KFF Health News contributor Andy Miller discussed the Trump presidency and health care on WUGA’s “The Georgia Health Report” on Nov. 8.

• Click here to hear Miller on “The Georgia Health Report”
• Read Stephanie Armour’s “Trump’s White House Return Poised To Tangle Health Care Safety Net”

KFF Health News correspondent Brett Kelman discussed dental implants on KCBS on Nov. 4.

• Click here to hear Kelman on KCBS
• Read Kelman’s “Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn,” with reporting from Anna Werner, CBS News

KFF Health News California correspondent Christine Mai-Duc discussed an abortion clinic lawsuit on KCBS on Oct. 31.

• Click here to hear Mai-Duc on KCBS
• Read Mai-Duc’s “‘A Pressure Campaign’: Beverly Hills Settles After Allegedly Blocking Abortion Clinic”

KFF Health News South Dakota correspondent Arielle Zionts discussed the Purchased/Referred Care program for Native American patients on “Native America Calling” on Oct. 24.

• Click here to hear Zionts on “Native America Calling”
• Read Zionts’, “Patients Suffer When Indian Health Service Doesn’t Pay for Outside Care,” with reporting from Katheryn Houghton

KFF Health News senior fellow and editor-at-large for public health Céline Gounder shared tips for preventing cardiovascular disease on CBS’ “CBS Mornings” on Oct. 24. Gounder also joined “CBS News 24/7” to discuss McDonald’s Quarter Pounder hamburgers linked to an E. coli outbreak and “CBS Mornings” to discuss a frozen waffle recall due to a potential listeria contamination, both on Oct. 22.

• Click here to watch Gounder on “CBS Mornings” on Oct. 24
• Click here to watch Gounder on “CBS News 24/7” on Oct. 22
• Click here to watch Gounder on “CBS Mornings” on Oct. 22

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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Este año, California ha dado el último paso para abrir el Medi-Cal, su programa de Medicaid, a todos los residentes que reúnan los requisitos, independientemente de su estatus migratorio.

Es una expansión significativa para un programa de protección social que ya de por sí es masivo.

El gasto anual de Medi-Cal asciende actualmente a  $157.000 millones, con los que atiende a unos 15 millones de residentes de bajos ingresos, más de un tercio de los californianos.

De ellos, aproximadamente 1.5 millones son inmigrantes que viven en Estados Unidos sin papeles, y su acceso a servicios de atención médica representa un costo estimado de $6.4 mil millones, según el Departamento de Servicios de Atención Médica.

Estos inmigrantes se han ido sumando al programa poco a poco, a medida que el estado fue eliminando el requisito de residencia legal. Primero, en 2016, se incluyó a los niños. En 2020, a los jóvenes de 19 a 25 años. En 2022, a las personas de 50 años o más. Finalmente, desde enero, a todos los adultos restantes.

Los defensores de los inmigrantes aplauden el aumento de personas inscriptas en el seguro público de California y elogian al estado por haber ampliado Medi-Cal y logrado que la tasa de personas sin cobertura médica bajara a un mínimo histórico de 6.4%.

Sin embargo, los proveedores de servicios de salud y los hospitales advierten que el estado no ha ampliado adecuadamente el número de profesionales ni ha aumentado lo suficiente los pagos de Medi-Cal. Por esta situación, algunos afiliados tienen problemas para encontrar prestadores de salud que los atiendan en plazos adecuados o directamente se quedan sin ninguna atención médica.

“La cobertura no significa necesariamente acceso”, afirmó Isabel Becerra, consejera delegada y presidenta de la Coalición de Centros de Salud Comunitarios del Condado de Orange, durante una cumbre sobre política sanitaria, el 2 de octubre en Los Ángeles. “Existe una escasez de profesionales de salud. Todos estamos luchando por recibir atención médica. Estamos compitiendo entre nosotros para conseguir que los médicos nos atiendan”.

Aunque el estado ha aumentado un 87,5% los pagos de Medi-Cal para la atención primaria, de maternidad y servicios de salud mental respecto de lo que paga Medicare, el seguro privado todavía tiende a pagar más, según la California Legislative Analyst’s Office.

Una iniciativa electoral presentada hace poco podría garantizar que los ingresos procedentes de un impuesto sobre los planes de salud gestionados se destinen a aumentar el pago a los proveedores de asistencia sanitaria que tratan a los pacientes de Medi-Cal.

Pero algunos creen que el próximo capítulo para dar cobertura a los inmigrantes requerirá algo más que Medi-Cal.

En 2022, Joaquín Arámbula, miembro de la Asamblea estatal por el Partido Demócrata, presentó un proyecto de ley en este sentido. Proponía que los aproximadamente 520.000 residentes indocumentados sin seguro que ganaran más del 138% del nivel federal de pobreza pudieran solicitar cobertura sanitaria subvencionada por el estado a través de Covered California, el mercado de seguros de salud estatal. Sin embargo, el proyecto de ley no avanzó en el comité este año.

La nueva entrega de la serie “Faces de Medi-Cal” muestra cómo Medi-Cal ha impactado en la vida de sus nuevos afiliados.

Entre ellos, Vanessa López Zamora, que por fin está recibiendo tratamiento para su hepatitis y cirrosis, pero tiene problemas para ver a un gastroenterólogo cerca de su casa; Douglas López, un trabajador de un parque de atracciones que atribuye la cobertura dental a la mejora de su bienestar; y Daniel García, que sufre de gota, pero ha renunciado a la búsqueda de un proveedor de atención primaria.

Todos ellos hablaron con KFF Health News luego de comenzar a ser beneficiarios de Medi-Cal.

“Empecé a sentirme mal hace mucho tiempo”

En marzo, el estómago de Vanessa López Zamora se había hinchado tanto que parecía que estaba embarazada. Había estado dolorida y vomitando durante días.

López Zamora contó que fue al servicio de urgencias de su localidad, el Kaweah Health Medical Center, pero no había ningún especialista disponible. Así que la mujer, de 31 años, fue trasladada en ambulancia a Adventist Health Bakersfield, a unas 80 millas de su casa en Visalia.

Contó que allí, los médicos le diagnosticaron hepatitis A y C y cirrosis, y le explicaron que eso le había causado lesiones internas en el hígado y el esófago.

Vanessa pasó cuatro días en el hospital y, para recibir tratamiento adicional, la remitieron a un gastroenterólogo, al que puede ir como nueva beneficiaria de Medi-Cal. Esta es una opción que no podía permitirse en el pasado, cuando tenía dolores de estómago y náuseas.

“Ha sido un proceso muy largo porque empecé a sentirme mal hace mucho tiempo”, dijo López Zamora, que trabaja como contable en una emisora de radio local de Visalia, en el valle de San Joaquín. “Mis hijas son muy pequeñas, y si no consigo el tratamiento necesario, no sabré cuánto tiempo me queda”, se lamentó.

López Zamora, que llegó a California desde Ciudad de México cuando tenía 8 años, está agradecida por la atención que recibió inicialmente.

Pero también está frustrada.

El gastroenterólogo al que la derivó el hospital está en Bakersfield y para Zamora es difícil ir: no conduce, y no puede viajar a otra ciudad.

El acceso limitado a especialistas —desde gastroenterólogos hasta cardiólogos— ha sido durante mucho tiempo un desafío para muchos pacientes de Medi-Cal, especialmente los que viven en zonas rurales o en regiones donde hay escasez de proveedores de salud.

El Valle de San Joaquín, donde vive López Zamora, tiene la menor oferta de especialistas del estado, según la California Health Care Foundation.

Michael Bowman, vocero Anthem Blue Cross, el plan de Medi-Cal de López Zamora, dijo en un correo electrónico que Anthem tiene una amplia red de especialistas que atienden a los beneficiarios de Medi-Cal, incluyendo más de 100 gastroenterólogos en un radio de 20 millas alrededor de Visalia.

López Zamora está tratando su cirrosis con medicamentos y dieta, pero en agosto su gastroenterólogo de Bakerfield descubrió signos de una condición precancerosa en el estómago.

Ella dijo que está buscando un especialista que atienda más cerca de su casa. Por ahora, su madre debe tomarse el día en el trabajo para llevarla a las citas médicas. Si no, toma el autobús.

López Zamora intentó utilizar el transporte proporcionado por Medi-Cal, pero se quedó varada en el hospital. Y ha tenido que cambiar dos veces de cita.

“Me llevaron, pero no me pudieron traer de vuelta porque no encontraban un Uber”, explicó.

Un proceso muy sencillo

Medi-Cal proporcionó a Douglas López el tratamiento dental que no podía costear.

En 2022, este hombre de 33 años ganaba el salario mínimo como trabajador de limpieza en un parque de atracciones. El plan de emergencia de Medi-Cal en el que se había anotado sólo cubría extracciones de urgencia.

Ese año, López experimentó un dolor agudo en las muelas de atrás cuando comía sus queridas bolitas de caramelo de coco y tamarindo de su Guatemala natal.

Un dentista le dijo que necesitaba varias obturaciones y tres endodoncias. Empezó el tratamiento, pero las facturas se fueron encareciendo: $150 la primera sesión, luego $200 y después $300.

“No podía permitírmelo”, recordó López, que vive en Fullerton. “Tenía que pagar el alquiler y la comida”.

Preocupado por perder los dientes, dejó de comer cualquier cosa que le causara dolor.

En enero, cuando el estado amplió la elegibilidad para el seguro a los residentes sin papeles de entre 26 y 49 años, el condado de Orange inscribió automáticamente a López en el plan Medi-Cal de Molina Healthcare. La cobertura transformó su atención, dijo.

Desde entonces, ya vio a un dentista seis veces. Le hicieron una limpieza, tres endodoncias, dos obturaciones y radiografías. Y Medi-Cal ha pagado la factura.

La experiencia de López contrasta con la de muchos otros beneficiarios, que luchan por obtener la atención que necesitan. El Centro de Investigación de Políticas de Salud de UCLA descubrió que el 21% de los dentistas de California vieron pacientes de Medi-Cal de todas las edades, según datos de 2019 a 2021.

Sin embargo, a menudo esos dentistas limitan el número de pacientes de Medi-Cal que reciben; entonces, solo el 15% de los adultos inscritos podrían recibir atención dental en un año determinado.

A López Medi-Cal lo ha ayudado. “Fue un proceso muy sencillo. Estaba muy emocionado porque podía buscar un dentista”, dijo. “Y mi miedo a perder los dientes por no recibir tratamiento desapareció”.

“Algo que ni siquiera puedes usar”

El año pasado, el dolor punzante en el brazo y en el pie que sufría Daniel García se agravó tanto que el hombre de 39 años fue una sala de emergencias.

García padece gota, un tipo de artritis inflamatoria que puede causarle un intenso dolor e hinchazón en las articulaciones. Cuando este año pudo tener la cobertura de Medi-Cal, pensó que por fin podría ir al médico para recibir tratamiento.

Pero el residente del condado de Los Ángeles dijo que no ha sido capaz de encontrar un proveedor de atención primaria que acepte tomar su seguro de Molina Healthcare.

“Es frustrante porque tienes algo que ni siquiera puedes usar”, dijo García, quien tampoco ha podido hacerse un examen físico anual. “He llamado y me dicen que no aceptan mi seguro”.

Molina declinó hacer comentarios sobre el caso de García y no respondió a preguntas sobre su red de atención primaria.

En California, casi 6 millones de personas viven en un total de 611 áreas donde escasea la atención primaria, según un análisis de KFF, que descubrió que el estado necesitaría sumar 881 profesionales para cerrar esta brecha.

García, trabajador de la construcción, dijo que leyó que podía controlar su artritis cambiando sus hábitos alimentarios. Ahora come más sano y ha reducido el consumo de azúcar y de Coca-Cola. En cuanto al dolor, lo alivia con ibuprofeno. Ha renunciado a buscar un proveedor de salud.

Mantener a los pacientes fuera de las salas de emergencias, que pueden ser hasta 12 veces más costosas que la atención primaria, es uno de los argumentos a favor de la expansión de Medi-Cal.

Estudios han demostrado que ampliar la cobertura de salud no solo reduce la cantidad de visitas a emergencias, sino que también aumenta el uso de atención preventiva por parte de los pacientes, según Drishti Pillai, directora de políticas de salud para inmigrantes en KFF.

 “Esto puede ayudar a ahorrar costos de salud, porque no se deja las enfermedades sin atención durante mucho tiempo, lo que podría hacer que su tratamiento se vuelva más complejo y costoso”, explicó Pillai.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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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KFF Health News has sued the U.S. Department of Health and Human Services Office of Inspector General to compel it to release a range of Medicare Advantage health plan audits and other financial records.

The suit, filed Nov. 12 in U.S. District Court in San Francisco under the Freedom of Information Act, or FOIA, seeks documents from the HHS inspector general’s office, which acts as a watchdog over federal health insurance programs run by the Centers for Medicare & Medicaid Services.

The suit asks for correspondence and other records of contact between HHS officials or their representatives and Medicare Advantage organizations concerning overpayment audit findings and potential financial penalties.

It also seeks records reflecting communication between HHS and CMS officials regarding the government’s policies for recovering overpayments discovered during Medicare Advantage audits, including a controversial decision in January 2023 to limit dollar recoveries for audits dating back a decade or more.

Additionally, the suit seeks copies of government contracts awarded to outside firms that have conducted Medicare Advantage audits, including budgets and performance evaluations, dating to 2020. In these audits, reviewers take a sample of 200 patients from a health plan and determine whether medical records support the diagnoses the government paid health plans to treat.

KFF Health News requested the records in August, but, more than two months later, “no documents, responsive or otherwise, have been produced,” the suit says.

Sam Cate-Gumpert, an attorney with Davis Wright Tremaine, which is representing KFF Health News pro bono in the case, said the information is “critically important to public oversight of government misspending.”

According to the suit, the inspector general’s office has audited the Medicare Advantage program more than three dozen times since 2019, revealing billions of dollars in overpayments.

But government officials have not recouped the overcharges, according to the suit.

The HHS Office of Inspector General “has left taxpayers footing the bill for billions of dollars in overpayments — even though HHS OIG’s primary purpose is to combat fraud and waste in Medicare and other federally funded health programs,” the suit alleges.

“In fact, taxpayers have been forced to pay for the Medicare Advantage program’s wasteful spending twice — first, because of the program itself, and second, because of the costs of the audits, which the government spends millions of dollars to conduct,” according to the suit.

Medicare Advantage, mostly run by private insurance companies, has enrolled more than 33 million seniors and people with disabilities, more than half of people on Medicare.

But the program has faced criticism that it costs billions of dollars more than it should with research showing that many health plans exaggerate how sick patients are to boost payments.

A FOIA lawsuit filed by KFF Health News in September 2019 prompted CMS to release summaries of 90 Medicare Advantage audits revealing millions of dollars in overpayments. As part of a settlement, CMS paid $63,000 in KFF Health News’ legal fees, though it did not admit to wrongfully withholding the records.

The HHS Office of Inspector General had no immediate comment on the suit.

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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California this year took the final step in opening Medi-Cal, its Medicaid program, to every eligible resident regardless of immigration status. It’s a significant expansion for an already massive safety net program.

Medi-Cal’s annual spending now stands at $157 billion, serving about 15 million low-income residents, more than a third of Californians. Of those, about 1.5 million are immigrants living in the U.S. without authorization, costing an estimated $6.4 billion, according to the Department of Health Care Services. They have been gradually added to the program as the state lifted legal residency as an eligibility requirement for children in 2016, young adults ages 19-25 in 2020, people 50 and older in 2022, and all remaining adults in January.

As California’s public insurance roll swells, advocates for immigrants praise the Golden State for an expansion that has helped reduce the uninsured rate to a record low 6.4%. Providers and hospitals, however, caution that the state hasn’t expanded its workforce adequately or increased Medi-Cal payments sufficiently, leaving some enrollees unable to find providers to see them in a timely manner — if at all.

“Coverage does not necessarily mean access,” said Isabel Becerra, CEO and president of the Coalition of Orange County Community Health Centers, during an Oct. 2 health policy summit in Los Angeles. “There’s a workforce shortage. We’re all fighting for those doctors. We’re fighting with each other for those doctors.”

Though the state has raised Medi-Cal payments for primary care, maternity care, and mental health services to 87.5% of what Medicare pays, private insurance still tends to pay more, according to the California Legislative Analyst’s Office.

A ballot initiative approved this month guarantees that revenue from a tax on managed-care plans goes toward raising the pay of health care providers who serve Medi-Cal patients.

Some believe the next chapter for covering immigrants will require more than Medi-Cal.

Democratic state Assembly member Joaquin Arambula in 2022 proposed legislation to allow the approximately 520,000 uninsured unauthorized residents who earn more than 138% of the federal poverty level to apply for state-subsidized health coverage through Covered California, the state’s health exchange. The bill, however, died in committee this year.

The final installment of the “Faces of Medi-Cal” series looks at how Medi-Cal has affected its newest enrollees. They include Vanessa López Zamora, who is finally getting treated for hepatitis and cirrhosis but has trouble seeing a gastroenterologist close to home; Douglas Lopez, an entertainment park worker who credits dental coverage for boosting his well-being; and Daniel Garcia, who suffers from gout but has given up his search for a primary care provider. All spoke to KFF Health News in Spanish after recently becoming eligible for Medi-Cal.

‘Started Feeling Sick a Long Time Ago’

In March, Vanessa López Zamora’s stomach had swollen so much it looked like she was pregnant. She had been vomiting and in pain for days.

She went to her local emergency room, at Kaweah Health Medical Center, but it didn’t have a specialist available, she said. So, the 31-year-old was transferred by ambulance to Adventist Health Bakersfield, about 80 miles from her home in Visalia.

Doctors diagnosed her with hepatitis A and C and cirrhosis, which had caused internal injuries to her liver and esophagus, she said. She spent four days in the hospital and for further treatment got a referral to a gastroenterologist, whom she can see as a new Medi-Cal enrollee — an option she couldn’t afford in the past when she had stomach pains and nausea.

“It’s been a very long process because I started feeling sick a long time ago.” said López Zamora, an accountant at a local radio station in Visalia in the San Joaquin Valley. “My girls are very little, and if I can’t get the necessary treatment, I won’t know how much time I have left.”

López Zamora, who came to California from Mexico City when she was 8 years old, is grateful for the care she initially received.

But she’s also frustrated.

The gastroenterologist the hospital referred her to is in Bakersfield — a tough journey for López Zamora, who doesn’t drive and can’t afford to travel to another city.

Limited access to specialists — from gastroenterologists to cardiologists — has been a long-standing challenge for many Medi-Cal patients, especially those in rural areas or regions facing staff shortages. The San Joaquin Valley, where López Zamora lives, has the lowest supply of specialists in the state, according to the California Health Care Foundation.

Michael Bowman, a spokesperson for Anthem Blue Cross, her Medi-Cal plan, said in an email that Anthem has a broad network of specialists that serve Medi-Cal beneficiaries, including more than 100 gastroenterologists within 20 miles of Visalia.

She is treating her cirrhosis with medication and diet, but in August her gastroenterologist in Bakerfield discovered signs of a precancerous condition in the stomach.

López Zamora said she is searching for a specialist closer to home. For now, she relies on her mother, who must take the day off work, to get to appointments or she takes the bus. She tried using transportation provided by Medi-Cal but was left stranded at the hospital. And she has rescheduled her appointments twice.

“They drove me up but didn’t take me back because they couldn’t find an Uber,” she said.

‘A Very Simple Process’

Medi-Cal gave Douglas Lopez the dental treatment he couldn’t afford.

The 33-year-old earned minimum wage as a cleaner in an entertainment park in 2022, and the emergency Medi-Cal plan he signed up for covered only emergency extractions.

That year, Lopez experienced a sharp pain in his back teeth when he ate his beloved coconut-and-tamarind candy balls from his native Guatemala.

A dentist told him that he needed several filings and three root canals. He began treatment, but the bills became more expensive: $150 the first session, then $200, then $300.

“I couldn’t afford it,” recalled Lopez, who lives in Fullerton. “I had to pay rent and food.”

Worried he would lose teeth, he stopped eating anything that would cause him pain.

In January, Orange County automatically enrolled Lopez in Molina Healthcare’s Medi-Cal plan when the state expanded insurance eligibility for unauthorized residents ages 26-49. The coverage has transformed his care, he said.

So far, Lopez has seen a dentist six times, for a cleaning, three root canals, two filings, and X-rays. And Medi-Cal has footed the bill.

Lopez’s experience contrasts with that of many other Medi-Cal enrollees, who struggle to get the care they need. The UCLA Center for Health Policy Research found that 21% of California dentists saw Medi-Cal patients of all ages, according to data from 2019 to 2021. Often those dentists limit the number of Medi-Cal patients they will see; only 15% of adult enrollees might get dental care in a given year.

Lopez said Medi-Cal has come through for him.

“It was a very simple process. I was so excited to search for a dentist,” Lopez said. “The fear of losing my teeth because I wasn’t getting treatment disappeared.”

‘Something That You Can’t Even Use’

Last year, the stabbing pain in Daniel Garcia’s arm and foot got so bad that the 39-year-old went to the ER.

Garcia has gout, a type of inflammatory arthritis that can cause intense pain and swelling in his joints. When he became eligible for Medi-Cal coverage this year, he thought he could finally see a doctor for treatment.

But the Los Angeles County resident said he hasn’t been able to find a primary care provider willing to take his Molina Healthcare insurance.

“It’s frustrating because you have something that you can’t even use,” said Garcia, who has been unable to get an annual physical. “I’ve called, and they say they don’t take my insurance.”

Molina declined to comment on Garcia’s case and didn’t respond to questions about its primary care network.

Nearly 6 million people in California live in a total of 611 primary care shortage areas, according to a KFF analysis, which found the state would need to add 881 practitioners to close this gap.

Garcia, a construction worker, said he read that he could manage his arthritis by changing his eating habits. He now eats healthier and has cut back on sugar and Coke. As for the pain, he eases it with ibuprofen. He has given up looking for a provider.

Keeping patients out of the ER, which can be 12 times as expensive as primary care, is one of the arguments for expanding Medi-Cal. Studies have shown that not only does expanding health coverage lead to lower rates of ER visits, but expanding coverage also leads to patients using preventive care more, said Drishti Pillai, immigrant health policy director at KFF, a health information nonprofit that includes KFF Health News.

“It can help save health care costs because conditions are no longer going untreated for a long time, in which case they may become more complex and expensive to treat,” Pillai said.

This article is part of “Faces of Medi-Cal,” a series exploring the impact of the state’s safety-net health program on enrollees.

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

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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El triunfo electoral del ex presidente Donald Trump y su regreso a la Casa Blanca probablemente traerán cambios que reducirían los programas nacionales de salud públicos, aumentando la tasa de personas sin seguro e imponiendo nuevas barreras al aborto y otros servicios de salud reproductiva.

Las repercusiones se sentirán mucho más allá de Washington, DC, e incluso podrían erosionar las protecciones al consumidor de la Ley de Cuidado de Salud a Bajo Precio (ACA), imponer requisitos de trabajo para Medicaid, recortar fondos para la red de seguridad, y desafiar a las agencias federales que protegen la salud pública.

Las restricciones al aborto podrían endurecerse a nivel nacional, con un posible esfuerzo para restringir el envío por correo de medicamentos abortivos.

Con la inclusión de Robert F. Kennedy Jr., líder del movimiento anti vacunas, en el círculo de asesores de Trump, intervenciones de salud pública con respaldo científico riguroso —como la fluoración del agua potable o la vacunación infantil— podrían también estar en la mira.

Trump derrotó a la vicepresidenta Kamala Harris con 277 votos del Colegio Electoral, según declaró la agencia de noticias Associated Press (AP) a las 5:34 am ET del miércoles 6. Obtuvo el 51% del voto a nivel nacional, en comparación con el 47.5 % de Harris, según las proyecciones de AP.

La victoria de Trump dará una plataforma mucho más amplia a los escépticos y críticos de los programas y acciones de salud federales. En el peor de los casos, las autoridades de salud pública temen que el país podría ver aumentos en enfermedades prevenibles, un debilitamiento de la confianza pública en la ciencia, y la adopción de políticas basadas en ideas desacreditadas, como el supuesto vínculo entre vacunas y autismo.

Trump declaró en una entrevista con NBC News el 3 de noviembre que “tomaría una decisión” sobre la prohibición de algunas vacunas, diciendo que consultaría con Kennedy, calificándolo como “un tipo muy talentoso”.

Aunque Trump ha dicho que no intentará nuevamente derogar ACA, su administración enfrentará una decisión inmediata el próximo año sobre si respaldar una extensión de los subsidios para las primas mejorados para los planes de seguro del Obamacare. Sin estos subsidios, se proyectan aumentos pronunciados de las primas que reducirían la inscripción. La tasa actual de personas sin seguro, de aproximadamente un 8%, casi con seguridad aumentaría.

Los detalles de sus políticas aún no han avanzado mucho más allá de los “conceptos de un plan” que Trump mencionó durante su debate con Harris, aunque el vicepresidente electo JD Vance dijo que la administración buscaría inyectar más competencia en los mercados de ACA.

Se proyecta que los republicanos obtendrán una mayoría en el Senado, además de la Casa Blanca, mientras que el control de la Cámara de Representantes aún no se había resuelto al miércoles temprano.

Las encuestas muestran que ACA ha ganado apoyo entre el público, incluidas disposiciones como las protecciones para condiciones preexistentes y la posibilidad de que los jóvenes permanezcan en los planes de salud familiars hasta los 26 años.

Los seguidores de Trump y otros que han trabajado en su administración dicen que el ex presidente quiere mejorar la ley de manera que reduzca los costos. Señalan que ya ha demostrado ser firme en cuanto a reducir los altos precios de la atención médica, aludiendo a esfuerzos durante su presidencia para promover la transparencia de precios en los costos médicos.

“En cuanto a asequibilidad, lo veo construyendo sobre el primer mandato”, dijo Brian Blase, quien se desempeñó como asesor de salud de Trump de 2017 a 2019. En comparación con una administración demócrata, dijo, habrá “mucho más enfoque” en “minimizar el fraude y el despilfarro”.

Los esfuerzos para debilitar ACA podrían incluir recortes de fondos para la promoción de inscripciones, permitir a los consumidores comprar más planes de salud que no cumplan con las protecciones al consumidor, y permitir a las aseguradoras cobrar primas más altas a las personas con enfermedades.

Los demócratas dicen que esperan lo peor.

“Sabemos cuál es su agenda”, dijo Leslie Dach, presidente ejecutivo de Protect Our Care, una organización de políticas y defensa de la atención médica en Washington, DC. Dach trabajó en la administración Obama ayudando a implementar ACA. “Van a aumentar los costos para millones de estadounidenses y les quitarán cobertura a millones, y, mientras tanto, darán exenciones fiscales a los ricos”.

Theo Merkel, director de la Private Health Reform Initiative en el Instituto Paragon de Salud, de orientación conservadora y dirigido por Blase, dijo que los subsidios mejorados de ACA, que se extendieron bajo la Ley de Reducción de la Inflación (IRA) en 2022 no mejoran los planes ni reducen las primas. Dijo que solo ocultan el bajo valor de los planes con mayores subsidios gubernamentales.

Otros partidarios de Trump dicen que el presidente electo podría apoyar la preservación de la autoridad de Medicare para negociar precios de medicamentos, otra disposición de la IRA.

Trump ha defendido la reducción de los precios de los medicamentos y, en 2020, promovió un modelo de prueba que habría vinculado los precios de algunos medicamentos en Medicare a costos más bajos en el extranjero, dijo Merkel, quien trabajó en la primera Casa Blanca de Trump. La industria farmacéutica demandó con éxito para bloquear el programa.

Dentro del círculo de Trump, algunos nombres ya han sido mencionados como posibles líderes para el Departamento de Salud y Servicios Humanos (HHS). Estos incluyen al ex gobernador de Louisiana, Bobby Jindal, y Seema Verma, quien dirigió los Centros de Servicios de Medicare y Medicaid (CMS) durante su administración.

Kennedy, quien suspendió su campaña presidencial independiente y respaldó a Trump, ha dicho a sus seguidores que Trump le prometió el control del HHS. Trump dijo públicamente antes del día de las elecciones que le daría a Kennedy un papel importante en su administración, aunque podría tener dificultades para obtener la confirmación del Senado para un puesto en el gabinete.

Mientras que Trump ha prometido proteger a Medicare y ha dicho que apoya la financiación de beneficios para el cuidado en el hogar, ha sido menos específico sobre sus intenciones para Medicaid, que brinda cobertura a personas de bajos ingresos y con discapacidades. Algunos analistas de salud esperan que el programa sea especialmente vulnerable a recortes de gastos, lo que podría ayudar a financiar la extensión de exenciones fiscales que expiran a fines del próximo año.

Los posibles cambios incluyen la imposición de requisitos de trabajo a los beneficiarios en algunos estados. La administración y los republicanos en el Congreso también podrían intentar cambiar la forma en que se financia Medicaid. Actualmente, el gobierno federal paga a los estados un porcentaje variable de los costos del programa. Los conservadores han buscado durante mucho tiempo poner un límite a las asignaciones federales a los estados, lo que según los críticos llevaría a recortes drásticos.

“Medicaid será un gran objetivo en una administración Trump”, dijo Larry Levitt, vicepresidente ejecutivo de políticas de salud en KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News.

Es menos claro el futuro potencial de los derechos de salud reproductiva.

Trump ha dicho que las decisiones sobre las restricciones al aborto deben dejarse a los estados. Trece estados prohíben el aborto con pocas excepciones, mientras que otros 28 restringen el procedimiento según la duración gestacional, según el Instituto Guttmacher, una organización de investigación y políticas centrada en el avance de los derechos reproductivos. Antes de las elecciones, Trump dijo que no firmaría una prohibición nacional del aborto.

Medidas estatales para proteger los derechos al aborto fueron adoptadas en cuatro estados, incluido Missouri, donde Trump ganó por aproximadamente 18 puntos, según informes preliminares de AP. Los votantes en Florida y Dakota del Sur rechazaron medidas a favor del derecho al aborto.

Trump podría actuar para restringir el acceso a medicamentos abortivos, utilizados en más de la mitad de los abortos, ya sea retirando la autorización de la Administración de Drogas y Alimentos (FDA) para los medicamentos o aplicando una ley del siglo XIX, la Ley Comstock, que los opositores al aborto dicen que prohíbe su envío. Trump ha dicho que, en general, no usaría la ley para prohibir el envío de medicamentos por correo.

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Former President Donald Trump’s election victory and looming return to the White House will likely bring changes that scale back the nation’s public health insurance programs — increasing the uninsured rate, while imposing new barriers to abortion and other reproductive care.

The reverberations will be felt far beyond Washington, D.C., and could include an erosion of the Affordable Care Act’s consumer protections, the imposition of work requirements in Medicaid and funding cuts to the safety net insurance, and challenges to federal agencies that safeguard public health. Abortion restrictions may tighten nationwide with a possible effort to restrict the mailing of abortion medications.

And with the elevation of vaccine skeptic Robert F. Kennedy Jr. to Trump’s inner circle of advisers, public health interventions with rigorous scientific backing — whether fluoridating public water supplies or inoculating children — could come under fire.

Trump defeated Vice President Kamala Harris with 277 Electoral College votes, The Associated Press declared at 5:34 a.m. ET on Wednesday. He won 51% of the vote nationally to Harris’ 47.5%, the AP projected.

Trump’s victory will give a far broader platform to skeptics and critics of federal health programs and actions. Worst case, public health authorities worry, the U.S. could see increases in preventable illnesses; a weakening of public confidence in established science; and debunked notions — such as a link between vaccines and autism — adopted as policy. Trump said in an NBC News interview on Nov. 3 that he would “make a decision” about banning some vaccines, saying he would consult with Kennedy and calling him “a very talented guy.”

While Trump has said he will not try again to repeal the Affordable Care Act, his administration will face an immediate decision next year on whether to back an extension of enhanced premium subsidies for Obamacare insurance plans. Without the enhanced subsidies, steep premium increases causing lower enrollment are projected. The current uninsured rate, about 8%, would almost certainly rise.

Policy specifics have not moved far beyond the “concepts of a plan” Trump said he had during his debate with Harris, though Vice President-elect JD Vance later said the administration would seek to inject more competition into ACA marketplaces.

Republicans were projected to claim a Senate majority, in addition to the White House, while control of the House was not yet resolved early Wednesday.

Polls show the ACA has gained support among the public, including provisions such as preexisting condition protections and allowing young people to stay on family health plans until they are 26.

Trump supporters and others who have worked in his administration say the former president wants to improve the law in ways that will lower costs. They say he has already shown he will be forceful when it comes to lowering high health care prices, pointing to efforts during his presidency to pioneer price transparency in medical costs.

“On affordability, I’d see him building on the first term,” said Brian Blase, who served as a Trump health adviser from 2017 to 2019. Relative to a Democratic administration, he said, there will be “much more focus” on “minimizing fraud and waste.”

Efforts to weaken the ACA could include slashing funds for enrollment outreach, enabling consumers to purchase more health plans that don’t comply with ACA consumer protections, and allowing insurers to charge sicker people higher premiums.

Democrats say they expect the worst.

“We know what their agenda is,” said Leslie Dach, executive chair of Protect Our Care, a health care policy and advocacy organization in Washington, D.C. He worked in the Obama administration helping to implement the ACA. “They’re going to raise costs for millions of Americans and rip coverage away from millions and, meanwhile, they will give tax breaks to rich people.”

Theo Merkel, director of the Private Health Reform Initiative at the right-leaning Paragon Health Institute, which Blase leads, said the enhanced ACA subsidies extended by the Inflation Reduction Act in 2022 do nothing to improve plans or lower premiums. He said they paper over the plans’ low value with larger government subsidies.

Other Trump supporters say the president-elect may support preserving Medicare’s authority to negotiate drug prices, another provision of the IRA. Trump has championed reducing drug prices, and in 2020 advanced a test model that would have tied the prices of some drugs in Medicare to lower costs overseas, said Merkel, who worked in Trump’s first White House. The drug industry successfully sued to block the program.

Within Trump’s circles, some names have already been floated as possible leaders for the Department of Health and Human Services. They include former Louisiana Gov. Bobby Jindal and Seema Verma, who ran the Centers for Medicare & Medicaid Services during the Trump administration.

Kennedy, who suspended his independent presidential run and endorsed Trump, has told his supporters that Trump promised him control of HHS. Trump said publicly before Election Day that he would give Kennedy a big role in his administration, but he may have difficulty winning Senate confirmation for a Cabinet position.

While Trump has vowed to protect Medicare and said he supports funding home care benefits, he’s been less specific about his intentions for Medicaid, which provides coverage to lower-income and disabled people. Some health analysts expect the program will be especially vulnerable to spending cuts, which could help finance the extension of tax breaks that expire at the end of next year.

Possible changes include the imposition of work requirements on beneficiaries in some states. The administration and Republicans in Congress could also try to revamp the way Medicaid is funded. Now, the federal government pays states a variable percentage of program costs. Conservatives have long sought to cap the federal allotments to states, which critics say would lead to draconian cuts.

“Medicaid will be a big target in a Trump administration,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News.

Less clear is the potential future of reproductive health rights.

Trump has said decisions about abortion restrictions should be left to the states. Thirteen states ban abortion with few exceptions, while 28 others restrict the procedure based on gestational duration, according to the Guttmacher Institute, a research and policy organization focused on advancing reproductive rights. Trump said before the election that he would not sign a national abortion ban.

State ballot measures to protect abortion rights were adopted in seven states, including Missouri, which Trump won by about 18 points, according to preliminary AP reports. Abortion rights measures were rejected by voters in Florida, South Dakota, and Nebraska.

Trump could move to restrict access to abortion medications, used in more than half of abortions, either by withdrawing the FDA’s authorization for the drugs or by enforcing a 19th-century law, the Comstock Act, that abortion opponents say bans their shipment. Trump has said he generally would not use the law to ban mail delivery of the drugs.

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RICHMOND, Vt. — On a warm autumn morning, Roger Brown walked through a grove of towering trees whose sap fuels his maple syrup business. He was checking for damage after recent flooding. But these days, his workers’ health worries him more than his trees’.

The cost of Slopeside Syrup’s employee health insurance premiums spiked 24% this year. Next year it will rise 14%.

The jumps mean less money to pay workers, and expensive insurance coverage that doesn’t ensure employees can get care, Brown said. “Vermont is seen as the most progressive state, so how is health care here so screwed up?”

Vermont consistently ranks among the healthiest states, and its unemployment and uninsured rates are among the lowest. Yet Vermonters pay the highest prices nationwide for individual health coverage, and state reports show its providers and insurers are in financial trouble. Nine of the state’s 14 hospitals are losing money, and the state’s largest insurer is struggling to remain solvent. Long waits for care have become increasingly common, according to state reports and interviews with residents and industry officials.

Rising health costs are a problem across the country, but Vermont’s situation surprises health experts because virtually all its residents have insurance and the state regulates care and coverage prices.

For more than 15 years, federal and state policymakers have focused on increasing the number of people insured, which they expected would shore up hospital finances and make care more available and affordable.

“Vermont’s struggles are a wake-up call that insurance is only one piece of the puzzle to ensuring access to care,” said Keith Mueller, a rural health expert at the University of Iowa.

Regulators and consultants say the state’s small, aging population of about 650,000 makes spreading insurance risk difficult. That demographic challenge is compounded by geography, as many Vermonters live in rural areas, where it’s difficult to attract more health workers to address shortages.

At least part of the cost spike can be attributed to patients crossing state lines for quicker care in New York and Massachusetts. Those visits can be more expensive for both insurers and patients because of long ambulance rides and charges from out-of-network providers.

Patients who stay, like Lynne Drevik, face long waits. Drevik said her doctor told her in April that she needed knee replacement surgeries — but the earliest appointment would be in January for one knee and the following April for the other.

Drevik, 59, said it hurts to climb the stairs in the 19th-century farmhouse in Montgomery Center she and her husband operate as an inn and a spa. “My life is on hold here, and it’s hard to make any plans,” she said. “It’s terrible.”

Health experts say some of the state’s health system troubles are self-inflicted.

Unlike most states, Vermont regulates hospital and insurance prices through an independent agency, the Green Mountain Care Board. Until recently, the board typically approved whatever price changes companies wanted, said Julie Wasserman, a health consultant in Vermont.

The board allowed one health system — the University of Vermont Health Network — to control about two-thirds of the state’s hospital market and allowed its main facility, the University of Vermont Medical Center in Burlington, to raise its prices until it ranked among the nation’s most expensive, she said, citing data the board presented in September.

Hospital officials contend their prices are no higher than industry averages.

But for 2025, the board required the University of Vermont Medical Center to cut the prices it bills private insurers by 1%.

The nonprofit system says it is navigating its own challenges. Top officials say a severe lack of housing makes it hard to recruit workers, while too few mental health providers, nursing homes, and long-term care services often create delays in discharging patients, adding to costs.

Two-thirds of the system’s patients are covered by Medicare or Medicaid, said CEO Sunny Eappen. Both government programs pay providers lower rates than private insurance, which Eappen said makes it difficult to afford rising prices for drugs, medical devices, and labor.

Officials at the University of Vermont Medical Center point to several ways they are trying to adapt. They cited, for example, $9 million the hospital system has contributed to the construction of two large apartment buildings to house new workers, at a subsidized price for lower-income employees.

The hospital also has worked with community partners to open a mental health urgent care center, providing an alternative to the emergency room.

In the ER, curtains separate areas in the hallway where patients can lie on beds or gurneys for hours waiting for a room. The hospital also uses what was a storage closet as an overflow room to provide care.

“It’s good to get patients into a hallway, as it’s better than a chair,” said Mariah McNamara, an ER doctor and associate chief medical officer with the hospital.

For the about 250 days a year when the hospital is full, doctors face pressure to discharge patients without the ideal home or community care setup, she said. “We have to go in the direction of letting you go home without patient services and giving that a try, because otherwise the hospital is going to be full of people, and that includes people that don’t need to be here,” McNamara said.

Searching for solutions, the Green Mountain Care Board hired a consultant who recommended a number of changes, including converting four rural hospitals into outpatient facilities, in a worst-case scenario, and consolidating specialty services at several others.

The consultant, Bruce Hamory, said in a call with reporters that his report provides a road map for Vermont, where “the health care system is no match for demographic, workforce, and housing challenges.”

But he cautioned that any fix would require sacrifice from everyone, including patients, employers, and health providers. “There is no simple single policy solution,” he said.

One place Hamory recommended converting to an outpatient center only was North Country Hospital in Newport, a village in Vermont’s least populated region, known as the Northeast Kingdom.

The 25-bed hospital has lost money for years, partly because of an electronic health record system that has made it difficult to bill patients. But the hospital also has struggled to attract providers and make enough money to pay them.

Officials said they would fight any plans to close the hospital, which recently dropped several specialty services, including pulmonology, neurology, urology, and orthopedics. It doesn’t have the cash to upgrade patient rooms to include bathroom doors wide enough for wheelchairs.

On a recent morning, CEO Tom Frank walked the halls of his hospital. The facility was quiet, with just 14 admitted patients and only a couple of people in the ER. “This place used to be bustling,” he said of the former pulmonology clinic.

Frank said the hospital breaks even treating Medicare patients, loses money treating Medicaid patients, and makes money from a dwindling number of privately insured patients.

The state’s strict regulations have earned it an antihousing, antibusiness reputation, he said. “The cost of health care is a symptom of a larger problem.”

About 30 miles south of Newport, Andy Kehler often worries about the cost of providing health insurance to the 85 workers at Jasper Hill Farm, the cheesemaking business he co-owns.

“It’s an issue every year for us, and it looks like there is no end in sight,” he said.

Jasper Hill pays half the cost of its workers’ health insurance premiums because that’s all it can afford, Kehler said. Employees pay $1,700 a month for a family, with a $5,000 deductible.

“The coverage we provide is inadequate for what you pay,” he said.

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Maria Sanchez immigrated to the Chicago area from Mexico about 30 years ago. Now 87, she’s still living in the U.S. without authorization. Like many longtime immigrants, she has worked — and paid taxes, including Medicare taxes — all that time.

But Sanchez never had health insurance, and when she turned 65, she couldn’t enroll in Medicare. She has never had preventive care or screenings. No physicals. No cholesterol checks. No mammograms.

“Nada, nada, nada,” she said in an interview conducted in Spanish. Nothing, nothing, nothing.

When she did get sick, she delayed seeking care until she was so ill that she was twice hospitalized with pneumonia. She finally got covered last year under a landmark Illinois program for older people without legal residency that took effect in December 2020.

Democratic-led states such as Illinois are increasingly opening public insurance programs to immigrants lacking permanent legal status. A dozen had already covered children; even more provided prenatal coverage. But now more states are covering adults living in the country without authorization — and some are phasing in coverage for seniors, who are more expensive and a harder political sell than kids.

The expansions recognize the costs that patients living here illegally can otherwise impose on hospitals. But the policies are under harsh attack from former President Donald Trump and other Republicans who seek to make his opponent, Vice President Kamala Harris, the face of reckless immigration policies.

Republicans point to Harris’ home state of California’s expansion of Medi-Cal coverage to immigrants of all ages regardless of legal status, saying it comes at the expense of American citizens.

It’s a regular complaint for Trump. “She’ll go around saying, ‘Oh, Trump is going to do bad things to Social Security,’” he said of Harris at a Sept. 13 news conference. “No, she’s going to do it because she’s putting these illegal immigrants onto Social Security, onto Medicare, and she’s going to destroy those programs, and the people are going to have to pay.”

Harris’ choice of Minnesota Gov. Tim Walz as her running mate has added fuel to Republican attacks at the intersection of immigration and health policy.

Under a law Walz signed, immigrants living without authorization in Minnesota will be able to gain health coverage starting next year through the state’s MinnesotaCare program for people with low incomes who aren’t eligible for Medicaid.

The issue is top of mind for some Americans. At an Oct. 10 town hall in Las Vegas, an audience member event host Univision identified as Ivett Castillo asked Harris what her administration would do about health care for people like her mother, who had immigrated from Mexico without authorization many years ago, worked her whole life, and died this year without ever receiving “the type of care and service that she needed or deserved.”

“What are your plans, or do you have plans, to support that subgroup of immigrants who have been here their whole lives, or most of them, and have to live and die in the shadows?” Castillo asked.

Harris noted her past support for a path to citizenship for unauthorized residents — and for a bipartisan border security bill that Senate Republicans killed earlier this year at the behest of Trump.

“This is one example of the fact that there are real people who are suffering because of an inability to put solutions in front of politics,” Harris said.

Even without such policies, immigrants can get free or inexpensive primary care at community clinics throughout the country — assuming they know it’s an option and feel safe at the facilities. But primary care can’t take care of all medical needs, particularly as people age and develop more complex health problems and chronic illnesses. So immigrants often rely on charity care, go into debt, or, like Sanchez, skimp. Some even return to their home countries for care.

Illinois, where Sanchez got covered, was a pioneer in extending insurance coverage to unauthorized migrants. Now, six states and the District of Columbia — all led by Democrats — cover at least some low-income older immigrants under Medicaid or Affordable Care Act waivers. Minnesota next year will become the seventh. State funds must be used for the expansions, as federal dollars generally can’t cover people lacking legal status.

Whether or how quickly more states follow remains to be seen, and if Trump wins the White House, his administration would likely try to thwart the trend, given that he has pledged mass deportations. Coverage for all immigrants is still a tough sell economically and politically — and the noncitizen population can’t vote its gratitude at the ballot box. Immigrant health initiatives in several other states have fizzled or been scaled back.

Maryland, for example, settled on opening its Obamacare exchange to people living in the state without authorization, starting in 2026 — but without taxpayer subsidies for their premiums.

Still, there’s enough activity in states to make advocates for immigrant health believe something has shifted. The pandemic’s severity and its uneven toll helped build support for covering older immigrants, said Lee Che Leong, the senior policy advocate at Northwest Health Law Advocates in Washington state.

“People are looking around and realizing that our health is interconnected, both globally and locally,” Leong said. “The pandemic really brought that home, that when you look at the disparities in who got covid, who was exposed to covid, and who died from covid.”

Access to U.S. health care has long been an obstacle for immigrants, even those in the country legally. People with green cards must wait five years for coverage under Medicaid or other government health programs. Some older green-card holders have to pay extra premiums for Medicare Part A — the portion that covers hospital care — if they haven’t been employed for at least 10 years in the U.S.

The new state health programs close those gaps, said Shelby Gonzales, vice president for immigration policy at the Center on Budget and Policy Priorities.

In July, Washington state started covering low-income immigrants in a Medicaid-like program called Apple Health Expansion, using a federal waiver. Enrollment is capped and the program filled quickly, but some slots were reserved for people 65 and older, Leong said. Earlier this year, the state opened its Obamacare exchange to immigrants living in the U.S. without authorization.

Oregon and Colorado now also offer some coverage to people in their states who lack legal status, though the Colorado program didn’t attract many older immigrants, according to data recently presented to the state Affordable Care Act exchange oversight committee.

New York has covered child immigrants lacking legal residency for years, and the state’s Medicaid program was opened in January to all adult immigrants regardless of status. About 25,000 people signed up in the first four months, according to New York Medicaid Director Amir Bassiri.

Back in Illinois, Maria Sanchez said her new coverage has been life-changing — and possibly lifesaving. Her bouts of pneumonia were severe, partly because she had delayed care. After her second hospitalization, she needed follow-up cardiac care. The hospital didn’t charge her for her stay.

But now, with her “tarjeta médica” — her medical card — she can see a doctor. Her heart condition is under control. She has seen a dentist. She’s getting her cataracts removed.

“With my medical card, I have peace of mind,” Sanchez said.

Illinois has gradually added coverage for other age groups; in summer 2022, it lowered eligibility to age 42. That means immigrants like Gaby Piceno, 45, can age more healthily.

“I don’t have to worry anymore,” she said, referring not just to herself but to her family.

But the coverage expansion has cost more than Illinois projected. People like Sanchez and Piceno, already on the rolls, remain covered, but new enrollment was paused this year. More people signed up than expected, and many continued seeking care in more costly hospital emergency departments rather than at doctors’ offices, said the state’s acting insurance commissioner, Ann Gillespie, who was an Illinois state senator when the program was established.

The state is now shifting covered immigrants into Medicaid managed-care plans, hoping to bring down the cost over time.

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María Sánchez emigró al área de Chicago desde México hace unos 30 años. Ahora, a sus 87, sigue viviendo en Estados Unidos sin papeles. Como muchos inmigrantes de larga data, ha trabajado —y pagado impuestos, incluyendo para Medicare— durante todo ese tiempo.

Pero Sánchez nunca tuvo seguro médico, y cuando cumplió 65, no pudo inscribirse en Medicare. Nunca ha tenido atención preventiva ni exámenes. No ha tenido chequeos físicos, ni mediciones de colesterol, ni mamografías.

“Nada, nada, nada”, dijo.

Cuando enfermaba, tardaba en buscar atención médica hasta que estaba tan mal que fue hospitalizada dos veces por neumonía. Finalmente, el año pasado obtuvo cobertura a través de un programa pionero en Illinois para personas mayores indocumentadas que entró en vigencia en diciembre de 2020.

Estados liderados por demócratas, como Illinois, están abriendo cada vez más programas de seguros públicos a inmigrantes sin papeles. Una docena ya cubría a niños; aún más proporcionaban cobertura prenatal. Pero ahora,  están cubriendo a adultos que viven en el país sin autorización, y algunos están ampliando la cobertura para personas mayores, que son más costosos y representan un desafío político mayor que los niños.

Estas expansiones reconocen los costos que estos pacientes pueden imponer sobre los hospitales. Pero estas políticas están bajo dura crítica del ex presidente Donald Trump y otros republicanos, quienes buscan presentar a su oponente, la vicepresidenta Kamala Harris, como la cara de políticas de inmigración irresponsables.

Los republicanos señalan la expansión de la cobertura de Medi-Cal en el estado natal de Harris, California, a inmigrantes de todas las edades independientemente de su estatus legal, argumentando que esto afecta a los ciudadanos estadounidenses.

Es una queja frecuente de Trump. “Ella va por ahí diciendo, ‘Oh, Trump va a hacer cosas malas con la Seguridad Social’”, dijo sobre Harris en una conferencia de prensa el 13 de septiembre. “No, ella va a hacerlo porque está poniendo a estos inmigrantes ilegales en la Seguridad Social, en Medicare, y va a destruir esos programas, y la gente tendrá que pagar”.

La elección de Harris del gobernador de Minnesota, Tim Walz, como compañero de fórmula ha añadido combustible a los ataques republicanos en la intersección de la inmigración y la política de salud.

Con la esperanza de presentar a la candidata demócrata presidencial Kamala Harris como extrema en inmigración, el ex presidente Trump y sus partidarios han dicho que ella quería otorgar beneficios de salud gratuitos, pagados por los contribuyentes, a inmigrantes en el país sin permiso legal. Pero esta declaración omite detalles clave.

Bajo una ley firmada por Walz, los inmigrantes que viven sin documentos en Minnesota podrán obtener cobertura de salud a partir del próximo año a través del programa MinnesotaCare del estado para personas de bajos ingresos que no son elegibles para Medicaid.

El tema es de gran interés para algunos estadounidenses. En un foro en Las Vegas el 10 de octubre, una integrante del público identificada por Univision como Ivett Castillo le preguntó a Harris qué haría su administración respecto a la atención médica para personas como su madre, quien había emigrado de México sin autorización muchos años atrás, trabajado toda su vida ahasta su muerte este año sin haber recibido “el tipo de atención y servicio que necesitaba o merecía”.

“¿Cuáles son sus planes, o tienen planes, para apoyar a ese subgrupo de inmigrantes que han estado aquí toda su vida, o la mayoría de ellos, y tienen que vivir y morir en las sombras?”, preguntó Castillo.

Harris mencionó su apoyo anterior a un camino a la ciudadanía para residentes sin papeles, y a un proyecto de ley bipartidista de seguridad fronteriza que los republicanos del Senado bloquearon a principios de este año por insistencia de Trump.

“Este es un ejemplo de que hay personas reales que sufren debido a la incapacidad de anteponer soluciones a la política”, dijo Harris.

Incluso sin estas políticas, los inmigrantes pueden recibir atención primaria gratuita o económica en clínicas comunitarias en todo el país, asumiendo que saben que es una opción y se sienten seguros en las instalaciones.

Pero la atención primaria no puede cubrir todas las necesidades médicas, especialmente a medida que las personas envejecen y desarrollan problemas de salud y enfermedades crónicas más complejas. Así que los inmigrantes suelen depender de la atención caritativa, endeudarse o, como Sánchez, evadir al doctor. Algunos incluso regresan a sus países de origen para recibir atención.

Illinois, donde Sánchez obtuvo cobertura, fue pionero en la extensión de cobertura de seguros a migrantes no autorizados. Ahora, seis estados y el Distrito de Columbia —todos liderados por demócratas— cubren al menos a algunos inmigrantes mayores de bajos ingresos bajo Medicaid o exenciones de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Minnesota se convertirá en el séptimo el próximo año. Para estas expansiones se utilizan fondos estatales, ya que los fondos federales generalmente no pueden cubrir a personas sin estatus legal.

Queda por ver si más estados seguirán esta tendencia y cuán rápido, y si Trump gana la Casa Blanca, es probable que su administración intente frenar esta tendencia, dado que ha prometido deportaciones masivas.

La cobertura para todos los inmigrantes sigue siendo una propuesta difícil tanto económica como políticamente, y la población no ciudadana no puede agradecer votando. Las iniciativas de salud para inmigrantes en varios otros estados han fracasado o se han reducido.

Maryland, por ejemplo, decidió abrir su mercado del Obamacare a personas que viven en el estado sin autorización a partir de 2026, pero sin subsidios de los contribuyentes para sus primas.

Aun así, hay suficiente actividad en los estados para que defensores de la salud de los inmigrantes crean que algo ha cambiado. La gravedad de la pandemia y su impacto desigual ayudaron a generar el apoyo para cubrir a inmigrantes mayores, dijo Lee Che Leong, defensora principal de políticas en Northwest Health Law Advocates en el estado de Washington.

“La gente está mirando a su alrededor y se da cuenta de que nuestra salud está interconectada, tanto global como localmente”, dijo Leong. “La pandemia realmente mostró eso, cuando miras las disparidades en quién se contagió de covid, quién estuvo expuesto a covid y quién murió por covid”.

Durante mucho tiempo, el acceso a la atención médica en el país ha sido un obstáculo para los inmigrantes, incluso aquellos que tienen papeles. Las personas con tarjetas de residencia deben esperar cinco años para obtener cobertura bajo Medicaid u otros programas de salud del gobierno. Algunos personas mayores con residencia tienen que pagar primas adicionales para Medicare Parte A —la parte que cubre la atención hospitalaria— si no han trabajado al menos 10 años en Estados Unidos.

Los nuevos programas de salud estatales cierran estas brechas, dijo Shelby Gonzales, vicepresidenta de política de inmigración en el Center on Budget and Policy Priorities.

En julio, el estado de Washington comenzó a cubrir a inmigrantes de bajos ingresos en un programa similar a Medicaid llamado Apple Health Expansion, utilizando una exención federal.

La inscripción es limitada y el programa se llenó rápidamente, pero se reservaron algunos lugares para personas de 65 años o más, dijo Leong. A principios de este año, el estado abrió su mercado de Obamacare a inmigrantes que viven en los EE. UU. sin autorización.

Oregon y Colorado ahora también ofrecen alguna cobertura a personas en sus estados que carecen de estatus legal, aunque el programa de Colorado no atrajo a muchos inmigrantes mayores, según datos presentados hace poco al comité de supervisión del mercado de ACA.

Nueva York ha cubierto a niños inmigrantes sin documentos durante años, y el programa de Medicaid del estado se abrió en enero para todos los inmigrantes adultos independientemente de su estatus. Aproximadamente 25,000 personas se inscribieron en los primeros cuatro meses, según el director de Medicaid de Nueva York, Amir Bassiri.

De vuelta en Illinois, María Sánchez dijo que su nueva cobertura ha cambiado su vida, y posiblemente le ha salvado la vida. Sus episodios de neumonía fueron graves, en parte porque retrasó la atención. Después de su segunda hospitalización, necesitó atención cardíaca de seguimiento. El hospital no le cobró por su estadía.

Pero ahora, con su “tarjeta médica”, puede ver a un médico. Su condición cardíaca está bajo control. Ha visto a un dentista. Va a tener una operación de cataratas. “Con mi tarjeta médica, tengo paz mental”, dijo Sánchez.

llinois ha agregado gradualmente cobertura para otros grupos de edad; en el verano de 2022, redujo la elegibilidad a los 42 años. Eso significa que inmigrantes como Gaby Piceno, de 45, pueden envejecer de manera más saludable.

“Ya no tengo que preocuparme”, dijo, refiriéndose no solo a sí misma, sino a su familia.

Pero la expansión de la cobertura ha costado más de lo proyectado en Illinois. Personas como Sánchez y Piceno, ya inscritas, siguen cubiertas, pero este año se frenó la nueva inscripción. Se inscribieron más personas de lo esperado, y muchas continuaron buscando atención en salas de emergencia de hospitales más costosos en lugar de en consultorios médicos, dijo la comisionada interina de seguros del estado, Ann Gillespie, quien era senadora estatal en Illinois cuando se estableció el programa.

El estado ahora está transfiriendo a los inmigrantes cubiertos a planes de atención administrada de Medicaid, con la esperanza de reducir el costo con el tiempo.

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It’s that time of year again: open enrollment for Affordable Care Act insurance — a period that runs from tomorrow to Jan. 15 in most states, a bit longer in some, and shorter in Idaho.

One of the biggest changes this time around: a new rule from the Biden administration that opens enrollment to Deferred Action for Childhood Arrivals recipients. DACA is a federal program offering some protection from deportation and providing work authorization to some people brought to the country as children by family members lacking permanent legal residency.

While the rule could allow an estimated 100,000 DACA recipients to sign up for health insurance in 2025, its fate is uncertain. That’s because it’s being challenged in federal court by Kansas and 18 other states, including Virginia, New Hampshire, North Dakota, and several others in the South and Midwest.

Separately, 19 states and D.C. filed a brief in support of the Biden administration rule that allows DACA recipients to enroll in ACA plans. Those states, led by New Jersey, include many on the East and West Coasts, including California, New York, Oregon and Washington.

The plaintiff states argue that the rule will cause management and resource burdens as more people enroll, and that it will encourage additional people to remain in the United States when they don’t have the proper paperwork. The lawsuit, filed in U.S. District Court for the District of North Dakota in August, seeks to postpone the rule’s effective date and overturn it, saying the expansion of the “lawfully present” definition by the Biden administration violates the law.

ACA plans are open to American citizens and lawfully present immigrants. Now the group often dubbed “Dreamers” will qualify as lawfully present for the purpose of enrolling and applying for tax credits to help cover premiums.

“More than one third of DACA recipients currently do not have health insurance, so making them eligible to enroll in coverage will improve their health and wellbeing, and help the overall economy,” Health and Human Services Secretary Xavier Becerra said in a May news release.

On Oct. 15, the district court heard arguments in the case, and a ruling might come soon, said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute’s Health Care Litigation Tracker.

But that hearing also launched a flurry of related motions and orders. For instance, U.S. District Judge Daniel Traynor ordered the federal government to provide North Dakota with the names of 128 DACA recipients in the state, under seal, to calculate any financial costs associated with complying with the Biden administration rule in order to determine whether the case should be heard there. The state has until Nov. 12 to respond. The federal government sought to squelch the order, but Traynor denied the request Monday.

And there could be more back-and-forth.

Once Traynor issues a final ruling in the case, it could be appealed by either side, delaying resolution of the lawsuit possibly into next year, when the outcome of Tuesday’s presidential election might also play a role. A new administration, for example, could issue new rules to change or reverse decisions made by the Biden administration.

Find more here on sign-up season, including deadlines, projected premium increases and scams.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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CITRUS COUNTY, Fla. — It was hard enough for Stephanie to get methadone treatment when she moved to Florida from Indiana last year. The nearest clinic was almost an hour’s drive away and she couldn’t drive herself. But at least she didn’t have to worry about the cost of care.

As a parent with young children who was unable to find a job after moving, Stephanie qualified for Medicaid despite Florida’s tight eligibility rules. The state insurance program for people with low incomes or disabilities covers the methadone she needs to reduce her opioid cravings and prevent withdrawal sickness.

For nearly a decade, methadone has helped her hold down a job and take care of her kids. “Just have a normal, really normal, life,” said Stephanie, 39, who asked that her last name be withheld because her two youngest children don’t know about her history of opioid use disorder or that she has been in treatment for opioid addiction. “All the things that some people take for granted.”

So it was devastating for Stephanie when she visited her clinic in summer 2023 and learned she had been dropped from the state’s Medicaid rolls as the program worked to redetermine the eligibility of each enrollee. Suddenly, her methadone prescription cost much more than she could afford.

She panicked, afraid a disruption in care would trigger debilitating withdrawal symptoms like vomiting, fever, cramps, joint pain, and tremors. “That’s the first thing I thought,” she said. “I’m going to be so sick. How am I going to get up and take care of the kids?”

As of September, more than 25 million Americans — including 1.9 million Floridians — had lost Medicaid coverage since the expiration of federal covid-19 pandemic protections in March 2023 that had kept people continually enrolled. Among them were patients in treatment for opioid addiction, such as Stephanie, for whom a loss of coverage could be deadly.

Research shows that, when taken as prescribed, medications for opioid use disorder — such as methadone and a similar medicine, buprenorphine — can reduce dangerous drug use and cut overdose fatalities by more than half. Other studies have found the risk of overdose and death increases when treatment is interrupted.

It is unclear how many people with opioid addiction have lost coverage in the Medicaid disenrollment, known as the “unwinding.” But researchers at KFF, a health information nonprofit that includes KFF Health News, estimate that more than 1 million low-income Americans depend on the federal-state Medicaid program for lifesaving addiction care.

At Operation PAR — a nonprofit addiction treatment provider from which Stephanie and thousands of others along Florida’s Gulf Coast get care — the percentage of opioid treatment patients with Medicaid has dropped from 44 to 28 since the unwinding began last year, the organization said.

Dawn Jackson, who directs Operation PAR’s newest clinic, about an hour north of Tampa in the small Citrus County city of Inverness, said it has been a struggle trying to stretch limited grant dollars to cover the recent surge of uninsured patients.

“There’s been sleepless nights,” Jackson said. “We’re saving lives — we’re not handing out Happy Meals here.”

Methadone and buprenorphine are considered the gold standard of care for opioid addiction. The drugs work by binding to the brain’s opioid receptors to block cravings and withdrawal symptoms without making a person feel high. Treatment reduces illicit drug use and the accompanying overdose risk.

However, few Americans who could benefit from the medicines actually receive them: The latest federal data shows that in 2021 only about 1 in 5 people who needed the medicines got them. The low numbers offer a sharp contrast to the record-high drug overdose epidemic, which killed nearly 108,000 Americans in 2022 and is driven primarily by opioids.

Zachary Sartor, a family medicine doctor in Waco, Texas, who specializes in addiction treatment, described the effect of such medications as “nothing short of remarkable.”

“The evidence in the medical literature shows us that things like employment and quality of life overall increase with access to these medications, and that definitely bears out with what we see in the clinic,” Sartor said. “That benefit just seems to grow over time as people stay on medications.”

Sartor, who works at a safety net clinic, prescribes buprenorphine, and most of his patients are uninsured or on Medicaid. Some are among the 2.5 million Texans who lost coverage during the state’s unwinding, he said, causing their out-of-pocket buprenorphine costs to abruptly rise as much as fourfold.

The loss of coverage — which also cuts access to health care beyond addiction treatment — often requires patients to make risky trade-offs.

Sartor said that can mean patients having to choose between medications to treat their addiction and drugs for other medical conditions. “You start to see the cycle of patients having to ration their care,” he said.

Many people who lost their insurance in the Medicaid unwinding have since seen it reinstated. But even a brief disruption in care is serious for someone with opioid use disorder, said Maia Szalavitz, a journalist and an author who writes about addiction.

“If you want to save people’s lives and you have a lifesaving medication available, you don’t interrupt their access to health care,” Szalavitz said. “They end up in withdrawal and they end up dying.”

When Stephanie lost her Medicaid coverage last year, Operation PAR was able to subsidize her out-of-pocket methadone costs, so she paid only $30 a week. That was inexpensive enough for her to stick with treatment for the six months it took to restore her Medicaid coverage.

But the patchwork of federal and state grants that Operation PAR uses to cover uninsured patients doesn’t always meet demand, and waiting lists for subsidized methadone treatment are not uncommon, said Jackson, who directs the clinic in Citrus County.

Even before the Medicaid unwinding, about 13% of people younger than 65 in Florida were uninsured, one of the highest rates in the country, according to census data. Florida is also one of 10 states that have not expanded Medicaid for low-income adults.

Jon Essenburg, chief business officer at Operation PAR, said a recent infusion of opioid settlement money wiped out the group’s waiting lists, at least for now. But he said settlement dollars — Florida expects to receive $3.2 billion over 18 years from opioid manufacturers and distributors — are not a long-term solution to persistent coverage gaps, which is why stabler reimbursement sources like Medicaid can help.

“Turning people away over money is the last thing we want to do,” Jackson said. “But we also know that we can’t treat everybody for free.”

Stephanie is grateful she never had to go without her medicine.

“I don’t even want to think about what it would have been like if they wouldn’t have worked with me and helped me with the funding,” Stephanie said. “It would have been a very dark rabbit hole, I’m afraid.”

Kim Krisberg is a contributing writer for Public Health Watch and co-leads the reporting project The Holdouts. Stephanie Colombini is a reporter for WUSF’s Health News Florida project.

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 spring, a few days after his 2nd birthday, Brigland Pfeffer was playing with his siblings in their San Diego backyard.

His mother, Lindsay Pfeffer, was a few feet away when Brigland made a noise and came running from the stone firepit, holding his right hand. She noticed a pinprick of blood between his thumb and forefinger when her older son called out, “Snake!”

“I saw a small rattlesnake coiled up by the firepit,” she said.

Pfeffer called 911, and an ambulance transported Brigland to Palomar Medical Center Escondido.

The Medical Procedure

When they arrived, Brigland’s hand was swollen and purple.

Antivenom, an antibody therapy that disables certain toxins, is usually administered via an intravenous line, directly into the bloodstream. But emergency room staffers struggled to insert the IV.

“They had so many people in that room trying his head, his neck, his feet, his arms — like, everything to find a vein,” Pfeffer said.

Still unable to start the antivenom, a doctor asked for her permission to try drastic measures. “Just get something going,” she recalled pleading.

It worked. Using a procedure that delivers medicine into the bone marrow, the medical team gave Brigland a starting dose of the antivenom Anavip.

He was transferred to the pediatric intensive care unit at Rady Children’s Hospital, where he received more Anavip.

The swelling that had spread to his armpit slowly decreased. A couple of days later, he left the hospital with his grateful parents.

Then the bills came.

The Final Bill

$297,461, which included two ambulance rides, an emergency room visit, and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278.80 of the total bill.

The Billing Problem: The High Cost of Antivenom

The Centers for Disease Control and Prevention estimates venomous snakes bite 7,000 to 8,000 people in the United States every year. About five people die. That number would be higher, the agency says, if not for medical treatment.

Many snakebites happen far from medical care, and not all emergency rooms keep costly antivenom in stock, which can add big ambulance bills to already expensive care.

It often takes more than a dozen vials, typically costing thousands per vial, to treat a snakebite. The median number per patient is 18 vials, said Michelle Ruha, an emergency room doctor in Arizona and a former president of the American College of Medical Toxicology.

Manufacturing, which hasn’t fundamentally changed since antivenom was developed more than a century ago, does not explain the high price. Venomous creatures are milked, then a small, non-harmful amount of toxin is injected into animals like horses or sheep. Antibodies are extracted from their blood and processed to make antivenom.

Why the high price? One explanation is that hospitals mark up products to balance overhead costs and generate revenue.

Brigland received Anavip at two hospitals that charged different prices.

Palomar, where emergency staffers treated Brigland, charged $9,574.60 per vial, for a total of $95,746 for the starting dose of 10 vials of Anavip.

Rady, the largest children’s hospital on the West Coast, charged $5,876.64 for each vial. For the 20 vials Brigland received there, the total was $117,532.80.

Neither hospital responded to requests for comment.

Those charges are “eye-popping,” said Stacie Dusetzina, who is a professor of health policy at Vanderbilt University Medical Center and reviewed the bills at the request of KFF Health News. “When you see the word ‘charges,’ that’s a made-up number. That isn’t connected at all, usually, to what the actual drug cost.”

For instance, Medicare — the government program for those who are at least 65 or disabled — pays about $2,000 for a vial of Anavip. On average, Dusetzina said, that is the price hospitals pay for it.

Leslie Boyer, a doctor and toxicology researcher, helped found a group that was instrumental in developing Anavip, as well as the other available snake antivenom, CroFab, which dominated the market for decades. In 2015, she published an editorial in the American Journal of Medicine breaking down the “true” cost of antivenom. (Boyer declined to comment for this article.)

Using cost data collected from factory supervisors, animal managers, hospital pharmacists and other sources, Boyer developed a model for a hypothetical antivenom, at a final cost of $14,624 per vial. She found the cost of venom, included in that total, was just 2 cents. Manufacturing accounted for $9 of the $14,624 total.

More than 70% of the price tag — $10,250 — is attributable to hospital markups, her research showed.

Another explanation for antivenom’s high cost is a lack of meaningful competition. Anavip entered the market in 2018 as the only competitor to CroFab. But its makers settled a patent infringement lawsuit with CroFab’s maker, requiring the makers of Anavip to pay royalties until 2028.

Anavip debuted at a retail price of $1,220 per vial. Boyer noted that the price later rose to cover the manufacturers’ millions of dollars in legal costs.

The Resolution

The insurer covering Brigland — Sharp Health Plan, which did not respond to requests for comment — negotiated down the antivenom charges by tens of thousands of dollars.

The cost was mostly covered by insurance. Brigland’s family paid $7,200, their plan’s out-of-pocket maximum.

Insurance did not pay all the claims, including one ambulance bill. Pfeffer said she received a letter this summer indicating they owe an additional $11,300 for Brigland’s care. While the landmark No Surprises Act protects patients from many out-of-network bills in emergencies, the law controversially exempted bills for ground ambulances.

Brigland’s hand healed, though nerve damage and scar tissue have left his right thumb less dexterous. He is now left-handed.

“He’s very, very lucky,” Pfeffer said.

The family has since installed snake fencing around the yard.

The Takeaway

There’s a saying in toxicology: Time is tissue. If bitten by a snake, “get to medical care,” Ruha said.

Not all emergency rooms have antivenom, and there are no online resources identifying which ones do. Ruha recommends going to a large hospital, which is more likely to have antivenom in stock than free-standing emergency rooms.

When the bill comes, be ready to negotiate, Dusetzina said. Providers know their charges are high and may be willing to take less.

You can compare the charges against average prices using cost estimation tools like Fair Health Consumer or Healthcare Bluebook.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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KINGSTREE, S.C. — One morning in late April, a small brick health clinic along the Thurgood Marshall Highway bustled with patients.

There was Joshua McCray, 69, a public bus driver who, four years after catching covid-19, still is too weak to drive.

Louvenia McKinney, 77, arrived complaining about shortness of breath.

Ponzella McClary brought her 83-year-old mother-in-law, Lula, who has memory issues and had recently taken a fall.

Morris Brown, the family practice physician who owns the clinic, rotated through Black patients nearly every 20 minutes. Some struggled to walk. Others pulled oxygen tanks. And most carried three pill bottles or more for various chronic ailments.

But Brown called them “lucky,” with enough health insurance or money to see a doctor. The clinic serves patients along the infamous “Corridor of Shame,” a rural stretch of South Carolina with some of the worst health outcomes in the nation.

“There is a lot of hopelessness here,” Brown said. “I was trained to keep people healthy, but like 80% of the people don’t come see the doctor, because they can’t afford it. They’re just dying off.”

About 50 miles from the sandy beaches and golf courses along the coastline of this racially divided state, Morris’ independent practice serves the predominantly Black town of roughly 3,200 people. The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease.

But South Carolina remains one of the few states where lawmakers refuse to expand Medicaid, despite research that shows it would provide medical insurance to hundreds of thousands of people and create thousands of health care jobs across the state.

The decision means there will be more preventable deaths in the 17 poverty-stricken counties along Interstate 95 that constitute the Corridor of Shame, Brown said.

“There is a disconnect between policymakers and real people,” he said. The African Americans who make up most of the town’s population “are not the people in power.”

The U.S. health care system, “by its very design, delivers different outcomes for different populations,” said a June report from the National Academies of Sciences, Engineering, and Medicine. Those racial and ethnic inequities “also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity.”

Over a recent two-decade span, mounting research shows, the United States has made almost no progress in eliminating racial disparities in key health indicators, even as political and public health leaders vowed to do so.

And that’s not an accident, according to academic researchers, doctors, politicians, community leaders, and dozens of other people KFF Health News interviewed.

Federal, state, and local governments, they said, have put systems in place that maintain the status quo and leave the well-being of Black people at the mercy of powerful business and political interests.

Across the nation, authorities have permitted nearly 80% of all municipal solid waste incinerators — linked to lung cancer, high blood pressure, higher risk of miscarriages and stillbirths, and non-Hodgkin lymphoma — to be built in Black, Latinx, and low-income communities, according to a complaint filed with the federal government against the state of Florida.

Federal lawmakers slowed investing in public housing as people of color moved in, leaving homes with mold, vermin, and other health hazards.

And Louisiana and other states passed laws allowing the carrying of concealed firearms without a permit even though gun violence is now the No. 1 killer of kids and teens. Research shows Black youth ages 1 to 17 are 18 times as likely to suffer a gun homicide as their white counterparts.

“People are literally dying because of policy decisions in the South,” said Bakari Sellers, a Democratic former state representative in South Carolina.

KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients.

From the cradle to the grave, Black Americans suffer worse health outcomes than white people. They endure greater exposure to toxic industrial pollution, dangerously dilapidated housing, gun violence, and other social conditions linked to higher incidence of cancer, asthma, chronic stress, maternal and infant mortality, and myriad other health problems. They die at younger ages, and covid shortened lives even more.

Disparities in American health care mean Black people have less access to quality medical care, researchers say. They are less likely to have health insurance and, when they seek medical attention, they report widespread incidents of discrimination by health care providers, a KFF survey shows. Even tools meant to help detect health problems may systematically fail people of color.

All signs point to systems rooted in the nation’s painful racist history, which even today affects all facets of American life.

“So much of what we see is the long tail of slavery and Jim Crow,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a nonprofit think tank.

Put simply, said Jameta Nicole Barlow, a community health psychologist and professor at George Washington University, government actions send a clear message to Black people: “Who are you to ask for health care?”

Past and Present

The end of slavery gave way to laws that denied Black people in the U.S. basic rights, enforced racial segregation, and subjected them to horrific violence.

“I can take facts from 100 years ago about segregation and lynchings for a county and I can predict the poverty rate and life expectancy with extraordinary precision,” said Luke Shaefer, a professor of social justice and public policy at the University of Michigan.

Starting in the 1930s, the federal government sorted neighborhoods in 239 cities and deemed redlined areas — typically home to Black people, Jews, immigrants, and poor white people — unfit for mortgage lending. That process concentrated Black people in neighborhoods prone to discrimination.

Local governments steered power plants, oil refineries, and other industrial facilities to Black neighborhoods, even as research linked them to increased risks of cardiovascular and respiratory diseases, cancer, and preterm births.

The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year. Elevated rates of six diseases, including cancer, addiction, and diabetes, accounted for more than 80% of the excess mortality for Black and other minority populations, according to “The Heckler Report,” released in 1985. During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems. The design of the U.S. health care system and structural barriers have led to persistent health inequities that cost more than a million lives and billions of dollars, according to the national academies report.

“When covid was first hitting, it was just sort of immediately clear who was going to suffer the most,” Ducas said, “not just because of differential access to care, but who was in a living environment that’s multigenerational or crowded, who is more likely to be in a job where they are an essential worker, who is going to be more reliant on public transportation.”

For example, in spring 2020, the North Carolina health department, led by current Centers for Disease Control and Prevention Director Mandy Cohen, failed to get covid testing to vulnerable Black communities where people were getting sick and dying from covid-related causes at far higher rates than white people.

And Black Americans were far more likely to hold jobs — in areas such as transportation, health care, law enforcement, and food preparation — that the government deemed essential to the economy and functioning of society, making them more susceptible to covid, according to research.

Until McCray, the bus driver in Kingstree, South Carolina, got covid in his mid-60s, he was strong enough to hold two jobs. He ended up on a feeding tube and a ventilator after he contracted covid in 2020 while taking other essential workers from this predominantly Black area to jobs in a whiter, wealthier tourist town.

Now he cannot work and at times has difficulty walking.

“I can tell you the truth now: It was only the good Lord that saved him,” said Brown, the rural physician who treated McCray and many patients like him.

Federal and state governments have spent billions of dollars to implement the Affordable Care Act, the Children’s Health Insurance Program, and other measures to increase access to health care. Yet, experts said, many of the problems identified in “The Heckler Report” persist.

When Lakeisha Preston in Mississippi was diagnosed with walking pneumonia in 2019, she ended up with a $4,500 medical bill she couldn’t pay. Preston works at Maximus, which has a $6.6 billion contract with the federal government to help people sign up for Medicare and Affordable Care Act health plans.

She is convinced that being a Black woman made her challenges more likely.

“Think about how many centuries the same thing has been happening,” said Preston, noting how her mother worked two jobs her entire life without a vacation and suffered from health conditions including diabetes, cataracts, and carpal tunnel syndrome. Today Preston can’t afford to put her 8-year-old son on her health plan, so he’s covered by Medicaid.

“We consistently offer healthcare plans that are on par, if not better, than those available to most Americans through state and federal exchanges,” said Eileen Cassidy Rivera, a Maximus spokesperson.

In email exchanges with the Biden administration, spokespeople insisted that it is making progress in closing the racial health gap. They said officials have taken steps to address food insecurity, housing instability, pollution, and other social determinants of health that help fuel disparities.

President Joe Biden issued an executive order on his first full day in office in 2021 that said “the COVID-19 pandemic has exposed and exacerbated severe and pervasive health and social inequities in America.” Later that year, the White House issued another executive order focused on improving racial equity and acknowledged that long-standing racial disparities in health care and other areas have been “at times facilitated by the federal government.”

“The Biden-Harris Administration is laser focused on addressing the health needs of Black Americans by dismantling persistent structural inequities,” said Renata Miller, a spokesperson for the administration.

The CDC, along with some state and local governments, declared racism a serious public health threat.

U.S. Rep. Alma Adams, a North Carolina Democrat, pushed for “Momnibus” legislation to reduce maternal mortality. Yet federal lawmakers left money for Black maternal health out of the historic Inflation Reduction Act in 2022.

“I come to this space as an elected official, knowing what it is like to be poor, knowing what it is like to not have insurance and having to get up at 3, 4 in the morning with my mom to take my sister to the emergency room,” Adams said.

In the 1960s in North Carolina, Adams and her family would take her sister Linda, who had sickle cell anemia, to the emergency room because they had no doctor and could not afford health insurance. Linda died at the age of 26 in 1971.

“You have to have some sensitivity for this work,” Adams said. “And a lot of folks that I’ve worked with don’t have it.”

Governor’s Veto

The website for Kingstree depicts idyllic images of small-town life, with white people sitting on a porch swing, kayaking on a river, eating ice cream, and strolling with their dogs. Two children wearing masks and a food vendor are the only Black people in the video, even though Black people make up 70% of the town’s population.

But life in Kingstree and surrounding communities is marked by poverty, a lack of access to health care, and other socioeconomic disadvantages that have given South Carolina poor rankings in key health indicators such as rates of death and obesity among children and teens.

Some 23% of residents in Williamsburg County, which contains Kingstree, live below the poverty line, about twice the national average, according to federal data.

There is one primary care physician for every 5,080 residents in Williamsburg County. That’s far less than in more urbanized and wealthier counties in the state such as Richland, Greenville, and Beaufort.

Edward Simmer, the state’s interim public health director, said that if “you are African American in a rural zone, it is like having two strikes against you.”

Asked if South Carolina should expand Medicaid, Simmer said the challenges South Carolina and other states confront are worsened by health care provider shortages and structural inequities too large and complicated for Medicaid expansion alone to solve.

“It is not a panacea,” he said.

But for Brown and others, the reason South Carolina remains one of the few states that have not expanded Medicaid — one step that could help narrow disparities with little cost to the state — is clear.

“Every year we look at the data, we see the health disparities and we don’t have a plan to improve,” Brown said. “It has become institutionalized. I call it institutional racism.”

A July report from George Washington University found that Medicaid expansion would provide insurance to 360,000 people and add 18,000 jobs in the health care sector in South Carolina.

“Racism is the reason we don’t have Medicaid expansion. Full stop,” said Janice Probst, a former director of the Rural and Minority Health Research Center in South Carolina. “These are not accidents. There is an idea that you can stay in power by using racism.”

South Carolina’s Republican governor, Henry McMaster, in July vetoed legislation that would have created a committee to consider Medicaid expansion, saying he did not believe it would be “fiscally responsible.”

Expanding Medicaid in the state could result in $4 billion in additional economic output from an influx of federal funds in 2026, according to the July report.

Beyond health care coverage and provider shortages, Black people “have never been given the conditions needed to thrive,” said Barlow, the George Washington University professor. “And this is because of white supremacy.”

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Tom Zawierucha, 58, a building services worker in New Jersey, wishes candidates would talk more about protecting older Americans from big medical bills.

Teresa Morton, 43, a freight dispatcher in Memphis, Tennessee, with two teenagers, wants to hear more about how elected officials would help working Americans saddled with unaffordable deductibles.

Yessica Gray, 28, a customer support representative in Wisconsin, craves relief from high drug prices and medical bills that have driven her and her husband deep into debt. “How much are we going to pay?” she said. “It’s just something that’s always on my mind.”

Health care hasn’t figured prominently in this increasingly acrimonious presidential campaign. And the economy has generally topped the list of voters’ concerns.

But Americans remain intensely worried about paying for medical care, national surveys show.

Two in 3 U.S. adults in a recent nationwide poll by West Health and Gallup said they’re concerned a major health event would land them in debt. A similar share said health care isn’t getting enough attention in the campaign.

To better understand voters’ health care concerns as the 2024 campaign nears an end, KFF Health News worked with research firm PerryUndem, which convened a pair of focus groups last week with 16 people from across the country. PerryUndem, which paid to organize the focus groups, is a nonpartisan firm based in Washington, D.C., that studies public views on health care and other issues.

The focus group participants represented a broad swath of the electorate, with some favoring Republican candidates, and others Democrats. But nearly all shared a common complaint: Neither presidential candidate has talked enough about how they’d help people struggling to pay for medical care.

“You don’t really hear anything much about health care costs,” said Bob Groegler, 46, who works in residential financing in eastern Pennsylvania. Groegler said he’s worried he may never be able to retire because he won’t have enough money to pay his medical bills.

Former President Donald Trump, the Republican nominee, hasn’t offered a detailed health care agenda, though he criticizes current laws and said he has “concepts of a plan” to improve the 2010 Affordable Care Act, often called Obamacare.

Vice President Kamala Harris, a Democrat, has laid out more detailed health care proposals, including building on legislation signed by President Joe Biden to lower patients’ bills.

In 2022, Biden signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35 monthly cap on insulin. The legislation also provides additional federal aid to help Americans buy health insurance through the Affordable Care Act, though this aid will expire unless Congress and the president renew it next year.

Harris has said she will expand the aid and push for new assistance to Medicare enrollees who need home care. She also has pledged to continue federal efforts to relieve medical debt, a nationwide problem that burdens about 100 million people.

But most of the focus group participants said they knew little about these proposals, complaining that hot-button issues like abortion have dominated the campaign.

Many also expressed deep skepticism that either Harris or Trump would do much to lighten the burden of medical bills.

“I believe they’re out of touch with our reality,” said Renata Bobakova, 46, a teacher and mother outside Cleveland. “We never know when we’ll get sick. We never know when we’ll fall down or sprain an ankle. And prices really can be astronomical. … I’m constantly worried about that.”

Bobakova, who is from Slovakia, said she went back to Europe to give birth to her daughter 10 years ago to avoid crippling medical debt she knew she’d incur in this country. Parents with private health coverage face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance.

Other focus group participants said they or people they knew had left the country to get cheaper prescription drugs. The U.S. has the highest medical prices in the world, research shows.

Several focus group participants, such as Kevin Gaudette, 64, a retired semiconductor engineer in North Carolina, blamed large hospitals, drug companies, and insurers for blocking efforts to lower patients’ costs to protect their profits. “I think everybody has their finger in the pie,” Gaudette said.

Martha Chapman, 64, who is also retired and lives in Philadelphia, pointed to what she called “corporate greed.” “I just don’t think it’s going to change,” she said.

In the closing days of the campaign, that cynicism represents a particular problem for Harris, said PerryUndem co-founder Michael Perry, who led the two focus groups.

Harris has tried to distinguish herself as the candidate who is more serious about policy and more sympathetic to voters’ economic struggles, Perry said. And in recent weeks, she’s begun airing new ads highlighting health care issues.

But even focus group participants who said they lean Democratic seemed to blame both candidates for not addressing Americans’ health care concerns. “They’re not feeling listened to,” Perry said.

Many of the participants nevertheless continued to express hope that an issue as important as health care would someday get the attention of elected officials, regardless of political party.

“We’re all human beings here. We’re all people just trying to make it,” said Zawierucha, the building services worker in New Jersey. “If we get sick or have to go in and get something done, we should have that peace of mind that we can go in there and not have to worry about paying it off for the next 20 years.”

“Just give us some peace of mind,” he said.

[Clarification: This article was revised at 11:35 a.m. ET on Oct. 24, 2024, to more clearly describe how the focus groups were organized.]

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).