for mental health services will only be greater,” she said.

Jocelin Reyes, 19, said having protection from deportation relieved her fears and anxieties. But now, the University of California-Santa Barbara student said, “the fear has tripled.” (Anna Gorman/KHN)

At a protest in downtown Los Angeles Tuesday against the Trump administration’s decision, Jocelin Reyes made a similar point. She said DACA’s protections had helped put some young immigrants’ fears to rest, as they were able to get jobs, attend college or graduate school and come out of hiding.

“A lot of people don’t understand how much fear we had” about being deported, said Reyes, 19, who is about to start school at the University of California-Santa Barbara. “Now that fear has tripled.”

Another demonstrator, DACA recipient Maria Garcia, 22, said that losing her job as a hotel receptionist would mean the end of her job-based health insurance — coverage she relies on for physical therapy for a knee injury and any time she gets sick.

“If they take away my DACA, I’ll get fired,” she said. “And then what will I do for health insurance?”

State Sen. Ricardo Lara (D-Bell Gardens) said ending DACA would only hurt “the well-being of these American children who have played by the rules.” And they could end up having to go to costly emergency rooms for medical care.

Lara, who led the charge to get all undocumented children covered by Medi-Cal, said one possible solution in California would be to increase the age limit for Medi-Cal coverage for kids from 18 to 26.

“We have to answer this call to ensure that our DACA students and workers are not pushed aside,” he said.

The California Medical Association said that terminating DACA could indeed hurt the health care workforce.

“Our nation’s health care system has the largest percentage of foreign-born and foreign-trained workers of any industry in the country. Already facing a national shortage of physicians and other health care professionals, revoking DACA could also undermine patient care and disrupt medical schools and hospitals for decades to come,” said California Medical Association President Ruth E. Haskins in a statement.

Ana B. Ibarra contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

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