MIAMI — GOP lawmakers in the 10 states that refused the Affordable Care Act’s Medicaid expansion for over a decade have argued their conservative approach to growing government programs would pay off in the long run.

Instead, the Republican-passed budget law that includes many of President Donald Trump’s priorities will pose at least as big a burden on patients and hospitals in the expansion holdout states as in the 40 states that have extended Medicaid coverage to more low-income adults, hospital executives and other officials warn.

For instance, Georgia, with a population of just over 11 million, will see as many people lose insurance coverage sold through ACA marketplaces as will California, with more than triple the population, according to estimates by KFF, a health information nonprofit that includes KFF Health News.

The new law imposes additional paperwork requirements on Obamacare enrollees, slashes the time they have each year to sign up, and cuts funding for navigators who help them shop for plans. Those changes, all of which will erode enrollment, are expected to have far more impact in states like Florida and Texas than in California because a higher proportion of residents in non-expansion states are enrolled in ACA plans.

The budget law, which Republicans called the “One Big Beautiful Bill,” will cause sweeping changes to health care across the country as it trims federal spending on Medicaid by more than $1 trillion over the next decade. The program covers more than 71 million people with low incomes and disabilities. Ten million people will lose coverage over the next decade due to the law, according to the nonpartisan Congressional Budget Office.

Many of its provisions are focused on the 40 states that expanded Medicaid under the ACA, which added millions more low-income adults to the rolls. But the consequences are not confined to those states. A proposal from conservatives to cut more generous federal payments for people added to Medicaid by the ACA expansion didn’t make it into the law.

“Politicians in non-expansion states should be furious about that,” said Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank.

The number of people losing coverage could accelerate in non-expansion states if enhanced federal subsidies for Obamacare plans expire at the end of the year, driving up premiums as early as January and adding to the rolls of uninsured. KFF estimates as many as 2.2 million people could become uninsured just in Florida, a state where lawmakers refused to expand Medicaid and, partly as a result, now leads the nation in ACA enrollment.

For people like Francoise Cham of Miami, who has Obamacare coverage, the Republican policy changes could be life-altering.

Before she had insurance, the 62-year-old single mom said she would donate blood just to get her cholesterol checked. Once a year, she’d splurge for a wellness exam at Planned Parenthood. She expects to make about $28,000 this year and currently pays about $100 a month for an ACA plan to cover herself and her daughter, and even that strains her budget.

Cham choked up describing the “safety net” that health insurance has afforded her — and at the prospect of being unable to afford coverage if premiums spike at the end of the year.

“Obamacare has been my lifesaver,” she said.

If the enhanced ACA subsidies aren’t extended, “everyone will be hit hard,” said Cindy Mann, a health policy expert with Manatt Health, a consulting and legal firm, and a former deputy administrator for the Centers for Medicare & Medicaid Services.

“But a state that hasn’t expanded Medicaid will have marketplace people enrolling at lower income levels,” she said. “So, a greater share of residents are reliant on the marketplace.”

Though GOP lawmakers may try to cut Medicaid even more this year, for now the states that expanded Medicaid largely appear to have made a smart decision, while states that haven’t are facing similar financial pressures without any upside, said health policy experts and hospital industry observers.

KFF Health News reached out to the governors of the 10 states that have not fully expanded Medicaid to see if the budget legislation made them regret that decision or made them more open to expansion. Spokespeople for Republican Gov. Henry McMaster of South Carolina and Republican Gov. Brian Kemp of Georgia did not indicate whether their states are considering Medicaid expansion.

Brandon Charochak, a spokesperson for McMaster’s office, said South Carolina’s Medicaid program focuses on “low-income children and families and disabled individuals,” adding, “The state’s Medicaid program does not anticipate a large impact on the agency’s Medicaid population.”

Enrollment in ACA marketplace plans nationwide has more than doubled since 2020 to 24.3 million. If enhanced subsidies expire, premiums for Obamacare coverage would rise by more than 75% on average, according to an analysis by KFF. Some insurers are already signaling they plan to charge more.

The CBO estimates that allowing enhanced subsidies to expire will increase the number of people without health insurance by 4.2 million by 2034, compared with a permanent extension. That would come on top of the coverage losses caused by Trump’s budget law.

“That is problematic and scary for us,” said Eric Boley, president of the Wyoming Hospital Association.

He said his state, which did not expand Medicaid, has a relatively small population and hasn’t been the most attractive for insurance providers — few companies currently offer plans on the ACA exchange — and he worried any increase in the uninsured rate would “collapse the insurance market.”

As the uninsured rate rises in non-expansion states and the budget law’s Medicaid cuts loom, lawmakers say state funds will not backfill the loss of federal dollars, including in states that have refused to expand Medicaid.

Those states got slightly favorable treatment under the law, but it’s not enough, said Grace Hoge, press secretary for Kansas Gov. Laura Kelly, a Democrat who favors Medicaid expansion but who has been rebuffed by GOP state legislators.

“Kansans’ ability to access affordable healthcare will be harmed,” Hoge said in an email. “Kansas, nor our rural hospitals, will not be able to make up for these cuts.”

For hospital leaders in other states that have refused full Medicaid expansion, the budget law poses another test by limiting financing arrangements states leveraged to make higher Medicaid payments to doctors and hospitals.

Beginning in 2028, the law will reduce those payments by 10 percentage points each year until they are closer to what Medicare pays.

Richard Roberson, president of the Mississippi Hospital Association, said the state’s use of what’s called directed payments in 2023 helped raise its Medicaid reimbursements to hospitals and other health institutions from $500 million a year to $1.5 billion a year. He said higher rates helped Mississippi’s rural hospitals stay open.

“That payment program has just been a lifeline,” Roberson said.

The budget law includes a $50 billion fund intended to insulate rural hospitals and clinics from its changes to Medicaid and the ACA. But a KFF analysis found it would offset only about one-third of the cuts to Medicaid in rural areas.

Trump encouraged Florida, Tennessee, and Texas to continue refusing Medicaid expansion in his first term, when his administration gave them an unusual 10-year extension for financing programs known as uncompensated care pools, which generate billions of dollars to pay hospitals for treating the uninsured, said Allison Orris, director of Medicaid policy for the left-leaning think tank Center on Budget and Policy Priorities.

“Those were very clearly a decision from the first Trump administration to say, ‘You get a lot of money for an uncompensated care pool instead of expanding Medicaid,’” she said.

Those funds are not affected by Trump’s new tax-and-spending law. But they do not help patients the way insurance coverage would, Orris said. “This is paying hospitals, but it’s not giving people health care,” she said. “It’s not giving people prevention.”

States such as Florida, Georgia, and Mississippi have not only turned down the additional federal funding that Medicaid expansion brings, but most of the remaining non-expansion states spend less than the national average per Medicaid enrollee, provide fewer or less generous benefits, and cover fewer categories of low-income Americans.

Mary Mayhew, president of the Florida Hospital Association, said the state’s Medicaid program does not adequately cover children, older people, and people with disabilities because reimbursement rates are too low.

“Children don’t have timely access to dentists,” she said. “Expectant moms don’t have access nearby to an OB-GYN. We’ve had labor and delivery units close in Florida.”

She said the law will cost states more in the long run.

“The health care outcomes for the individuals we serve will deteriorate,” Mayhew said. “That’s going to lead to higher cost, more spending, more dependency on the emergency department.”

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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The Host Emmarie Huetteman KFF Health News Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and KFF Health News’ “What the Health?” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail. 

Health and Human Services Secretary Robert F. Kennedy Jr.’s announcement that the federal government will cancel nearly $500 million in mRNA research funding is unnerving not only for those who develop vaccines, but also for public health experts who see the technology behind the first covid-19 shots as the nation’s best hope to combat a future pandemic.

And President Donald Trump is demanding that major pharmaceutical companies offer many American patients the same prices available to patients overseas. It isn’t the first time he’s made such threats, and drugmakers — who scored a couple of wins against Medicare negotiations in the president’s tax and spending law — are unlikely to volunteer to drop their prices.

This week’s panelists are Emmarie Huetteman of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.

Panelists Sarah Karlin-Smith Pink Sheet @SarahKarlin @sarahkarlin-smith.bsky.social Read Sarah's stories. Sandhya Raman CQ Roll Call @SandhyaWrites @SandhyaWrites.bsky.social Read Sandhya's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• Explaining the decision to cancel some mRNA vaccine funding, a priority for vaccine critics, Kennedy falsely claimed that the technology is ineffective against respiratory illnesses. Researchers have been making headway into mRNA vaccines for maladies such as bird flu and even cancer, and the Trump administration’s opposition to backing vaccine development weakens the prospects for future breakthroughs.
• Trump’s insistence that big-name drugmakers voluntarily lower their prices underscores how few tools the presidency has to deliver results on this important pocketbook issue for many Americans. Medicare’s ability to negotiate drug prices took a hit under Trump’s big tax-and-spending law, which included two provisions advocated by the pharmaceutical industry that would delay or exclude some expensive drugs from the dealmaking process.
• A year after Trump promised on the campaign trail to secure coverage of in vitro fertilization, the White House reportedly is not planning to compel insurers to pay for those pricey reproductive services — a change that would require an act of Congress and could raise costs overall.
• And with Congress back home for its August recess and a late September deadline looming, the annual government funding process is in progress — but unlikely to resolve quickly or cleanly. Senate appropriators are further along in their work than usual, but the House of Representatives has yet to release its version, which is expected to cut deeper and hit social issues like abortion harder.

Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too: 

Emmarie Huetteman: KFF Health News’ “New Medicaid Federal Work Requirements Mean Less Leeway for States,” by Katheryn Houghton and Bram Sable-Smith. 

Sarah Karlin-Smith: Slate’s “Confessions of a Welfare Queen,” by Maria Kefalas. 

Sandhya Raman: CQ Roll Call’s “Sweden’s Push for Smokeless Products Leads Some To Wonder About Risks,” by Sandhya Raman. 

Lauren Weber: The New York Times’ “‘Hot Wasps’ Found at Nuclear Facility in South Carolina,” by Emily Anthes. 

Also mentioned in this week’s podcast:

• The Washington Post’s “How RFK Jr.’s mRNA Crackdown Affects Vaccinemaking and Future Pandemics,” by Carolyn Y. Johnson and Lauren Weber.
• The AP’s “Fact Focus: Trump Says He’s Cut Drug Prices By Up to 1,500%. That’s Not Possible,” by Melissa Goldin.
• The Washington Post’s “Medicare, Medicaid Plan To Experiment with Covering Weight Loss Drugs,” by Paige Winfield Cunningham.
• The Washington Post’s “White House Has No Plan To Mandate IVF Care, Despite Campaign Pledge,” by Riley Beggin and Jeff Stein.

Credits Francis Ying Audio producer Stephanie Stapleton Editor

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As the federal government reworks rules for a $42 billion broadband expansion program, millions of Americans live in places where there aren’t enough health care providers and internet speeds aren’t good enough for telehealth. A KFF Health News analysis found people in these “dead zones” live sicker and die younger on average than their peers in well-connected regions.

KFF Health News has partnered with InvestigateTV to tell the stories of residents whose health care falls into the gap. InvestigateTV’s Caresse Jackman and KFF Health News’ Sarah Jane Tribble take viewers to Alabama, Idaho, and West Virginia to explain why those connectivity gaps persist.

Explore the full investigation here.

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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WATERLOO, Iowa — John-Paul Sager appreciates the care he has received at Department of Veterans Affairs hospitals and clinics, but he thinks it should be easier for veterans like him to use their benefits elsewhere.

Sager, a Marine Corps and Army veteran, uses his VA coverage for non-VA treatment of back injuries stemming from his military service. But he said he sometimes must make several phone calls to obtain approval to see a local chiropractor. “It seems like it takes entirely too long,” he said.

Many veterans live hours from VA facilities, or they need health services that aren’t readily available from the VA. In such cases, the department is supposed to provide a referral and pay for private care. Critics say it often hesitates to do so.

Republicans controlling Congress aim to streamline the process of obtaining what is known as community care.

Two Republican senators have introduced legislation that would make it easier for rural veterans to seek care at local hospitals and clinics. The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump’s first term.

Critics worry that steering veterans to private care facilities drains federal money from the VA hospital and clinic system. But supporters say veterans shouldn’t be forced to travel long distances or wait months for the treatment they could obtain at local hospitals and clinics.

“My main concern is for veterans, not for the VA,” Sen. Kevin Cramer (R-N.D.) told KFF Health News. “I don’t believe we have an obligation to sustain the bureaucracy.”

About 9 million veterans are enrolled in the VA health system. Last year, about 3 million of them — including 1.2 million rural veterans — used their benefits to cover care at non-VA facilities, according to data provided by the department.

Cramer sponsored a bill that would allow veterans who live within 35 miles of a rural, “critical access” hospital to use VA benefits to cover care there or at affiliated clinics without referrals from VA staff.

Cramer, who serves on the Senate Veterans’ Affairs Committee, noted his state has just one VA hospital. It’s in Fargo, on the state’s eastern border, which is more than 400 miles by car from parts of western North Dakota.

Many North Dakota veterans drive past multiple community hospitals to get to the VA hospital for treatment, he said. Meanwhile, many rural hospitals are desperate for more patients and income. “I kept thinking to myself, ‘This doesn’t make any sense at all,’” Cramer said.

Cramer said previous laws, including the VA Mission Act, made it easier for veterans to use their benefits to cover care at community hospitals and clinics.

But he said veterans still must fill out too much paperwork and obtain approval from VA staffers to use non-VA facilities.

“We can’t let the VA itself determine whether a veteran is qualified to receive local care,” he said.

U.S. Rep. Mark Takano of California, who is the top Democrat on the House Veterans’ Affairs Committee, said he sees the need for outside care for some veterans. But he contends Republicans are going overboard in shifting the department’s money to support private health care facilities.

The VA provides specialized care that responds to veterans’ needs and experiences, he argues.

“We must prevent funds from being siphoned away from veterans’ hospitals and clinics, or VA will crumble,” Takano said in a statement released by his office. “Veterans cannot afford for us to dismantle VA direct care in favor of shifting more care to the community.”

Some veterans’ advocacy groups have also expressed concerns.

Jon Retzer, deputy national legislative director for the Disabled American Veterans, said the group wants to make it easier for veterans to find care. Rural and female veterans can have a particularly tough time finding appropriate, timely services at VA hospitals and clinics, he said. But the Disabled American Veterans doesn’t want to see VA facilities weakened by having too much federal money diverted to private hospitals and clinics.

Retzer said it’s true that patients sometimes wait for VA care, but so do patients at many private hospitals and clinics. Most delays stem from staff shortages, he said, which afflict many health facilities. “This is a national crisis.”

Retzer said the Disabled American Veterans favors continuing to require referrals from VA physicians before veterans can seek VA-financed care elsewhere. “We want to ensure that the VA is the primary provider of that care,” he said.

Veterans Affairs Secretary Doug Collins has pledged to improve the community care program while maintaining the strength of the department’s hospitals and clinics. The department declined a KFF Health News request to interview Collins.

Marcus Lewis, CEO of First Care Health Center, which includes a hospital in Park River, North Dakota, supports Cramer’s bill. Lewis is a Navy veteran who uses the VA’s community care option to pay for treatment of a back injury stemming from his military service.

Overall, Lewis said, the community care program has become easier to use. But the application process remains complicated, and participants must repeatedly obtain VA referrals for treatment of chronic issues, he said. “It’s frustrating.”

Park River is a 1,400-person town about 50 miles south of the Canadian border. Its 14-bed hospital offers an array of services, including surgery, cancer care, and mental health treatment. But Lewis regularly sees a VA van picking up local veterans, some of whom travel 140 miles to Fargo for care they’re entitled to receive locally.

“I think a lot of folks just don’t want to fight the system,” he said. “They don’t want to go through the extra hoops, and so they’ll jump in the van, and they’ll ride along.”

Rep. Mike Bost (R-Ill.), chairman of the House Veterans’ Affairs Committee, said veterans in some areas of the country have had more trouble than others in getting VA approval for care from private clinics and hospitals.

Bost helped gain the House’s approval for Trump’s request for $34.7 billion for the community care program in 2026. Although spending on the program has gone up and down in recent years, the appropriation represents an increase of about 50% from what it was in 2025 and 2022. The Senate included similar figures for next year in its version of a military spending budget that passed Aug. 1.

Bost also co-sponsored a House bill that would spell out requirements for the VA to pay for community care.

Sager hopes the new proposals make life easier for veterans. The Gulf War veteran lives in the northeastern Iowa town of Denver. He travels about 15 miles to Waterloo to see a chiropractor, who treats him for back and shoulder pain from injuries he suffered while training Saudi troops in hand-to-hand combat.

Sager, who remains active in the Army Reserve, also visits a Waterloo outpatient clinic run by the VA, where his primary care doctor practices. He appreciates the agency’s mission, including its employment of many veterans. “You just feel like you’re being taken care of by your own,” he said.

He believes the VA can run a strong hospital and clinic system while offering alternatives for veterans who live far from those facilities or who need care the VA can’t promptly provide.

The local VA doesn’t offer chiropractic care, so it pays for Sager to visit the private clinic. But every few months, he needs to obtain fresh approval from the VA. That often requires several phone calls, he said.

Sager is one of about a dozen veterans who use the community care program to pay for visits at Vanderloo Chiropractic Clinic, office manager Linda Gill said.

Gill said the VA program pays about $34 for a typical visit, which is comparable to private insurance, but the paperwork is more burdensome. She said leaders of the chiropractic practice considered pulling out of the VA program but decided to put up with the hassles for a good cause. She wishes veterans didn’t have to jump through so many hoops to obtain convenient care.

“After what they’ve done for us? Please,” she said.

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HHS announced the beginning of a coordinated wind-down of its mRNA vaccine development activities under the Biomedical Advanced Research and Development Authority.

Cuando el presidente Donald Trump firmó una ley que agrega requisitos laborales para algunos beneficiarios de Medicaid, es posible que haya perjudicado a legisladores de al menos 14 estados que estaban diseñando sus propios planes, según observadores del sector de salud.

Georgia es el único estado con un requisito laboral para Medicaid, pero varios estados llevan años intentando implementarlo, solo para ser bloqueados por los tribunales o, más recientemente, por la administración Biden.

Algunos buscan modificaciones específicas a las nuevas normas para cada estado. Otros pretenden implementar los requisitos laborales antes de que la ley federal entre en vigencia a finales de 2026.

Las acciones de estos estados y la enorme ley de impuestos y gastos de Trump comparten una exigencia: para mantener la cobertura de Medicaid, los adultos que puedan trabajar deben demostrar que lo están haciendo por un mínimo de horas en un trabajo o estudiando, o bien calificar para una de las pocas exenciones.

Pero ahora, los estados que se adelantaron deben asegurarse de que sus propuestas, que requieren aprobación federal, no se alejen demasiado de la ley de Trump.

“El estatuto establece el mínimo y el máximo” para los requisitos laborales, afirmó Sara Rosenbaum, profesora de derecho y políticas sanitarias de la Universidad George Washington.

Por ejemplo, Dakota del Sur anunció en julio que no presentaría una solicitud para los requisitos laborales como se había planeado previamente, ante la preocupación de que las normas estatales, menos estrictas, no se permitieran bajo la nueva ley federal. El secretario del Departamento de Servicios Sociales del estado advirtió que trabajar en una propuesta estatal mientras se debatían las normas federales podría ser “un ejercicio inútil”.

El plan de Arkansas, por otro lado, es más estricto que la ley federal. No hay exenciones a sus requisitos laborales en la solicitud, que está pendiente en los Centros de Servicios de Medicare y Medicaid (CMS).

La propuesta de Arizona también incluye algo que no está en la ley federal: la prohibición de que los “adultos sin discapacidad” reciban beneficios de Medicaid por más de cinco años en total a lo largo de su vida.

Funcionarios gubernamentales de Arkansas y Arizona afirmaron estar trabajando con funcionarios federales para adecuar sus planes a las nuevas normas.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS), afirmó que el departamento está analizando cómo interactúan las nuevas normas federales con las exenciones estatales.

El HHS debe publicar, antes de junio del próximo año, las normas que describan cómo los estados implementarán los requisitos laborales, según Elizabeth Hinton, quien ha monitoreando estas exenciones como parte del Programa de Medicaid y Personas sin Seguro de KFF, una organización sin fines de lucro dedicada a la información de salud que incluye a KFF Health News.

“No sabemos exactamente qué cubrirá”, declaró Hinton.

Hinton agregó que no está claro cómo responderán los funcionarios federales a las solicitudes de los estados, pero dijo que “somos conscientes de que algunos piensan que no hay margen de maniobra”.

Los estados pueden ajustar sus programas de Medicaid mediante las llamadas “exenciones de demostración”, sujetas a la aprobación federal. Estas exenciones están diseñadas para probar nuevas ideas en áreas política “grises”.

Los estados que han presentado o planean presentar solicitudes con requisitos laborales incluyen: Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Montana, New Hampshire, Carolina del Norte, Ohio, Carolina del Sur, Dakota del Sur y Utah.

Los republicanos del Congreso que aprobaron el proyecto de ley de reconciliación presupuestaria permitieron a los estados utilizar exenciones para acelerar la aplicación de las normas nacionales. Tara Sklar, profesora a cargo del Programa de Derecho y Políticas de Salud de la Universidad de Arizona, afirmó que espera que los estados que soliciten requisitos más estrictos tengan posibilidades de ser aprobados, mientras que los más flexibles podrían ser rechazados.

Sklar dijo que oficiales federales podrían ver con buenos ojos el plan de Arizona, ya que un límite vitalicio de cinco años para Medicaid es diferente a los requisitos laborales. Incluso si el gobierno federal aprueba estos requisitos más estrictos que los que exige la ley federal, es probable que esos programas enfrenten impugnaciones legales, afirmó.

La ley federal incluye un mínimo de 80 horas mensuales para trabajar o estudiar, con exenciones para ciertos adultos, como personas con problemas médicos delicados y padres con hijos pequeños dependientes.

Montana es el primer estado en redactar una solicitud de exención desde que el Congreso finalizó los requisitos laborales nacionales. Legisladores estatales aprobaron inicialmente los requisitos laborales —denominados estándares de “participación comunitaria” según el plan estatal— en 2019, pero la solicitud del estado se estancó hasta el final del primer mandato de Trump y durante la administración Biden.

Luego de la reelección de Trump, los legisladores de Montana levantaron la fecha de vencimiento de 2025 de su programa de expansión de Medicaid, declarando permanente el programa que cubría a más de 76.000 adultos en abril, con la expectativa de que la administración Trump aprobara los requisitos laborales.

A mediados de julio, las autoridades estatales publicaron su plan preliminar para hacerlo realidad “tan pronto como sea posible”.

El plan de Montana se alinea en gran medida con la ley federal, pero crearía exenciones adicionales, incluso para personas sin hogar o que huyen de la violencia doméstica.

La senadora estatal republicana Gayle Lammers afirmó que los requisitos laborales que también protegen a las personas que necesitan Medicaid fueron un factor clave para persuadir a los legisladores a mantener el programa de expansión. En ese momento, las autoridades desconocían la postura del gobierno federal sobre los requisitos laborales. Y ahora, según Lammers, tiene sentido que Montana se apegue a su plan.

“El estado debería tener voz y voto”, afirmó Lammers. “Somos muy independientes y cada persona es diferente”.

En Carolina del Sur, las autoridades estatales buscan implementar requisitos laborales para un número limitado de nuevos beneficiarios de Medicaid elegibles. Carolina del Sur es uno de los 10 estados que no ha ampliado la elegibilidad para Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Sin embargo, en junio presentó una solicitud al gobierno federal para una expansión parcial de Medicaid que incluye un componente de requisito de trabajo que refleja en gran medida las nuevas normas federales.

En una carta al Secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., el gobernador de Carolina del Sur, el republicano Henry McMaster, calificó la propuesta estatal como “una solución específica para el estado”.

El único estado con un programa de requisito de trabajo activo ahora quiere reducirlo y espera la aprobación federal para hacerlo. “Georgia Pathways to Coverage” vence a finales de septiembre a menos que los CMS autoricen una extensión del programa con un cambio clave: exigir a los afiliados que documenten su trabajo una vez al año, no mensualmente. Esto representa un cambio con respecto al diseño inicial del programa, pero también difiere de las nuevas normas federales, que exigen verificaciones cada seis meses.

Fiona Roberts, vocera de la agencia de Medicaid de Georgia, afirmó que el estado aún espera saber si necesita modificar su plan.

Por lo tanto, Georgia se encuentra entre los estados en estado de incertidumbre, a la espera de la orientación del gobierno federal.

Los corresponsales de KFF Health News, Sam Whitehead y Lauren Sausser, contribuyeron con este informe.

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When President Donald Trump signed a law adding work requirements for some Medicaid recipients, he may have undercut lawmakers in at least 14 states who were designing their own plans, according to health industry observers.

Georgia is the only state with a work requirement in place for Medicaid, but several states have been pursuing such a policy for years, only to be blocked by courts or, most recently, the Biden administration. Some seek state-specific touches to the new rules. Others aim to implement work requirements before the federal law takes effect at the end of 2026.

These states’ moves and Trump’s massive tax-and-spending law share one demand: To keep their Medicaid health coverage, adults who can work must prove they’re logging a minimum number of hours at a job or school, or else qualify for one of the few exemptions.

But now, states that jumped ahead need to ensure their proposals, which require federal approval, don’t stray too far from Trump’s law.

“The statute sets both the floor and ceiling” for work requirements, said Sara Rosenbaum, a health law and policy professor with George Washington University.

South Dakota, for example, announced in July that it would not submit an application for work requirements as previously planned amid concerns that the state’s laxer rules would not be allowed under the new federal law. The state’s Department of Social Services secretary had warned that working on a state proposal while the federal rules are being hashed out could be “an exercise in futility.”

Arkansas’ plan, on the other hand, is more stringent than the federal law. There are no exemptions to its work requirements in the application, which is pending with the Centers for Medicare & Medicaid Services.

Arizona’s proposal also includes something that’s not in the federal law: a ban on “able-bodied adults” receiving Medicaid benefits for longer than five years total in their lives.

Arkansas and Arizona government officials said they were working with federal officials to square their plans with the new standards.

Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, said the department is analyzing how the new federal standards interact with state waivers.

The federal health department must release rules by next June that outline how states are to implement work requirements, according to Elizabeth Hinton, who has been tracking such waivers as part of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News.

“We don’t exactly know what that will cover,” Hinton said.

It’s unclear how federal officials will respond to the states’ requests, she added, but “we are aware that some folks think there is no wiggle room here.”

States can tweak their Medicaid programs through what are known as demonstration waivers, which are subject to federal approval. The waivers are designed to test new ideas in policy gray areas.

The states that have filed or plan to file such applications with work requirements include Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Montana, New Hampshire, North Carolina, Ohio, South Carolina, South Dakota, and Utah.

Congressional Republicans who passed the budget reconciliation bill left room for states to use waivers to fast-track the national standards. Tara Sklar, a professor leading the University of Arizona’s Health Law & Policy Program, said she expects states seeking certain stricter requirements to have a chance of approval, while more lenient ones may face denials.

Federal officials may look favorably on Arizona’s plan, Sklar said, as a five-year lifetime Medicaid limit is different from work requirements. Even if the federal government greenlights stricter work requirements than the federal law calls for, those programs are likely to face legal challenges, she added.

The federal law includes an 80-hour-per-month minimum for work or education, with exemptions for certain adults, including people who are medically frail and parents with young, dependent children.

Montana is the first state to draft a waiver application since Congress finalized national work requirements. State lawmakers first approved work requirements — called “community engagement” standards under the state plan — in 2019, but the state’s application stalled through the end of the first Trump term and the Biden administration.

After Trump was elected again, Montana lawmakers lifted the 2025 expiration date of its Medicaid expansion program, making permanent the program that covered more than 76,000 adults in April, with the expectation that the Trump administration would approve work requirements. In mid-July, state officials released their draft plan to make that a reality “as soon as is practicable.”

The Montana plan largely aligns with the federal law, but it would create additional exemptions, including for people who are homeless or fleeing domestic violence.

Republican state Sen. Gayle Lammers said work requirements that also protect such people who need Medicaid were a big part of persuading legislators to keep the expansion program. At the time, officials didn’t know where the federal government would land on work requirements. And now, Lammers said, it makes sense for Montana to stick to its plan.

“The state should have a say,” Lammers said. “We’re very independent, and everyone is different.”

In South Carolina, state officials are seeking to roll out work requirements for a limited number of newly eligible Medicaid beneficiaries. South Carolina is one of 10 states that has not expanded Medicaid eligibility under the Affordable Care Act, and yet the state submitted a request with the federal government in June for a partial Medicaid expansion that includes a work requirement component that largely reflects the new federal standards.

In a letter to Health and Human Services Secretary Robert F. Kennedy Jr., South Carolina Gov. Henry McMaster, a Republican, called South Carolina’s proposal “a state-specific solution.”

The only state with an active work requirement program now wants to scale it back and awaits federal approval to do so. “Georgia Pathways to Coverage” expires at the end of September unless CMS greenlights an extension of the program with a key change: requiring enrollees to document once a year that they’re working, not monthly. That’s a pivot away from the program’s initial design but also differs from the new federal rules, which call for checks every six months.

Fiona Roberts, a spokesperson for Georgia’s Medicaid agency, said the state is still waiting to hear whether it needs to alter its plan.

So Georgia is among the states in limbo, awaiting guidance from the federal government.

KFF Health News correspondents Sam Whitehead and Lauren Sausser contributed to this report.

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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SACRAMENTO, Calif. — As smoke from Canadian wildfires drifted across North America, and western U.S. states girded for their annual fire siege, Neeta Thakur was well into her search for ways to offset the damage of such fumes on people’s health, especially among minority and low-income communities.

For more than a decade, the University of California-San Francisco researcher relied on federal grants without incident. But Thakur, a doctor and a scientist, suddenly found herself leading the charge for public health science against President Donald Trump’s political ideology.

Thakur, 45, a pulmonologist who also is medical director of the Zuckerberg San Francisco General Hospital Chest Clinic, is the lead plaintiff among six UC researchers who in June won a class-action preliminary injunction against the efforts of several federal agencies to carry out Trump’s executive orders seeking to eliminate research grants deemed to focus on areas of diversity, equity, and inclusion. The administration has filed a notice of appeal, and the outcome, whether or not she and her colleagues prevail, could influence both the future of academic research and the health of those she’s spent her life trying to help.

“When this moment hit us, where science was really under attack and lives are at stake, it doesn’t surprise me that she stepped up,” said Margot Kushel, who directs the UCSF Action Research Center for Health Equity and has known Thakur for more than a decade through their work at the center and San Francisco General, the public county hospital.

“We don’t think our work should be political, to be honest,” Kushel said. “Saving people’s lives and making sure people don’t die doesn’t seem to me that it should be a partisan issue.”

Thakur said that after the abrupt funding cuts, she and the other researchers “felt pretty powerless and found that the class-action lawsuit was a way for us to join together and sort of take a stance.”

The suit was filed independently by the researchers and allowed them to show the harm inflicted not just on their own work “but more broadly on public health and public health research,” she said.

Thakur’s study, which received more than $1.3 million in funding from the Environmental Protection Agency and was set to run through November, explores the impact of increased wildfire smoke on low-income communities and communities of color, populations that already experience heightened pollution and other environmental health disparities. The goal is to find ways to help residents limit their smoke exposure, Thakur said, adding that the results could help people no matter their circumstances.

Preliminary findings show that smoke can trigger breathing emergencies among children days after exposure, knowledge that could lead to better treatment, and that smoke intensity may peak during just a few hours when protection is most needed, indicating the need for more precise and timely safety messaging.

Thakur said her studies on health equity and health disparities saw growing federal support during the covid pandemic and a national focus on racism spurred by the murder of George Floyd. The EPA had solicited the grant in 2021 for her and her team to research how climate change affects underserved communities.

Trump, in one of several executive orders blocking federal funding for DEI programs, said they “use dangerous, demeaning, and immoral race- and sex-based preferences” that he said have “prioritized how people were born instead of what they were capable of doing.”

EPA Administrator Lee Zeldin said in March that, in cooperation with the Department of Government Efficiency, the administration had canceled more than 400 grants topping $2 billion “to rein in wasteful federal spending.”

The order by U.S. District Judge Rita Lin in San Francisco temporarily blocking the grant terminations covered the EPA, as well as grants by the National Endowment for the Humanities and the National Science Foundation. Lin’s ruling was not a nationwide injunction of the sort restricted by the U.S. Supreme Court in a June decision.

The Trump administration agencies affected by the order have reinstated the UC grants as the lawsuit proceeds. The government filed a motion for a temporary stay on the order pending the outcome of its appeal, but a decision had not been issued as of publication.

The EPA declined to comment on the judge’s order blocking the attempted cancellation of the research funding, citing the ongoing litigation, and attorneys representing the government did not respond to requests for comment.

Thakur defends the need for research that spotlights disadvantaged communities. Her interest in health equity stems from childhood experiences. The daughter of immigrants from India, with a physician and an engineer as parents, she grew up relatively well-off in a mixed-income neighborhood in Phoenix. While she prospered, however, she had friends who couldn’t afford college or became pregnant as teenagers.

“I see my research being directed towards trying to understand how where you live and what you experience impacts your health,” Thakur said.

When the grants were suspended in April, the researchers were unable to finish identifying ways to help protect communities from wildfire smoke. Thakur had to dismiss a student intern and dip into discretionary funds to pay her postdoctoral fellow. At least three research papers that could have directly affected public health were in danger of going unpublished without the funding, she said.

The government reinstated her team’s grants about three weeks after the judge’s order, and Thakur is in the process of picking up the pieces. She’s hopeful that researchers can publish two of the three studies they were working on.

Thakur said she is now cautiously optimistic after experiencing “a roller coaster of emotions.” Putting together a project and conducting the research takes years, she said, so “to have all of that end suddenly, it brought me a range of emotions one thinks about when folks are experiencing grief. There’s denial, anger.”

But the Trump administration’s actions have already sapped morale in the field. Rebecca Sugrue, Thakur’s postdoctoral fellow and an expert in health equity and climate change, is rethinking her entire career path.

“I kind of came to the realization that all the expertise I had built up were the kind of things that were being deprioritized,” Sugrue said. She said she and other postdoctoral students and more junior members of the research team even had discussions about leaving academia: “‘Unstable’ and ‘uncertain’ were words that were used a lot.”

The lasting damage is not lost on Thakur. If the grants ultimately disappear, universities won’t have the typical programs to train students or to support academic research, she said, adding that, “I think there are concerns that the sort of divestment from science and research in these particular areas will cause generations of impact.”

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

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HHS Secretary Kennedy, Jr. and FDA Commissioner Dr. Makary joined Secretary of Agriculture Rollins to celebrate her signing of six new SNAP state waiver.

Sean Keveney has been appointed Chief Counsel at the FDA.

Si quieres vacunarte contra covid-19 este otoño, ¿lo cubrirá el seguro médico de tu empleador? No hay una respuesta clara.

El secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., un veterano activista antivacunas, ha modificado radicalmente la forma en que se aprueban estas vacunas, y para quiénes se recomiendan, creando incertidumbre cuando la cobertura era rutinaria.

Las agencias dentro del Departamento de Salud y Servicios Sociales (HHS)  responsables de especificar quién debe vacunarse no están necesariamente sincronizadas, emitiendo recomendaciones en apariencia contradictorias basadas en la edad o los factores de riesgo de enfermedades graves.

Pero la ambigüedad podría no afectar tu cobertura, al menos este año.

“Creo que en 2025 es muy probable que los planes de las empresas cubran las vacunas contra covid-19”, afirmó Jeff Levin-Scherz, médico de atención primaria, líder de salud poblacional de la consultora de gestión WTW y profesor adjunto de la Escuela de Salud Pública T.H. Chan de la Universidad de Harvard.

Ya lo han presupuestado, “y sería un gran esfuerzo administrativo intentar excluir la cobertura para quienes no tienen mayor riesgo”, dijo.

Con tantos cambios, es importante consultar con tu empleador o aseguradora sobre las políticas de cobertura antes de arremangarte la camisa.

Esto es lo que sabemos hasta ahora y lo que aún no está claro.

¿Cómo han cambiado las recomendaciones?

Lo que antes era sencillo ahora es mucho más confuso. El año pasado, las vacunas contra covid de Moderna y Pfizer-BioNTech se recomendaron para cualquier persona a partir de los 6 meses de edad.

Este año, la recomendación de los Centros para el Control y Prevención de Enfermedades (CDC) es más restringida. Aunque las vacunas se recomiendan ampliamente para adultos mayores de 19 años, ya no para embarazadas sanas ni para niños y adolescentes sanos de 6 meses a 17 años.

Kennedy anunció los cambios en un video en mayo, citando como justificación los riesgos de seguridad para los jóvenes y las embarazadas.

Sin embargo, sus afirmaciones han sido ampliamente cuestionadas por expertos en vacunas, pediatría y salud femenina. Un análisis de FactCheck.org reveló que el secretario “tergiversó la investigación científica para hacer afirmaciones infundadas sobre la seguridad de las vacunas para embarazadas y niños”.

Además, los cambios anunciados recientemente en el marco de aprobación de vacunas han reducido aún más la elegibilidad.

Moderna anunció el 10 de julio que la Administración de Drogas y Alimentos (FDA) había aprobado completamente su vacuna contra covid Spikevax, pero la aprobación está restringida a adultos mayores de 65 años y a personas de entre 6 meses y 64 años que tienen un mayor riesgo de desarrollar un caso grave de covid.

Otras dos vacunas contra covid que se espera estén disponibles este otoño, Nuvaxovid de Novavax y mNexspike de Moderna, también tienen restricciones. Están aprobadas para personas mayores de 65 años y para aquellas de entre 12 y 64 años que tienen afecciones subyacentes que las aumentan el riesgo de desarrollar covid grave.

Por ahora,  la vacuna contra covid Comirnaty de Pfizer sigue aprobada o autorizada a partir de los 6 meses sin ninguna restricción basada en factores de riesgo para covid.

Sin embargo, la FDA podría cambiar esto en cualquier momento, según expertos. El aumento de las restricciones “es definitivamente la dirección en la que se están moviendo”, afirmó Jen Kates, vicepresidenta sénior de KFF, autora de un análisis sobre las normas de cobertura del seguro de vacunas.

El HHS no ofreció comentarios oficiales para este artículo.

¿Cómo podrían estos cambios afectar mi cobertura para la vacuna?

Esa es la gran pregunta, y la respuesta es incierta. Sin cobertura, las personas podrían deber cientos de dólares por la vacuna.

La mayoría de los planes de salud privados están obligados por ley a cubrir las vacunas recomendadas, ya sea para covid, el sarampión o la gripe, sin cobrarles a sus miembros. Sin embargo, según el análisis de KFF, este requisito entra en vigencia después que un panel federal —el Comité Asesor sobre Prácticas de Inmunización (ACIP)— recomiende las vacunas y las adopte el director de los CDC.

El comité aún no ha votado sobre las recomendaciones de la vacuna contra covid para este otoño. Se espera que su próxima reunión sea en agosto o septiembre. Aun así, los empleadores y las aseguradoras pueden optar por cubrir las vacunas por su cuenta, como muchos lo hacían antes de que la ley los obligara. Sin embargo, podrían exigir a las personas que pagaran algo de sus bolsillos.

Además, las recomendaciones más restrictivas de las diferentes agencias del HHS podrían resultar en que algunos planes de salud se nieguen a pagar a ciertas categorías de personas para que reciban ciertas vacunas, según expertos.

“No creo que un empleador o una aseguradora nieguen la cobertura”, dijo Kates. “Pero podrían decir: debes tener este producto”.

Eso podría significar que una persona de 45 años sin afecciones subyacentes que aumenten su riesgo de covid podría tener que recibir la vacuna de Pfizer en lugar de la de Moderna si quiere que su plan de salud la cubra, dicen expertos.

Además, hasta 200 millones de personas podrían calificar para las vacunas porque tienen afecciones como asma o diabetes que aumentan su riesgo de enfermedad grave, según un comentario publicado por funcionarios de la FDA en el New England Journal of Medicine.

Profesionales de atención médica pueden ayudar a las personas a determinar si califican para la vacuna según sus afecciones de salud.

Tina Stow, vocera del America’s Health Insurance Plans (AHIP), que representa a los planes de salud, declaró que los planes seguirán cumpliendo con los requisitos federales para la cobertura de la vacuna.

¿Cuáles son las opciones para las personas embarazadas o con hijos que quieran vacunar?

Según una encuesta de KFF publicada el 1 de agosto, muchos padres tienen dudas sobre la vacunación de sus hijos. Aproximadamente la mitad afirmó desconocer si las agencias federales recomiendan que los niños sanos se vacunen este otoño. Entre la otra mitad, la mayoría dijo que no se recomienda la vacuna.

Mientras tanto, la recomendación de Kennedy de no vacunar a los niños sanos tiene una salvedad importante: si un padre quiere que su hijo se vacune contra covid y un profesional de salud lo recomienda, el niño puede recibirla bajo el modelo de “toma de decisiones clínicas compartidas” y debería estar cubierta sin costos compartidos.

Algunos expertos en políticas señalan que, de todos modos, esta es la forma en que se suele brindar atención a los niños. “Más allá de cualquier requisito, las vacunas siempre se han proporcionado con decisiones compartida”, afirmó Amanda Jezek, vicepresidenta sénior de políticas públicas y relaciones gubernamentales de la Infectious Diseases Society of America.

No existe una asignación similar para las personas embarazadas. Sin embargo, aunque Kennedy ha declarado que las vacunas contra covid ya no se recomiendan para embarazadas sanas, el embarazo es una de las afecciones médicas subyacentes que aumentan el riesgo de enfermarse gravemente por covid, según los CDC. Esto podría hacer que las embarazadas sean elegibles para la vacuna.

Dependiendo de la etapa del embarazo, podría ser difícil saber si se debe negar la vacuna a alguien debido a su condición. “Esto es un territorio desconocido”, afirmó Sabrina Corlette, codirectora del Center on Health Insurance Reforms de la Universidad de Georgetown.

¿Cómo afectarán estos cambios el acceso a la vacuna? ¿Podré seguir yendo a la farmacia para vacunarme?

“Si se espera que se vacunen muchas menos personas, menos centros ofrecerán las vacunas”, afirmó Levin-Scherz. Esto podría ser un obstáculo especialmente importante para quienes buscan dosis pediátricas de la vacuna contra covid.

Además, la autoridad de los farmacéuticos para administrar vacunas depende de varios factores. Por ejemplo, en algunos estados pueden administrar vacunas aprobadas por la FDA, mientras que en otros deben haber sido recomendadas por el ACIP, explicó Hannah Fish, directora sénior de iniciativas estratégicas de la National Community Pharmacists Association. Dado que el ACIP aún no ha recomendado las vacunas contra covid para el otoño, esto podría suponer un obstáculo en algunos estados.

“Dependiendo de las normas, es posible que aún se pueda obtener la vacuna en una farmacia, pero es posible que tengan que llamar al médico para que envíe una receta”, explicó Fish.

¿Qué significan estos cambios a largo plazo?

Es imposible saberlo. Pero dado el escepticismo sonoro de Kennedy sobre las vacunas y su aceptación de teorías refutadas desde hace tiempo sobre la conexión entre las vacunas y el autismo, entre otras cosas, a los profesionales médicos y de salud pública les preocupa que estas opiniones influyan en las políticas futuras.

“Los cambios en las recomendaciones que se hicieron con respecto a los niños y las mujeres embarazadas no se basaron necesariamente en una buena base científica”, dijo Corlette.

Convencer a la gente de que necesita la vacuna contra covid anualmente ya es un desafío, y los cambios en las directrices podrían dificultarlo aún más, advierten algunos expertos en salud pública.

“Lo preocupante es que esto podría reducir aún más la vacunación contra covid”, dijo Jezek.

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Now that the Republicans’ big tax-and-spending bill has become law, new bureaucratic hurdles have emerged for millions of Americans who rely on Medicaid for health coverage. A provision in the new law dictates that, in most states, for the first time, low-income adults must start meeting work requirements to keep their coverage.

Some states have already tried doing this, but Georgia is the only state that has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.

When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn’t opposed to work requirements — in principle.

But when she left her job at a faith-based nonprofit to start her own project, the Be Well Black Girl Initiative, she needed health coverage. She soon came face-to-face with how daunting it can be to prove you are meeting the state’s work requirements.

“I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I’m like, I know the process,” Corporal said. “I’ve been in human services.”

Corporal has been a social worker for more than two decades in Georgia and was familiar with the state’s social service programs. For years, it had been her job to help others access benefit programs.

But her challenges with paperwork and the process had only begun.

Health advocates point to Georgia’s system as a sign that the new law will lead to excessive red tape, improper denials, and lost health coverage.

Beginning in 2027, the law will require adults on Medicaid who are under 65 to report how they engaged in at least 80 hours per month of work, education, or volunteer activities. Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.

Most states will have to set up verification systems similar to Georgia’s, which can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data. More than $50 million of that was spent on building and operating the eligibility reporting system. Right now, just under 7,500 people are enrolled in Georgia.

For Corporal, 48, forgoing coverage wasn’t an option. She had been diagnosed with pre-diabetes and had other medical concerns.

“I have breast cancer in my family history,” she said. “So it was like, I gotta get my mammograms.”

On paper, it looked as if she qualified for Georgia’s program, called Georgia Pathways to Coverage.

It offers Medicaid to adults — who otherwise wouldn’t qualify for traditional Medicaid in Georgia — with incomes up to the federal poverty level ($15,650 per year for an individual, or $26,650 per year for a family of three), as long as they can show that for at least 80 hours a month they’re working, attending school, training for a job, or volunteering.

Corporal was eager to apply. She was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.

She gathered up the various documents and forms needed to verify her duties and volunteer hours, then submitted them through Georgia’s online portal.

“And we were denied. I was like, this makes no sense,” said Corporal, who has a master’s degree in social work. “I did everything right.”

In the end, it took eight months fighting to prove that she and her son, a full-time college student in Georgia, qualified for Medicaid. She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.

Corporal recently pulled up one of the denial notices on her cellphone to read aloud: “Your case was denied because you didn’t submit the correct documents. And you didn’t meet the qualifying activity requirement,” she read from the email.

When she tried to call the state Medicaid agency for answers, it was difficult reaching anyone who could explain what was wrong with her application paperwork, she said.

“Or, they’ll say they called you, and we look at our call log. Nobody called me,” she said. “And the letter will say, you missed your appointment, and it’ll come on the same day” as it was scheduled.

Corporal’s Pathways to Coverage application was finally approved in March after she spoke about her experience at a public hearing covered by Atlanta news outlets.

When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia’s Department of Human Services, emailed this statement: “Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case.”

Brown added that Georgia is implementing tech fixes to streamline the uploading and processing of participants’ documents. They include “rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents.”

Now that Corporal has coverage, she is having to recertify her volunteer hours every month using the same glitchy reporting system. It’s stressful, she said.

“It’s still a nightmare, even once I got through the red tape and got approved,” Corporal said. “Now maintaining it is bringing another level of anxiety.”

But she wonders how anyone without her professional background manages to get into the program at all.

“I think the system has to be simplified,” she said.

Because Georgia set up its work requirement before the recently passed law, it needed permission from the federal government through a special waiver.

It is now seeking an extension of that waiver to continue the Pathways program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to reverify their hours from once a month to once per year.

But for now, Corporal’s experience remains typical. And many health advocates fear it will be replicated under Trump’s budget law with its new national Medicaid work mandate. 

“In Georgia, we have seen that people just can’t get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn’t file their paperwork or there’s been some other glitch,” said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.

Another state, Arkansas, tried work requirements in 2018.

But it didn’t go any better there, said Joan Alker, who leads the Center for Children and Families at Georgetown University.

“A lot of the problems were similar to Georgia,” she said, “in terms of the website closed at night, people couldn’t get a hold of people.”

Some Republicans who backed the spending and tax legislation said the idea behind the national Medicaid work mandate was to ensure that as many people as possible who can work, do work. And to eliminate what the Trump administration deems waste, fraud, and abuse. 

“What we’re doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it,” U.S. House Speaker Mike Johnson said during a June appearance on “The Megyn Kelly Show.” “You’re talking about the elderly, disabled, you know, young single pregnant moms who are down on their luck, right? But it’s not being used for those purposes because it’s been expanded under the last two Democrat presidents and to cover everybody. So, you’ve got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we’re doing is restoring work requirements to Medicaid. OK, this is common sense.”

National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients ages 19-64 already have jobs. The remainder includes students, or those who are too sick or disabled to work.

“Work requirements don’t work, except to cut people off of health insurance,” she said.

The logistical steps required to report one’s activities assume that a recipient has reliable internet or transportation to travel to an agency — things that low-income Georgians may not have.

The paperwork requirements to gain coverage are time-consuming, said one Medicaid recipient, Paul Mikell.

Mikell is a licensed truck driver but does not have coverage through that job. He’s also an electrician who currently does property maintenance in exchange for free housing.

Mikell has had Medicaid through Pathways for nearly two years and has had problems navigating the Pathways web portal. 

“And I know it wasn’t my device because I would go to the library and use the computer, I would try different devices, and I’ve had the same issues,” he said. “Regardless of the device, it’s something with the website.”

Another time, he said, his attempt to recertify his work hours was delayed because of paperwork issues.

“They said I was ineligible for everything because of a typo in the system or something, I don’t know what it was. I eventually was able to speak to someone and she fixed it,” he said.

This article is from a partnership with WABE and NPR.

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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If you want a covid-19 shot this fall, will your employer’s health insurance plan pay for it? There’s no clear answer.

Health and Human Services Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist, has upended the way covid vaccines are approved and for whom they’re recommended, creating uncertainty where coverage was routine.

Agencies within HHS responsible for spelling out who should get vaccinated aren’t necessarily in sync, issuing seemingly contradictory recommendations based on age or risk factors for serious disease.

But the ambiguity may not affect your coverage, at least this year.

“I think in 2025 it’s highly likely that the employer plans will cover” the covid vaccines, said Jeff Levin-Scherz, a primary care doctor who is the population health leader for the management consultancy WTW and an assistant professor at Harvard’s T.H. Chan School of Public Health. They’ve already budgeted for it, “and it would be a large administrative effort to try to exclude coverage for those not at increased risk,” he said.

With so much in flux, it’s important to check with your employer or insurer about coverage policies before you roll up your sleeve.

Here’s what we know so far, and what remains unclear.

Q: How have the recommendations changed?

What used to be straightforward is now much murkier. Last year, the Moderna and Pfizer-BioNTech covid vaccines were recommended for anyone at least 6 months old.

This year, the recommendation by the Centers for Disease Control and Prevention is narrower. Although the vaccines are broadly recommended for adults 19 and older, they are no longer recommended for healthy pregnant people or for healthy children 6 months through 17 years old.

Kennedy announced the changes in a video in May, citing safety risks for young people and pregnant people as justification.

But his claims have been widely disputed by experts in vaccines, pediatrics, and women’s health. An analysis by FactCheck.org found that the secretary “misrepresented scientific research to make unfounded claims about vaccine safety for pregnant people and children.”

In addition, recently announced changes to the vaccine approval framework have further chipped away at eligibility.

Moderna announced July 10 that the FDA had fully approved its Spikevax covid vaccine — but approval is restricted to adults 65 and older, and for people from 6 months through 64 years old who are at increased risk of developing a serious case of covid.

Two other covid vaccines expected to be available this fall, Novavax’s Nuvaxovid and Moderna’s mNexspike, are also restricted. They are approved for people 65 or older and those 12 to 64 who have underlying health conditions that put them at higher risk of developing severe covid.

Notably, Pfizer’s Comirnaty covid vaccine is still approved or authorized for people 6 months of age and older without any restrictions based on risk factors for covid — at least for now. But the FDA could change that at any time, experts said.

Increasing restrictions “is definitely the direction they are moving,” said Jen Kates, a senior vice president at KFF who authored a KFF analysis of vaccine insurance coverage rules. KFF is a health information nonprofit that includes KFF Health News.

HHS did not provide an on-the-record comment for this article.

Q: How might these changes alter my insurance coverage for the vaccine?

That’s the big question, and the answer is uncertain. Without insurance coverage, people could owe hundreds of dollars for the shot.

Most private health plans are required by law to cover recommended vaccines, whether for covid, measles, or the flu, without charging their members. But that requirement kicks in after the shots are recommended by a federal panel — the Advisory Committee on Immunization Practices — and adopted by the CDC director, according to the KFF analysis. The committee hasn’t yet voted on covid vaccine recommendations for this fall. Its next meeting is expected to occur in August or September.

Still, employers and insurers can opt to cover the vaccines on their own, as many did before the law required them to do so. But they may require people to pay something for it.

In addition, the narrower recommendations from different HHS agencies might result in some health plans declining to pay for certain categories of people to get certain vaccines, experts said.

“I don’t think an employer or insurer would deny coverage,” Kates said. “But they could say: You have to get this product.”

That could mean a 45-year-old with no underlying health conditions raising their covid risk might have to get the Pfizer shot rather than the Moderna version if they want their health plan to pay for it, experts said.

In addition, up to 200 million people may qualify for the vaccines because they have health conditions such as asthma or diabetes that increase their risk of severe disease, according to a commentary published by FDA officials in the New England Journal of Medicine.

Health care professionals can help people determine whether they qualify for the shot based on health conditions.

Tina Stow, a spokesperson for AHIP, which represents health plans, said in a statement that plans will continue to follow federal requirements for vaccine coverage.

Q: What are the options for people who are pregnant or have children they want to have vaccinated?

Many parents are confused about getting their kids vaccinated, according to a KFF poll released on Aug. 1. About half say they don’t know whether federal agencies recommend healthy children get the vaccine this fall. Among the other half, more say the vaccine is not recommended than recommended.

Meanwhile, Kennedy’s recommendation that healthy children not get vaccinated has a notable caveat: If a parent wishes a child to get a covid vaccine and a health care provider recommends it, the child can receive it under the “shared clinical decision-making” model, and it should be covered without cost sharing.

Some policy experts point out that this is the way care for kids is typically provided anyway.

“Outside of any requirements, vaccines have always been provided through shared decision-making,” said Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America.

There’s no similar allowance for pregnant people. However, even though Kennedy has stated that covid vaccines are no longer recommended for healthy pregnant people, pregnancy is one of the underlying medical conditions that put people at high risk for getting very sick from covid, according to the CDC. That could make pregnant people eligible for the shot.

Depending on the stage of someone’s pregnancy, it could be difficult to know whether someone should be denied the shot based on their condition. “This is uncharted territory,” said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms.

Q: How will these changes affect access to the vaccine? Will I still be able to go to the pharmacy for the shot?

“If far fewer are expected to be vaccinated, fewer sites will offer the vaccinations,” Levin-Scherz said. This could be an especially notable hurdle for people looking for pediatric doses of a covid vaccine, he said.

In addition, pharmacists’ authority to administer vaccines depends on several factors. For example, in some states they can administer shots that have been approved by the FDA, while in others the shots must have been recommended by the ACIP, said Hannah Fish, senior director of strategic initiatives at the National Community Pharmacists Association. Since ACIP hasn’t yet recommended covid shots for the fall, that could create a speed bump in some states.

“Depending on the rules, you still may be able to get the shot at the pharmacy, but they might have to call the physician to send over a prescription,” Fish said.

Q: What do these changes mean long-term?

It’s impossible to know. But given Kennedy’s vocal skepticism of vaccines and his embrace of long-disproven theories about connections between vaccines and autism, among other things, medical and public health professionals are concerned those views will shape future policies.

“The recommendation changes that were made with respect to children and pregnant women were not necessarily made in good science,” Corlette said.

It’s already a challenge to convince people they need annual covid shots, and shifting guidelines may make it tougher, some public health experts warn.

“What’s concerning is that this could even further depress the uptake of the covid vaccines,” Jezek said.

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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HHS announced repeals of federal policy that financially rewarded hospitals for reporting staff vaccination rates.

A new breed of cosmetic surgery chains, some backed by private equity investors, are competing for a slice of the nation’s growing body-contouring market.

The chains sell an array of body-reshaping operations, such as “Mommy Makeovers” and liposuction, targeting customers willing to pay up to $20,000 out-of-pocket for a new figure.

A joint investigation by KFF Health News and NBC News found that cosmetic surgery chains have been the target of scores of medical malpractice and negligence lawsuits alleging disfiguring injuries — including 12 wrongful death cases filed over the past seven years.

Injured patients have accused the chains of hiring doctors with minimal cosmetic surgery training, of failing to recognize and treat life-threatening infections and other dangerous surgical complications, and of using high-pressure sales tactics that minimized safety risks, court records show. The companies have denied the allegations in court.

“These people promise to turn you into the fairest person in the land, and the risks aren’t often worth the reality,” said Sean Domnick, a Florida attorney who heads the American Association for Justice, a trial lawyers’ group.

Robert Centeno, a medical director for Sono Bello, the largest of the chains, disagrees. He said the company’s mission is to “help each and every one of our patients live their best lives now.” Sono Bello offers “life-changing transformations” that enhance a person’s “appearance as well as their quality of life,” said Centeno, a surgeon at the company’s Troy, Michigan, office. Sono Bello boasts it is “America’s top cosmetic surgery specialist.”

But many established plastic surgeons worry that chain surgery groups may be inclined to spend more effort on marketing and sales than on making sure their doctors are properly credentialed and capable of handling any complications that arise.

Medical practices owned by private equity or investment firms have more money to spend drawing in patients and “the ability to operate and provide quality patient care is now less important,” said Mark Domanski, a plastic surgeon in Northern Virginia.

Erin Schaeffer, 37, spent a week in a Florida hospital battling a severe infection after having a type of tummy tuck and liposuction at the Jacksonville branch of Sono Bello.

More than a year later, scars remain on her lower body. And in a lawsuit, she is accusing Sono Bello of using an obstetrician-gynecologist who was inadequately trained to remove her excess skin and fat, a procedure she says caused excruciating pain. Sono Bello and the doctor denied the allegations in a joint court filing.

“I literally felt like I was skinned alive,” Schaeffer said.

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 story can be republished for free (details).

Una larga lista de familiares paternos de Lynda Hollander padecían enfermedades cardíacas y varios habían tenido cirugías importantes. Por eso, cuando llegó a los 50 años y vio que sus niveles de colesterol aumentaban luego de la menopausia dijo que “no quería correr ningún riesgo”.

Un cardiólogo le explicó que, basándose en factores como la edad, el sexo, el colesterol y la presión arterial, tenía un riesgo moderado de sufrir un evento cardíaco grave, como un infarto, en los próximos 10 años.

Los médicos suelen aconsejar a estos pacientes sobre la importancia de la dieta y el ejercicio, pero Hollander, que ahora tiene 64 años y es trabajadora social en West Orange, Nueva Jersey, no tenía mucho margen de mejora. Ya era una corredora obstinada y, aunque “de vez en cuando me salto la dieta”, su alimentación era básicamente saludable. Los intentos por perder peso no redujeron su colesterol.

Su médico le dijo que una prueba de calcio en las arterias coronarias, algo de lo que Hollander nunca había oído hablar, podría proporcionar una estimación más precisa de su riesgo de padecer una enfermedad cardíaca aterosclerótica. Se trata de una tomografía computarizada breve e indolora que indicaría si se estaba desarrollando calcificaciones y placa en las arterias que llegan al corazón.

Cuando la placa se rompe, puede causar coágulos que bloquean el flujo sanguíneo y provocan ataques cardíacos. La tomografía ayudaría a determinar si a Hollander le beneficiaría tomar una estatina, que podría reducir la placa y prevenir su formación.

“Cada año, más personas se someten a esta prueba”, afirmó Michael Blaha, codirector del programa de cardiología preventiva de la Universidad Johns Hopkins. Según su equipo de investigación, las pruebas de calcio se cuadruplicaron entre 2006 y 2017, y las búsquedas en Google de términos relacionados han aumentado aún más.

Sin embargo, “sigue sin utilizarse lo suficiente teniendo en cuenta su valor”, agregó.

Una de las razones es que, aunque la prueba es relativamente barata (a veces cuesta hasta $300, pero a menudo $100 o menos), los pacientes suelen tener que pagarla de su bolsillo. Medicare rara vez la cubre, aunque algunos médicos dicen que debería.

Los pacientes con una puntuación CAC de cero (sin calcificación) tienen un riesgo menor que el indicado en sus evaluaciones iniciales y no son candidatos para tomar medicamentos que reducen el colesterol. Pero la puntuación de Hollander era de 50, no alta, pero tampoco insignificante.

“Fue el primer indicio de lo que estaba pasando dentro de mis arterias”, contó.

Aunque las directrices varían, los cardiólogos suelen ofrecer estatinas a los pacientes con puntuaciones de calcio superiores a cero y sugieren estatinas de mayor intensidad cuando las puntuaciones superan los 100.

Con una puntuación superior a 300, el riesgo de los pacientes se aproxima al de las personas que ya han sufrido un infarto, por lo que pueden necesitar un tratamiento aún más agresivo.

Desde entonces, Hollander toma una dosis baja de rosuvastatina (nombre comercial: Crestor), complementada con un fármaco no estatínico, una inyección llamada evolocumab (Repatha).

Así es como se supone que funciona la prueba de calcio. No es una prueba de detección para todo el mundo. Está destinada únicamente a pacientes seleccionados asintomáticos, de entre 40 y 75 años, que nunca han sufrido un infarto o un ictus y que no están tomando medicamentos para el colesterol.

La prueba ayuda a responder una pregunta concreta: ¿estatinas o no estatinas?

Si un médico calcula que el riesgo de enfermedad cardiovascular aterosclerótica en 10 años es del 5% o inferior, no es necesario tomar medicamentos por el momento. Por encima del 20%, “no hay duda de que el riesgo es lo suficientemente alto como para justificar la medicación”, aseguró Philip Greenland, cardiólogo preventivo de la Universidad Northwestern y coautor de una reciente publicación en JAMA.

“Es el rango intermedio donde hay más incertidumbre”, dijo, incluyendo el riesgo “límite” del 5% al 7,5% y el riesgo “intermedio” del 7,5% al 20%.

¿Por qué agregar otra medición a estas evaluaciones, que ya incorporan factores de riesgo como el tabaquismo y la diabetes?

“La puntuación de riesgo se obtiene a partir de una gran población, mediante modelos matemáticos”, explicó Blaha. “Podemos decir que esta puntuación describe el riesgo de enfermedad cardíaca entre miles de personas. Pero hay muchas limitaciones a la hora de aplicarlas a un individuo”.

Sin embargo, una tomografía de calcio produce una imagen de las arterias de un individuo. Alexander Zheutlin, cardiólogo e investigador de la Universidad Northwestern, muestra a los pacientes sus imágenes para que puedan ver las calcificaciones de color más claro.

Los cardiólogos suelen ser partidarios de las pruebas de calcio, ya que se encuentran con frecuencia con pacientes reacios a tomar estatinas.

Las personas que se sienten bien pueden dudar a la hora de empezar a tomar medicamentos por el resto de su vida, a pesar del historial probado de las estatinas en la reducción de los infartos, los accidentes cerebrovasculares y las muertes súbitas cardíacas.

En 2019, una encuesta realizada a casi 5.700 adultos a los que se les había recomendado un tratamiento con estatinas reveló que una cuarta parte no lo estaba siguiendo. De ellos, el 10% había rechazado las estatinas y el 30% había empezado a tomarlas y luego las había dejado, principalmente por miedo a los efectos secundarios.

Un informe de consenso de expertos del Colegio Americano de Cardiología situó recientemente la tasa de dolor muscular, la queja más común de los usuarios de estatinas, entre el 5% y el 20%. Los investigadores consideran exagerado el miedo a los efectos secundarios, citando estudios que muestran que los informes de dolor muscular eran comparables tanto si los pacientes tomaban estatinas como si tomaban placebos.

“El riesgo real es mucho, mucho menor que el riesgo percibido”, afirmó Zheutlin.

Puede que esto sea poco consuelo para las personas que sufren dolor, pero los cardiólogos sostienen que reducir las dosis o cambiar a estatinas diferentes suele resolver el problema. A algunos pacientes les va mejor con un medicamento para el colesterol que no es una estatina.

Hollander, por ejemplo, sufría “calambres musculares que me despertaban por la noche”. Su médico le recomendó reducir la dosis, por lo que ahora Hollander toma Crestor tres días a la semana y se inyecta Repatha dos veces al mes.

(Las estatinas también conllevan un riesgo muy bajo de una afección peligrosa, la rabdomiólisis, que provoca la degradación muscular, y aumentan ligeramente la probabilidad de desarrollar diabetes).

Algunas advertencias: Nadie ha realizado un ensayo clínico aleatorio para demostrar si las pruebas de calcio reducen finalmente los infartos y las muertes cardíacas. Por eso, aunque varias asociaciones profesionales respaldan las pruebas de calcio para ayudar a determinar el tratamiento, el grupo independiente U.S. Preventive Services Task Force ha calificado las pruebas actuales de “insuficientes” para recomendar su uso generalizado.

Un ensayo de este tipo sería caro y difícil de llevar a cabo, con muchas variables que podrían influir en los resultados. Además, las farmacéuticas no están muy interesadas en financiarlo, ya que un resultado positivo podría significar que los pacientes con puntuaciones cero evitarían por completo los medicamentos para el colesterol.

Pero un estudio australiano reciente con pacientes asintomáticos con antecedentes familiares de enfermedad coronaria descubrió que, después de tres años, los que se habían hecho escáneres de calcio tenían una reducción sostenida del colesterol y un riesgo significativamente menor de enfermedad cardíaca que los que no se la habían realizado.

La prueba “lleva a más recetas de estatinas, mayor fidelidad a las estatinas, menos progresión de la aterosclerosis y menos crecimiento de la placa”, dijo Greenland sobre el estudio, en el que no participó. “Inclina la balanza”.

Otra preocupación: las personas de 75 años o más. La mayoría tendrá placa arterial, lo que hace que los beneficios de la prueba sean “menos claros”, indicó Zheutlin, autor principal de un artículo reciente de JAMA Cardiology que señala que las pruebas de CAC pueden ser tanto sobreutilizadas como infrautilizadas.

Dado que los adultos mayores se enfrentan a más enfermedades crónicas y problemas médicos, la reducción del colesterol puede no ser una prioridad. Un estudio que en estos momentos recluta a mayores de 75 años debería responder a algunas preguntas sobre las estatinas, las tomografías de calcio y la demencia en unos años.

Mientras tanto, los cardiólogos consideran que la tomografía o escáner de calcio es una herramienta convincente.

“Es increíblemente frustrante”, observó Zheutlin. Con las estatinas, “tenemos medicamentos económicos, seguros y eficaces disponibles en cualquier farmacia” que ayudan a prevenir los ataques cardíacos. Si los resultados de la prueba CAC resultan más influyentes que las evaluaciones de riesgo tradicionales por sí solas, más pacientes podrían aceptar tomarlas, expresó.

Un escáner de calcio ayudó a Stephen Patrick, de 70 años, ejecutivo tecnológico jubilado de San Francisco, a llegar a ese punto. “Durante años tuve el cholesterol al límite, y logré combatirlo con menos tostadas con queso” y mucho ejercicio, dijo. “No tomaba medicamentos y me enorgullecía”.

El otoño pasado, con el colesterol total y el LDL por encima de los niveles recomendados, su médico le sugirió un escáner de calcio. Su puntuación: 176.

Ahora toma atorvastatina (Lipitor) a diario y sus niveles de colesterol han bajado drásticamente. “Quizá lo hubiera hecho de todos modos”, afirmó. “Pero la puntuación de calcio me hizo prestar más atención”.

The New Old Age se produce en alianza con The New York Times.

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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A long list of Lynda Hollander’s paternal relatives had heart disease, and several had undergone major surgeries. So when she hit her mid-50s and saw her cholesterol levels creeping up after menopause, she said, “I didn’t want to take a chance.”

A cardiologist told Hollander that based on factors like age, sex, cholesterol, and blood pressure, she faced a moderate risk of a major cardiac event, like a heart attack, within the next 10 years.

Doctors typically counsel such patients about the importance of diet and exercise, but Hollander, now 64, a social worker in West Orange, New Jersey, didn’t have much room for improvement. She was already a serious runner, and although “I fall off the wagon once in a while,” her diet was basically healthy. Attempts to lose weight didn’t lower her cholesterol.

Her doctor explained that a coronary artery calcium test, something Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. Her doctor explained that a coronary artery calcium test, something Ms. Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. A brief and painless CT scan, it would indicate whether calcifications and plaque were developing in the arteries leading to her heart.

When plaque ruptures, it can cause clots that block blood flow and trigger heart attacks. The scan would help determine whether Hollander would benefit from taking a statin, which could reduce plaque and prevent more from forming.

“The test is used by more people every year,” said Michael Blaha, co-director of the preventive cardiology program at Johns Hopkins University. Calcium scans quadrupled from 2006 to 2017, his research team reported, and Google searches for related terms have risen even more sharply.

Yet “it’s still being underused compared to its value,” he said.

One reason is that although the test is comparatively inexpensive — sometimes up to $300, but often $100 or less — patients usually must pay for it out-of-pocket. Medicare rarely covers it, though some doctors argue that it should.

Patients with a CAC score of zero — no calcification — have lower risk than their initial assessments indicate and aren’t candidates for cholesterol-lowering drugs. But Hollander’s score was in the 50s — not high but not negligible.

“It was the first indication of what was going on inside my arteries,” she said.

Though guidelines vary, cardiologists generally offer statins to patients with calcium scores over zero, and suggest higher intensity statins when scores exceed 100. At over 300, patients’ risks approach those of people who’ve already had heart attacks; they may need still more aggressive treatment.

Hollander has taken a low dose of rosuvastatin (brand name: Crestor) ever since, supplemented by a non-statin drug, a shot called evolocumab (Repatha).

This is the way calcium testing is supposed to work. It’s not a screening test for everyone. It’s intended only for selected asymptomatic patients, ages 40 to 75, who have never had a heart attack or a stroke and are not already on cholesterol drugs.

The test helps answer a pointed question: to statin, or not to statin.

If a doctor calculates the 10-year risk of atherosclerotic cardiovascular disease at 5% or lower, drugs are unnecessary for now. Over 20%, “there’s no doubt the risk is sufficiently high to justify medication,” said Philip Greenland, a preventive cardiologist at Northwestern University and co-author of a recent review in JAMA.

“It’s the in-between range where it’s more uncertain,” he said, including “borderline” risk of 5% to 7.5% and “intermediate” risk of 7.5% to 20%.

Why add another measurement to these assessments, which already incorporate risk factors like smoking and diabetes?

“A risk score is derived from a large population, with mathematical modeling,” Blaha explained. “We can say that this score describes the risk of heart disease among thousands of people. But there are lots of limitations in applying them to one individual.”

A calcium scan, however, produces an image of one individual’s arteries. Alexander Zheutlin, a cardiology fellow and researcher at Northwestern University, shows patients their images, so that they can see the lighter-colored calcifications.

Cardiologists tend to be fans of calcium testing, because they so regularly encounter patients who are reluctant to take statins. People who feel fine may hesitate to start drugs they’ll take for the rest of their lives, despite statins’ proven history of reducing heart attacks, strokes and cardiac deaths.

In 2019, a survey of almost 5,700 adults for whom statin therapy was recommended found that a quarter were not in treatment. Of those, 10% had declined a statin and 30% had started and then discontinued, primarily citing fear of side effects.

An American College of Cardiology expert consensus report recently put the rate of muscle pain, statin users’ most common complaint, at 5% to 20%. Researchers consider the fear of side effects overblown, citing studies showing that reports of muscle pain were comparable whether patients took statins or placebos.

“The actual risk is much, much lower than the perceived risk,” Zheutlin said.

That may be little comfort to people who are in pain, but cardiologists argue that reducing doses or switching to different statins usually solves the problem. Some patients will do better on a non-statin cholesterol drug.

Hollander, for example, suffered “muscle cramps that would wake me up at night.” Her doctor advised fewer doses, so Hollander now takes Crestor three days a week and self-injects Repatha twice monthly.

(Statins also carry a very low risk of a dangerous condition, rhabdomyolysis, that causes muscle breakdown, and they slightly increase the chance of diabetes.)

Some caveats: No one has undertaken a randomized clinical trial to show whether calcium testing eventually reduces heart attacks and cardiac deaths. That’s why, although several professional associations endorse calcium scans to help determine treatment, the independent U.S. Preventive Services Task Force has called the current evidence “insufficient” to recommend widespread use.

Such a trial would be expensive and difficult to mount, with many confounding variables. And pharmaceutical companies aren’t eager to underwrite one, since a successful result could mean that patients with zero scores avoid cholesterol drugs altogether.

But a recent Australian study of asymptomatic patients with family histories of coronary artery disease found that, after three years, those who had undergone calcium scans had sustained a reduction in cholesterol and a significantly lower risk of heart disease than those who had not been tested.

The test “leads to more statin prescriptions, better adherence to statins, less progression of atherosclerosis, and less plaque growth,” Greenland said of the study, in which he was not involved. “It tips the scale.”

Another concern: people age 75 and older. Most will have arterial plaque, making a scan’s benefit “less clear-cut,” said Zheutlin, lead author of a recent JAMA Cardiology article pointing out that CAC testing can be both overused and underused.

Because older adults face more chronic diseases and medical issues, cholesterol-lowering may become a lower priority. A study now enrolling participants over 75 should answer some questions about statins, calcium scans, and dementia in a few years.

Meanwhile, cardiologists see calcium scans as a persuasive tool.

“It’s incredibly frustrating,” Zheutlin said. With statins, “we have cheap, safe, effective drugs available at any pharmacy” that help prevent heart attacks. If CAC test results prove more influential than traditional risk assessments alone, he said, more patients might agree to take them.

A calcium scan helped Stephen Patrick, 70, a retired tech executive in San Francisco, reach that point. “For years, I was borderline on cholesterol, and I managed to beat it back with less cheese toast” and lots of exercise, he said. “I was on no meds, and I took pride in that.”

Last fall, with both his total and his LDL cholesterol higher than recommended, his doctor suggested a calcium scan. His score: 176.

He’s taking atorvastatin (Lipitor) daily, and his cholesterol levels have dropped dramatically. “I might have tried it anyway,” he said. “But the calcium score meant I had to pay more attention.”

The New Old Age is produced through a partnership with The New York Times.

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.

USE OUR CONTENT

This story can be republished for free (details).

A long list of Lynda Hollander’s paternal relatives had heart disease, and several had undergone major surgeries. So when she hit her mid-50s and saw her cholesterol levels creeping up after menopause, she said, “I didn’t want to take a chance.”

A cardiologist told Hollander that based on factors like age, sex, cholesterol, and blood pressure, she faced a moderate risk of a major cardiac event, like a heart attack, within the next 10 years.

Doctors typically counsel such patients about the importance of diet and exercise, but Hollander, now 64, a social worker in West Orange, New Jersey, didn’t have much room for improvement. She was already a serious runner, and although “I fall off the wagon once in a while,” her diet was basically healthy. Attempts to lose weight didn’t lower her cholesterol.

Her doctor explained that a coronary artery calcium test, something Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. Her doctor explained that a coronary artery calcium test, something Ms. Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. A brief and painless CT scan, it would ‌indicate whether the fatty deposits called plaque were developing in the arteries leading to her heart.

When plaque ruptures, it can cause clots that block blood flow and trigger heart attacks. The scan would help determine whether Hollander would benefit from taking a statin, which could reduce plaque and prevent more from forming.

“The test is used by more people every year,” said Michael Blaha, co-director of the preventive cardiology program at Johns Hopkins University. Calcium scans quadrupled from 2006 to 2017, his research team reported, and Google searches for related terms have risen even more sharply.

Yet “it’s still being underused compared to its value,” he said.

One reason is that although the test is comparatively inexpensive — sometimes up to $300, but often $100 or less — patients usually must pay for it out-of-pocket. Medicare rarely covers it, though some doctors argue that it should.

Patients with a CAC score of zero — no calcification — have lower risk than their initial assessments indicate and aren’t candidates for cholesterol-lowering drugs. But Hollander’s score was in the 50s — not high but not negligible.

“It was the first indication of what was going on inside my arteries,” she said.

Though guidelines vary, cardiologists generally offer statins to patients with calcium scores over zero, and suggest higher intensity statins when scores exceed 100. At over 300, patients’ risks approach those of people who’ve already had heart attacks; they may need still more aggressive treatment.

Hollander has taken a low dose of rosuvastatin (brand name: Crestor) ever since, supplemented by a non-statin drug, a shot called evolocumab (Repatha).

This is the way calcium testing is supposed to work. It’s not a screening test for everyone. It’s intended only for selected asymptomatic patients, ages 40 to 75, who have never had a heart attack or a stroke and are not already on cholesterol drugs.

The test helps answer a pointed question: to statin, or not to statin.

If a doctor calculates the 10-year risk of atherosclerotic cardiovascular disease at 5% or lower, drugs are unnecessary for now. Over 20%, “there’s no doubt the risk is sufficiently high to justify medication,” said Philip Greenland, a preventive cardiologist at Northwestern University and co-author of a recent review in JAMA.

“It’s the in-between range where it’s more uncertain,” he said, including “borderline” risk of 5% to 7.5% and “intermediate” risk of 7.5% to 20%.

Why add another measurement to these assessments, which already incorporate risk factors like smoking and diabetes?

“A risk score is derived from a large population, with mathematical modeling,” Blaha explained. “We can say that this score describes the risk of heart disease among thousands of people. But there are lots of limitations in applying them to one individual.”

A calcium scan, however, produces an image of one individual’s arteries. Alexander Zheutlin, a cardiology fellow and researcher at Northwestern University, shows patients their images, so that they can see the lighter-colored calcifications.

Cardiologists tend to be fans of calcium testing, because they so regularly encounter patients who are reluctant to take statins. People who feel fine may hesitate to start drugs they’ll take for the rest of their lives, despite statins’ proven history of reducing heart attacks, strokes and cardiac deaths.

In 2019, a survey of almost 5,700 adults for whom statin therapy was recommended found that a quarter were not in treatment. Of those, 10% had declined a statin and 30% had started and then discontinued, primarily citing fear of side effects.

An American College of Cardiology expert consensus report recently put the rate of muscle pain, statin users’ most common complaint, at 5% to 20%. Researchers consider the fear of side effects overblown, citing studies showing that reports of muscle pain were comparable whether patients took statins or placebos.

“The actual risk is much, much lower than the perceived risk,” Zheutlin said.

That may be little comfort to people who are in pain, but cardiologists argue that reducing doses or switching to different statins usually solves the problem. Some patients will do better on a non-statin cholesterol drug.

Hollander, for example, suffered “muscle cramps that would wake me up at night.” Her doctor advised fewer doses, so Hollander now takes Crestor three days a week and self-injects Repatha twice monthly.

(Statins also carry a very low risk of a dangerous condition, rhabdomyolysis, that causes muscle breakdown, and they slightly increase the chance of diabetes.)

Some caveats: No one has undertaken a randomized clinical trial to show whether calcium testing eventually reduces heart attacks and cardiac deaths. That’s why, although several professional associations endorse calcium scans to help determine treatment, the independent U.S. Preventive Services Task Force has called the current evidence “insufficient” to recommend widespread use.

Such a trial would be expensive and difficult to mount, with many confounding variables. And pharmaceutical companies aren’t eager to underwrite one, since a successful result could mean that patients with zero scores avoid cholesterol drugs altogether.

But a recent Australian study of asymptomatic patients with family histories of coronary artery disease found that, after three years, those who had undergone calcium scans had sustained a reduction in cholesterol and a significantly lower risk of heart disease than those who had not been tested.

The test “leads to more statin prescriptions, better adherence to statins, less progression of atherosclerosis, and less plaque growth,” Greenland said of the study, in which he was not involved. “It tips the scale.”

Another concern: people age 75 and older. Most will have arterial plaque, making a scan’s benefit “less clear-cut,” said Zheutlin, lead author of a recent JAMA Cardiology article pointing out that CAC testing can be both overused and underused.

Because older adults face more chronic diseases and medical issues, cholesterol-lowering may become a lower priority. A study now enrolling participants over 75 should answer some questions about statins, calcium scans, and dementia in a few years.

Meanwhile, cardiologists see calcium scans as a persuasive tool.

“It’s incredibly frustrating,” Zheutlin said. With statins, “we have cheap, safe, effective drugs available at any pharmacy” that help prevent heart attacks. If CAC test results prove more influential than traditional risk assessments alone, he said, more patients might agree to take them.

A calcium scan helped Stephen Patrick, 70, a retired tech executive in San Francisco, reach that point. “For years, I was borderline on cholesterol, and I managed to beat it back with less cheese toast” and lots of exercise, he said. “I was on no meds, and I took pride in that.”

Last fall, with both his total and his LDL cholesterol higher than recommended, his doctor suggested a calcium scan. His score: 176.

He’s taking atorvastatin (Lipitor) daily, and his cholesterol levels have dropped dramatically. “I might have tried it anyway,” he said. “But the calcium score meant I had to pay more attention.”

The New Old Age is produced through a partnership with The New York Times.

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A little-known federal agency that sends more than $12 billion annually to support community health centers, addiction treatment services, and workforce initiatives for America’s neediest people has been hobbled by the Trump administration’s staffing purges.

The cuts are “just a little astonishing,” said Carole Johnson, who previously led the Health Resources and Services Administration. She left the agency in January with the administration change and has described the sweeping staff cuts as a “big threat” to the agency’s ability to distribute billions of dollars in grants to hospitals, clinics, nonprofits, and other organizations nationwide.

Since February, about a quarter of workers at HRSA — including analysts, auditors, scientists, grant managers, and nursing consultants — have left, according to a KFF Health News analysis.

The agency, headquartered in a nondescript gray-and-glass office building tucked into side streets in Rockville, Maryland, employed about 2,700 staffers in early 2025. Employees worked behind the scenes to manage and monitor thousands of projects nationwide that fund primary health providers, HIV/AIDS treatment and prevention, maternal and child care programs, rural hospitals, and workforce training.

On the ground, HRSA’s grants have helped create telehealth initiatives for mothers in rural New Mexico, funded workforce training for Indigenous nurses in South Dakota, and supported Healthy Start programs for expectant mothers and babies in places like rural Georgia.

Ryan Alcorn, a co-founder and the chief executive of GrantExec, a company that helps organizations match and apply for funding, said every American benefits from the programs HRSA’s funding supports: “When the safety net fails, hospitals become overwhelmed, unpaid costs rise, and premiums go up for everyone.”

Several former HRSA leaders, who have been in touch with employees, confirmed the magnitude of the cuts estimated by KFF Health News. Johnson said she believes the actual number of workers lost is larger.

More than 700 workers were fired or chose to leave from February through the end of June. The analysis is based on data from the HHS employee directory, which may not include workers who opted out of being listed, and may not be an exact count of the worker roster, which is in flux.

Johnson, who is now a senior fellow at the Century Foundation, and several other former employees interviewed by KFF Health News said they are concerned that specific programs will be eliminated, but also that reduced staffing could affect ongoing program oversight. The agency’s workforce ethos, Johnson said, is one in which “if there were two people left at HRSA, they would work around the clock to try to get the money out.”

For at least one program, revealed during a tense moment on Capitol Hill in July, money to help low-income and minority students has already stopped flowing to colleges and universities. The Scholarship for Disadvantaged Students program, established through congressional legislation, helped schools pay for students to train to become dentists, physician assistants, midwives, and nurses — all of whom are in short supply in rural and some urban areas. Candice Chen, acting associate administrator of HRSA’s health workforce bureau, confirmed the agency “did have competitions that were canceled.”

When U.S. Rep. Diana DeGette (D-Colo.) asked whether they were canceled by the Trump administration, Chen paused before speaking again: “Well, the funding decisions were made across the administration.”

Asked about the canceled funding, officials from several schools declined to comment. Patrick Gonzales, a spokesperson for the University of Texas-Rio Grande Valley, said in an emailed statement that the school is “helping students navigate this transition with clarity and care.”

U.S. Sen. Angela Alsobrooks (D-Md.) has called for Health and Human Services Secretary Robert F. Kennedy Jr.’s resignation or firing, “whichever one comes first,” saying there was “no defensible answer” to eliminating thousands of workers across federal agencies.

In April, nearly a dozen Democratic senators sent a letter to Kennedy demanding answers about the mass firings, noting HRSA is the “primary agency tasked with improving access to health care for vulnerable populations.”

HHS did not respond to the senators’ letter. Kennedy and the Department of Health and Human Services “has refused to answer basic questions about why the administration conducted mass firings in this office,” said Sen. Lisa Blunt Rochester (D-Del.).

President Donald Trump’s proposed fiscal 2026 budget eliminates HRSA as well as some of its programs, including grants to rural hospitals, workforce training, Ryan White HIV/AIDS programs, and emergency medical services for children. HRSA spokesperson Andrea Takash said in an emailed response that HHS is “undertaking organizational changes that support multiple goals while ensuring continuity of essential services.”

HRSA continues to process new funding announcements and awards for the health centers, workforce programs, child and maternal health initiatives, and “many more of our critical programs and services,” Takash said.

HRSA’s largest bureau supports thousands of community health centers that serve over 31 million people nationwide. Before the end of September, the agency’s grants are still scheduled to pay out billions more to health clinics and other organizations nationwide.

Cuts to health centers could come under more scrutiny because their funding has “a lot of bipartisan” support, said Celli Horstman, a senior research associate at the Commonwealth Fund, a health research nonprofit. HRSA’s funding, which includes Section 330 grants, goes to “keeping the doors open” at federally qualified health centers nationwide, Horstman said.

An additional 42% of health center funding comes from Medicaid, a federal and state insurance program that covers people with low incomes and those with disabilities, she said. Congress recently voted to reduce Medicaid funding.

Joe Stevens, spokesperson for the Virginia Community Healthcare Association, said health centers are rethinking “how they do business” because of the Medicaid cuts and the increased administrative challenges faced when processing their HRSA grants, which have been more challenging to obtain since February. Virginia’s health clinics treat about 400,000 people annually, Stevens said.

“It’s a system that’s been in place for 50-plus years, and this is the first time they’re having issues receiving their funds,” he said, noting that clinics now must also provide an itemized list of how the money is to be used after grants have been approved.

“Our health centers are understaffed, so having somebody to have to enter that information every two weeks is just more time,” Stevens said.

For months, HRSA staff across all departments have worked through changes to their technology systems and transitioned work to others as employees left their jobs. Workers have continued to process grants despite an executive order that froze federal funding and a March announcement that HHS would lay off 10,000 workers and shut down entire agencies — including HRSA.

One former employee said that, at this point, “all we’re doing now is keeping the lights on.”

Michael Warren, who left the agency in June, ran HRSA’s Maternal and Child Health Bureau. Warren described the bureau’s staffing cuts as “substantial.” The bureau awarded more than $628 million in grants between Oct. 1, 2024, and July 22, 2025, to programs that included providing block grants to states and funding home visiting programs, through which trained staffers work with families with young children.

Warren, who is now the chief medical and health officer for the March of Dimes, said America faces a crisis as one of the “most dangerous places in the world to give birth among other high-income countries, and that shouldn’t be the case.”

With tears brimming, Warren said his former employees “wake up every morning, they work all day, and they go to sleep every night thinking about what they can do for mothers, children, and families.”

Methodology

For this article, KFF Health News calculated workforce reductions at the Health Resources and Services Administration using public information from the Department of Health and Human Services directory posted online. We compared the number and type of employees listed with HRSA in February to those in early July. Our employee totals exclude people listed as interns, fellows, student trainees, or volunteers. The directory is not an official count of HRSA employees, but it offers detailed snapshots of trends so far this year. Reporters also cross-checked the estimates with former employees.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

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.

USE OUR CONTENT

This story can be republished for free (details).

FDA is requiring safety labeling changes to all opioid pain medications to better emphasize and explain the risks.