When Alyne Diamond fell off a horse in August 2023 and broke her back, her employer-based health plan through UnitedHealthcare covered her emergency care in Aspen, Colorado. It also covered related pain management and physical therapy after she returned home to New York City. The bills totaled more than $100,000.

The real estate lawyer, now 67, was eligible for Medicare at the time but hadn’t enrolled. Since she was still working, she thought her employer health insurance plan would cover her.

That misunderstanding has had financial repercussions that she continues to deal with today.

More than a year after her riding accident, Diamond was back at the emergency room after she tripped on a step while entering a New York restaurant. Her face covered in blood, Diamond was examined by staff, who did multiple CT scans. The bill for that care: $12,000.

This time, though, the insurance coverage wasn’t routine. Nearly all her claims were denied.

Diamond was caught in a fairly common coverage snag: People who have group health insurance when they become eligible for Medicare sometimes find themselves on the hook for their medical bills because their group plan stops paying.

Diamond contacted several people at UnitedHealthcare before she found out why the insurer refused to pay her claims.

When Diamond turned 65 in 2022, Medicare — unbeknownst to her — became the “primary payer” for her claims, meaning the federal health program for older or disabled people was supposed to take the lead in covering her medical bills, before other insurers paid anything. (As secondary payer, Diamond’s employer policy picked up 20% of what Medicare would have paid.)

Had she signed up for the government insurance plan when she turned 65, Diamond could have avoided a financially perilous situation that left her unexpectedly responsible for the medical costs she incurred during that time.

She began to understand what had happened as she made inquiries about the denied claims.

Diamond said she was told that UnitedHealthcare audited her claims last year and determined it had been improperly paying for her care, perhaps because her pricey medical claims after her fall from the horse raised a red flag.

The insurer not only stopped paying current claims but also moved to claw back tens of thousands of dollars it had paid to providers in the two years since she turned 65. Some of those providers are now seeking payment from her.

“It’s horrifying,” she said. “For about two months I was devastated. I thought, ‘Where am I going to get the money to pay all these people? There goes my retirement.’”

The mistake has already cost her $25,000 and may cost her much more if providers continue to bill her for amounts that UnitedHealthcare has clawed back for care she received before signing up for Medicare in February.

A UnitedHealthcare spokesperson declined to provide an on-the-record statement, citing safety concerns.

Patient advocates say they frequently hear from people who, like Diamond, thought they didn’t need to sign up for Medicare upon turning 65 because they had group health coverage.

That assumption is generally correct if they or their spouse is working at a company with at least 20 employees. In that case, employer coverage is considered primary and they can delay signing up for Medicare as long as they or their spouse continues to be employed there.

But if someone has employer coverage through a company with fewer than 20 workers, Medicare generally becomes the primary payer when they turn 65. The real estate law firm at which Diamond is a partner has a handful of employees.

Similarly, if someone is older than 65 and has retiree health coverage or has left their job and opted to continue their employer coverage under the Consolidated Omnibus Budget Reconciliation Act, also known as COBRA, Medicare pays first. The issue can also arise for people who are younger than 65 if they are eligible for Medicare because of a disability. In those instances, Medicare pays first if they or their family member works at a company with fewer than 100 employees.

If people in these groups don’t sign up for Medicare when they become eligible, they can find themselves responsible for all their medical bills for years. (They may also owe a penalty for late enrollment in the Medicare program.)

“It’s very alarming and there’s no current fix to the situation,” said Fred Riccardi, president of the New York-based Medicare Rights Center, a national patient advocacy organization.

The Centers for Medicare & Medicaid Services did not respond to a request for comment.

Mark Scherzer, a lawyer in Germantown, New York, who helps people with insurance problems, and who advised Diamond, said he gets calls a couple of times a month from people who face this issue.

“What I see constantly now is that insurers go back and they claw back the money from the doctor and the doctor then claws the money back from the patient,” he said.

Costly claims may trigger an insurer to examine someone’s coverage.

Those big claims “seem to get on the insurer’s radar,” said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center.

UnitedHealthcare has recouped over $50,000 in medical bills from some of the providers who treated Diamond in New York after her riding accident. She’s paid them about $25,000 so far. Some have agreed to let her pay the amount Medicare would have paid.

But there may be more bills to come. Under New York law, health plans have two years after claims are paid to claw back payments from providers, and providers have three years to sue patients for medical debt. So, while there is still time for Diamond to be billed, the clock will eventually run out.

Diamond plans to sue the broker who manages her company’s health plan and other benefits for negligence.

“The Medicare secondary payment rules basically say that if you didn’t sign up because you didn’t know Medicare was supposed to be primary, that’s on you,” said Melanie Lambert, senior Medicare advocate at the Center for Medicare Advocacy in Connecticut.

Lambert said she has seen the issue “many, many times.” In some instances, if a beneficiary can demonstrate they were misled by an employer or a federal employee, they may qualify for relief or a special enrollment period, she said.

In a 2023 letter to the acting secretary of the Department of Labor, the National Association of Insurance Commissioners advocated applying a “commonsense rule to COBRA plans, individual health insurance, and other coverage sources: those entitled to Medicare Part B but not enrolled in it should not lose benefits they pay for from a non-Medicare coverage source.”

The Department of Labor didn’t respond to a request for comment.

In earlier times, people started collecting Social Security benefits then automatically got Medicare when they turned 65.

Now, enrolling in Medicare is more complicated for many people, said Tricia Neuman, a senior vice president and the executive director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

“As more people are delaying going on Social Security and delaying going on Medicare, there’s more opportunities for people to make mistakes, and those mistakes are costly,” Neuman said.

Coverage experts say there are no clear requirements for insurers, employers, or the federal government to notify people about how the payment rules governing coordination of benefits between health plans may change when they become eligible for Medicare.

The information appears in a chart in the government’s “Medicare & You” handbook, if someone knows to look for it. But it is not easy to find.

A straightforward fix could solve many of the problems people face in this area, Scherzer said. Since every health plan knows its enrollees’ ages, why not require them to notify people approaching 65 of possible benefit coordination issues with Medicare? “It’s so simple and such a no-brainer.”

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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MIAMI — Josefina Muralles works a part-time overnight shift as a receptionist at a Miami Beach condominium so that during the day she can care for her three kids, her aging mother, and her brother, who is paralyzed.

She helps her mother feed, bathe, and give medicine to her adult brother, Rodrigo Muralles, who has epilepsy and became disabled after contracting covid-19 in 2020.

“He lives because we feed him and take care of his personal needs,” said Josefina Muralles, 41. “He doesn’t say, ‘I need this or that.’ He has forgotten everything.”

Though her husband works full time, the arrangement means their household income is just above the federal poverty line — too high to qualify for Florida’s Medicaid program but low enough to make Muralles and her husband eligible for subsidized health insurance through the Affordable Care Act marketplace, also known as Obamacare.

Next year, Muralles said, she and her husband may not be able to afford that health insurance coverage, which has paid for her prescription blood thinners, cholesterol medication, and two surgeries, including one to treat a genetic disorder.

Extra subsidies put in place during the pandemic — which reduced the premiums Muralles and her husband paid by more than half, to $30 a month — are in place only through Dec. 31. Without enhanced subsidies, Affordable Care Act insurance premiums would rise by more than 75% on average, with bills for people in some states more than doubling, according to estimates from KFF, a health information nonprofit that includes KFF Health News.

Florida and Texas would be hit especially hard, as they have more people enrolled in the marketplace than other states. Some of their congressional districts alone, especially in South Florida, have more people signed up for Obamacare than entire states.

Like many of the more than 24 million Americans enrolled in the insurance marketplace this year, Muralles was unaware that the enhanced subsidies are slated to expire. She said she cannot afford a premium hike because inflation has already eaten into her household’s budget.

“The rent is going up,” she said. “The water bill is going up.”

Low-income enrollees like the Muralles couple would see the biggest percentage increases in premiums if enhanced subsidies expire.

Middle-income enrollees who earn more than four times the federal poverty line would no longer be eligible for subsidies at all. Those middle-income enrollees (who earn at least $62,600 for a single person in 2025) are disproportionately older, self-employed, and living in rural areas.

Julio Fuentes, president of the Florida State Hispanic Chamber of Commerce, said many of his organization’s members are small business owners who rely on Obamacare for health coverage.

“It’s either this or nothing,” he said.

The Congressional Budget Office estimated that letting the enhanced subsidies expire would, by 2034, increase the number of people without health insurance by 4.2 million. In tandem with changes to Medicaid in the House of Representatives’ reconciliation bill and the Trump administration’s proposed rules for the marketplace, including toughening income verification and shortening enrollment periods, it would increase the number of uninsured people by 16 million over that time period.

A study by the Urban Institute, a nonprofit think tank, found that Hispanic and Black people would see greater coverage losses than other groups if the extra subsidies lapse.

Fuentes noted that about 5 million Hispanics are enrolled in the ACA marketplace, and that Donald Trump won the Hispanic vote in Florida in 2024. He hopes the president and congressional Republicans see extending the enhanced subsidies as a way to hold on to those voters.

“This is probably a good way, or a good start, to possibly grow that base even more,” he said.

Enrollment in the marketplace has grown faster since 2020 in the states won by Trump in 2024. A recent KFF survey found that 45% of Americans who buy their own health insurance identify as or lean Republican, including 3 in 10 who identify as Make America Great Again supporters. Smaller shares identify as Democrats or Democratic-leaning independents (35%) or do not lean toward either party (20%).

Kush Desai, a White House spokesperson, said the rules proposed by the Trump administration, combined with the provisions in the House-passed budget bill, would “strengthen the ACA marketplace.” He noted that the CBO projects the legislation would reduce premiums for some plans about 12% on average by 2034 — but out-of-pocket costs would rise or remain the same for most subsidized ACA consumers.

“Democrats know Americans broadly support ending waste, fraud, and abuse, as The One, Big, Beautiful Bill does, which is why they are desperately trying to change the conversation,” Desai said.

But Lauren Aronson, executive director of Keep Americans Covered, a group in Washington, D.C., representing health insurers, hospitals, physicians, and patient advocates, said it is critical to raise awareness about the likely impact of losing the enhanced subsidies, which are also known as advanced premium tax credits. She is encouraged that Democrats have proposed legislation to extend the enhanced tax credits, and that some Republican senators have voiced support.

What worries Aronson most is that the Republican-controlled Congress is more focused on extending tax cuts than enhanced subsidies, she said. The current bill extending the 2017 tax cuts would increase the federal deficit by about $2.4 trillion over the next decade, according to the CBO, while making the enhanced subsidies permanent would increase the deficit by $358 billion over roughly the same period.

“Congress is moving forward on a tax reconciliation package that purports to benefit working families,” Aronson said. “But if you don’t take care of the tax credits, working families will be left holding the bag.”

Brian Blase, president of Paragon Health Institute, a conservative health policy think tank, said the enhanced subsidies were supposed to be a temporary measure during the covid-19 pandemic to help people at risk of losing coverage.

Instead, he said, the enhanced subsidies facilitated fraud because enrollees did not need to verify their income eligibility to receive zero-premium plans if they reported incomes at or near the federal poverty level.

The enhanced subsidies also worsen health inflation, discourage employers from offering health insurance benefits, and crowd out alternative models, such as short-term insurance and Farm Bureau plans, Blase said.

“Permitting these subsidies to expire would just be going back to Obamacare as it was written,” Blase said. “That is a more efficient program than the program that we have now.”

New rules for the marketplace proposed by the Trump administration in March are already designed to address fraud, said Anna Howard, a policy expert with the American Cancer Society Cancer Action Network, which advocates for increased health insurance coverage. Howard said extending the enhanced tax credits would help ensure that people who are legitimately eligible for coverage can get it.

“We don’t want to see over 5 million people be kicked off their health insurance coverage out of fears of fraud when the policies being proposed don’t necessarily address fraud,” she said.

Without affordable premiums, many consumers will turn to short-term health plans, health care cost-sharing ministries, and other forms of coverage that do not have the benefits or protections of the health law, she said.

“These are plans that don’t provide coverage for prescription drugs, or they have lifetime and annual limits,” she said. “For a cancer patient, those plans don’t work.”

Though the enhanced subsidies do not expire until the end of the year, the Blue Cross Blue Shield Association would prefer Congress to act by fall to avoid confusion during open enrollment, said David Merritt, a senior vice president. Insurers are preparing rates to meet state deadlines. By October, consumers will receive 60-day plan renewal notices with their 2026 premiums.

Without enhanced subsidies, Merritt said, competition in the marketplace will wither, leading to fewer coverage options and higher prices, especially in states that have not expanded Medicaid eligibility and where Obamacare enrollment spiked during the past four years, like Florida and Texas. “Voters and patients are really going to see the impact,” he said.

Republican and Democratic representatives for some of the Florida congressional districts with the highest numbers of people in the marketplace did not respond to repeated interview requests.

Muralles, of North Miami, Florida, said she wants her representatives to work in the interest of constituents like herself, who need health insurance coverage to care for their families.

“Now is the time to prove to us that they are with us,” Muralles said. “When everybody’s healthy, everybody goes to work, everybody can pay taxes, everybody can have a better life.”

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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Nearly two-thirds of adults oppose President Donald Trump’s “One Big Beautiful Bill” approved in May by the House of Representatives, according to a KFF poll released Tuesday.

And even Trump’s most ardent supporters like the legislation a lot less when they learn how it would cut federal spending on health programs, the poll shows.

The KFF poll found that about 61% of Republicans and Republican-leaning independents — and 72% of the subset who identify with Trump’s “Make American Great Again” movement — support the bill, which would extend many of Trump’s 2017 tax cuts while reducing spending on domestic programs, including cutting billions from Medicaid.

But when pollsters told survey respondents about the bill’s consequences for health care, opposition grew, including among MAGA supporters.

For example, after being told that the bill would decrease funding for local hospitals and increase the number of people without health insurance, support among those who back MAGA dropped more than 20 percentage points — resulting in fewer than half the group still backing the bill.

Ashley Kirzinger, KFF’s director of survey methodology and associate director of its Public Opinion and Survey Research program, said it’s no surprise polling shows that party affiliation affects how most of the public views the bill.

“But the poll shows that support, even among MAGA supporters, drops drastically once the public hears more about how the bill could impact local hospitals and reduce Medicaid coverage,” she said.

“This shows how the partisan lens wears slightly when the public learns more about how the legislation could affect them and their families.”

KFF is a health policy research, polling, and news organization that includes KFF Health News.

House Speaker Mike Johnson, a Louisiana Republican who won passage of the legislation in the chamber he controls by a single vote on May 22, has insisted the bill would not “cut Medicaid.” The nonpartisan Congressional Budget Office, which calculates the effects of legislation on the nation’s deficits and debt, says the measure would reduce federal spending on Medicaid by $793 billion over 10 years, resulting in nearly 8 million more people becoming uninsured.

The bill is encountering strident opposition from the health industry, most notably hospitals that expect to see large cuts in funding as a result of millions of people losing Medicaid coverage. The House-passed legislation would increase the frequency of eligibility checks and require that most nondisabled adults regularly prove they are working, studying, or volunteering at least 80 hours a month to keep their coverage.

“This is common sense,” Johnson said May 25 on the CBS News program “Face the Nation.” “And when the American people understand what we are doing here, they applaud it.”

Critics say the bill marks the latest attempt by Republicans to roll back the Affordable Care Act.

As the Senate moves toward a possible vote on its version of the legislation before Independence Day, the KFF poll shows Medicaid and the ACA are more popular than ever.

About 83% of adults support Medicaid, including large majorities of Democrats (93%), independents (83%), and Republicans (74%). That’s up from 77% in January, with the poll finding the biggest jump in favorability among Republicans.

Medicaid and the related Children’s Health Insurance Program cover about 78 million people who are disabled or have low incomes.

About two-thirds of adults hold favorable views of the ACA, the most since the law’s enactment in 2010, as recorded in KFF polls. The law has only been consistently popular with a majority of adults since about 2021.

Views of the ACA remain split along partisan lines, with most Republicans (63%) holding unfavorable views and most Democrats (94%) and independents (71%) viewing it favorably.

The poll found other indications that the public may not understand key provisions of the GOP bill, including its work requirements.

The poll finds two-thirds of the public — including the vast majority of Republicans (88%) and MAGA supporters (93%) and half (51%) of Democrats — initially support requiring nearly all adults on Medicaid to prove they are working or looking for work, in school, or doing community service, with exceptions such as for caregivers and people with disabilities.

However, attitudes toward this provision shifted dramatically when respondents were presented with more information.

For example, when told most adults with Medicaid are already working or unable to work, and that those individuals could lose coverage due to the challenge of documenting it, about half of supporters changed their view, resulting in nearly two-thirds of adults opposing Medicaid work requirements and about a third supporting them.

The poll of 1,321 adults was conducted online and by telephone June 4-8 and has a margin of error of plus or minus 3 percentage points.

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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Cuts to Medicaid and other federal health programs proposed in President Donald Trump’s budget plan would rapidly push more than 300 financially struggling rural hospitals toward a fiscal cliff, according to researchers who track the facilities’ finances.

The hospitals would be at a disproportionate risk of closure, service reductions, or ending inpatient care, according to a report authored by experts from the Cecil G. Sheps Center for Health Services Research following a request from Senate Democrats, who released the findings publicly Thursday. Many of those hospitals are in Kentucky, Louisiana, California, and Oklahoma, according to the analysis.

Trump’s budget plan, dubbed the “One Big Beautiful Bill Act,” contains nearly $700 billion in Medicaid cuts, according to the nonpartisan Congressional Budget Office. House Republicans passed the bill in late May, and it now awaits Senate consideration.

The proposed cuts to Medicaid raise the stakes for rural hospitals nationwide, many of which already operate on razor-thin, if not negative, margins. Diminished reimbursements from the state-federal health insurance program for those with low incomes or disabilities would further erode hospitals’ ability to stay open and maintain services for their communities — populations with more severe health needs than their urban counterparts.

“It’s very clear that Medicaid cuts will result in rural hospital closures,” said Alan Morgan, CEO of the National Rural Health Association, a nonprofit advocacy and research organization.

The Senate Democrats sent a letter to Trump, Senate Majority Leader John Thune, and House Speaker Mike Johnson asking them to reconsider the Medicaid cuts.

Sen. Edward Markey (D-Mass.), one of the Senate Democrats who requested the information from Sheps, in a statement said communities should know exactly what they stand to lose if Congress approves the reductions to Medicaid.

“People will die” if rural hospitals close, he said. “No life or job is worth a yes vote on this big billionaire bill.”

Hospitals that do stay afloat likely will do so by cutting services that are particularly dependent on Medicaid reimbursements, such as labor and delivery units, mental health care, and emergency rooms. Obstetric services are among the most expensive and are being eliminated by a growing number of rural hospitals, expanding the areas that lack nearby maternity or labor and delivery care. Iowa, Texas, and Minnesota had the most rural obstetrics service closures between 2011 and 2023, according to the health analytics and consulting firm Chartis, which also studies rural hospital finances.

Nearly half of rural hospitals are operating in the red and 432 are vulnerable to closure. Medicaid cuts would push them further into financial peril.

That vulnerability stems at least partly from rural Americans’ being more likely to depend on Medicaid than the general population. For instance, nearly 50% of rural births are covered by the program, compared with 41% of births overall. But Medicaid covers only about half of what private insurance reimburses for childbirth-related services. Rural health systems have been struggling to meet the needs of their communities without the cuts to Medicaid, which brings in $12.2 billion, or nearly 10% of rural hospital net revenue, according to a Chartis report from May.

Hospitals in rural areas would collectively lose more than $1.8 billion with a 15% cut to Medicaid. That loss in revenue is roughly equivalent to 21,000 full-time hospital employees’ salaries.

Rural hospitals’ margins have been deteriorating for 10 to 15 years, said Michael Topchik, executive director for the Chartis Center for Rural Health, which analyzes and consults on rural hospital finances. Ten years ago, about one-third of rural hospitals were operating in the red. That’s closer to 50% now, he said.

It’s even higher in the 10 states that did not expand Medicaid eligibility under the Affordable Care Act, with 53% of rural hospitals there already operating in the red and more than 200 vulnerable to closure.

Other policies continue to affect rural hospitals, according to Chartis. Facilities will lose $509 million this year due to a 2% Medicare reimbursement cut — what’s known as sequestration — and $159 million in reimbursement for bad debt and charity care combined.

Some rural hospitals have responded to the increasing financial pressures in recent years by joining larger networks, such as Intermountain Health or Sanford, which are connected to facilities in the Mountain West and Midwest. But about half of rural hospitals are still independent, Topchik said, and struggle with a perennial collision of low patient volume and high fixed costs.

“We can’t Henry Ford our way out of this by increasing volumes to dilute costs and reduce prices,” he said. “It’s expensive, and that’s the reason the federal government, for a long time, has reimbursed rural hospitals in a variety of manners to help keep them whole.”

Rural hospitals play an important role in their communities. They provide health care to Americans who are older, sicker, and poorer and have less access overall to providers compared with people who live in urban areas. In many cases, a local rural hospital is the largest employer in a community and can trigger substantial local economic declines if it closes.

“When you close a hospital, oftentimes, the community follows,” Morgan said.

More than 10 million Americans enrolled in Medicaid live in counties that have at least one rural hospital, according to Chartis estimates. Kentucky, Texas, New York, North Carolina, California, and Michigan have the largest estimated populations of rural Medicaid enrollees.

And while Utah is not a state identified as especially vulnerable, health leaders there are concerned about rural hospital closures if Medicaid funding is cut, said Matt McCullough, the rural hospital improvement director for the Utah Hospital Association.

Facilities in rural parts of Utah are often governed by a board made up of community members — farmers, ranchers, and business owners who care about keeping their hospitals open, McCullough said, because they were born there and their kids were born there.

“They’ll do anything to see it stay open and provide good quality care to their neighbors, family members,” he said. “It’s people that they know and care about.”

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“One out of every $5 or $6 in Medicaid [payments] is improper.”

Russell Vought stated on June 1, 2025, in an interview on CNN’s “State of the Union.”

Responding to charges that President Donald Trump’s tax and spending bill would cut Medicaid coverage for millions of Americans, Trump administration officials misleadingly counter that it targets only waste, fraud, and abuse.

During an interview on CNN’s “State of the Union,” Russell Vought, the administration’s director of the Office of Management and Budget, framed Medicaid as sagging under the weight of improper payments.

An “improper” payment refers to payments made erroneously to beneficiaries and their providers or without sufficient documentation.

Pressed June 1 by CNN host Dana Bash about concerns that low-income Americans would suffer if the bill becomes law, Vought called such arguments “totally ridiculous.”

“This bill will preserve and protect the programs, the social safety net, but it will make it much more commonsense,” Vought said. “Look, one out of every $5 or $6 in Medicaid [payments] is improper.”

That would mean Medicaid’s improper payment rate is 16% to 20%.

In a 2024 report covering the years 2022, 2023, and 2024, Medicaid’s parent agency — the Centers for Medicare & Medicaid Services — said the rate was about 5.1%.

One conservative group, the Paragon Health Institute, said the agency has been using an incomplete calculation method and that the percentage could be as high as 25%. Other experts told PolitiFact that the actual numbers could be higher than what the federal government reports, although not as high as Paragon’s estimate.

The White House did not respond to an inquiry for this article.

How High Is the Medicaid Improper Payment Rate?

Medicaid and its closely related Children’s Health Insurance program provides health care and long-term care to roughly 83 million lower-income beneficiaries, accounting for about one-fifth of health care spending overall. It is funded through a mix of federal and state money and is administered by states under federal government rules.

Every year, the Centers for Medicare & Medicaid Services publishes official numbers for the share of improper Medicaid payments, and in other federal health insurance programs the agency oversees.

In a 2024 review of payments made in 2022, 2023, and 2024, the agency found that 5.09% of Medicaid payments totaling $31.10 billion were improper.

The 5.09% rate represented a decrease from the 8.58% rate cited in its 2023 report, which was also based on a three-year time span. The 2024 figure represented the third consecutive annual decline.

Are These Numbers Complete?

In March 2025, Brian Blase, a conservative health policy analyst and president of Paragon Health, a health policy think tank, co-authored a report that said the official CMS improper payment rate figures were unrealistically low for eight of the past 10 years, because in some years the agency failed to undergo widespread auditing of its beneficiaries’ Medicaid eligibility.

From 2017 to 2019, during Trump’s first term, Blase served as Trump’s special assistant for economic policy. Before that, he served as a health policy analyst for the Senate Republican Policy Committee and has worked for the Heritage Foundation, a conservative think tank.

The report said if the agency’s analysis had looked at eligibility checks every year, more ineligible beneficiaries and payments on their behalf would have been discovered. The report said this might have increased the improper payment rate as high as 25%, based on the rates found in 2020 and 2021, when a high number of eligibility checks were included in the agency’s methodology.

However, it’s hard to confirm whether lack of eligibility auditing caused higher improper payment rates in 2020 and 2021, said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, a liberal think tank.

Wagner said Medicaid enrollment procedures have fluctuated, which could help explain the higher rates in some years rather than others. Using two years of data to generalize about trends across a decade, she said, is not necessarily valid.

Robert Westbrooks, the federal Pandemic Response Accountability Committee executive director who worked in government oversight roles during Democratic and Republican administrations, told PolitiFact it’s plausible that the officially reported improper payment rates for Medicaid could be too low.

However, Westbrooks said pinpointing how much higher the rate is in reality is a speculative process. “I don’t believe anyone can credibly quantify the [difference],” he said.

What Is an Improper Payment?

Health care experts emphasized that improper payments are not the same thing as waste, fraud, or abuse.

CMS maintains official definitions for these terms:

• Fraud: “When someone knowingly deceives, conceals, or misrepresents to obtain money or property from any health care benefit program.”
• Waste: “Overusing services or other practices that directly or indirectly result in unnecessary costs to any health care benefit program. Examples of waste are conducting excessive office visits, prescribing more medications than necessary, and ordering excessive laboratory tests.”
• Abuse: “When health care providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any health care benefit program,” which can include overbilling or misusing billing codes.

By contrast, an improper payment “includes any payment to an ineligible recipient, any payment for an ineligible good or service, any duplicate payment, any payment for a good or service not received, and any payment that does not account for credit for applicable discounts,” KFF, a health information nonprofit that includes KFF Health News, wrote this year.

“Although all fraudulent payments are improper, not all improper payments are fraudulent,” said Jessica Tillipman, associate dean for government procurement law at George Washington University’s law school. “Most providers identify the improper payments and return them knowing how aggressively enforced” the legal provisions are. “When they don’t, they open the door to significant liability.”

CMS said about 79% of improper payments happened when there was insufficient documentation.

This typically involved cases in which a state or provider missed an administrative step, and it did not necessarily indicate fraud or abuse, the agency said. Instead, it could be an accidental oversight or mistake.

In other words, it was rare for ordinary beneficiaries to be scamming the government. “The vast majority of fraud in Medicaid is committed by providers or other actors, not enrollees,” Wagner said.

Our Ruling

Vought said that “one out of every $5 or $6 in Medicaid [payments] is improper.”

The official improper payment rate calculated by the Centers for Medicare & Medicaid Services in 2024 was about 5%, smaller than the 16% to 20% rate Vought described.

A health policy analyst and former Trump adviser said methodological shortcomings in the agency’s analysis could mean the rate is as high as 25%. Although it’s possible the rate is higher than the 5% the government reported, how much higher is speculative.

The statement contains an element of truth but ignores critical facts, namely the federal government’s own data. We rate the statement Mostly False.

Our Sources

Russell Vought, interview with CNN’s “State of the Union,” June 1, 2025.

Centers for Medicare & Medicaid Services, “Fiscal Year 2024 Improper Payments Fact Sheet,” Nov. 15, 2024.

Centers for Medicare & Medicaid Services, “PERM Error Rate Findings and Reports,” accessed June 4, 2025.

Centers for Medicare & Medicaid Services, “2024 Medicaid & CHIP Supplemental Improper Payment Data,” accessed June 4, 2025.

Paymentaccuracy.gov, “Annual Improper Payments Datasets,” accessed June 3, 2025.

KFF, “5 Key Facts About Medicaid Program Integrity — Fraud, Waste, Abuse and Improper Payments,” March 18, 2025.

KFF, “Virtual Event Transcript — The Health Wonk Shop: Understanding Fraud and Abuse in Medicaid,” April 24, 2025.

Paragon Health Institute, “Medicaid’s True Improper Payments Double Those Reported by CMS,” March 3, 2025.

Government Accountability Office, “Improper Payments: Information on Agencies’ Fiscal Year 2024 Estimates,” March 11, 2025.

Email interviews with Tammie Smith and Craig Palosky, spokespersons for KFF, June 2, 2025.

Email interview with Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities.

Email interview with Jessica Tillipman, associate dean for government procurement law at George Washington University’s law school, June 3, 2025.

Email interview with Robert Westbrooks, Pandemic Response Accountability Committee executive director who worked in government oversight roles during Democratic and Republican administrations, June 3, 2025.

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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ST. PAUL, Minn. — High school senior Joshua Yang understands sacrifice. When he was midway through 10th grade, his mom survived a terrible car crash. But her body developed tremors, and she lost mobility. After countless appointments, doctors diagnosed her with Parkinson’s disease, saying it was likely triggered by brain injuries sustained in the wreck.

At 15, Yang, an aspiring baseball player and member of his school’s debate team, took on a new role: his mother’s caregiver.

Researchers estimate that Yang, now 18, counted among at least 5.4 million U.S. children who provide care to an adult in their home. As state officials eye federal Medicaid funding cuts that could drastically reduce home care services for those who are disabled or have chronic health conditions, many predict that number will rise.

That’s bad news for kids: Studies show that when young people take on care for adults with medical conditions, their health and academic outcomes decline. At the same time, their loved ones receive untrained care.

“It all fell to me,” said Yang, whose sisters were 9 and 10 at the time of their mom’s accident, and whose stepdad worked nights. His grades fell and he quit after-school activities, he said, unable to spare the time.

Early on, Yang found reprieve from a personal care nurse who gave them supplies, such as adult diapers, and advice on items to purchase, such as a chair for the shower. And for about a year, Yang was able to work for a personal care agency and earn $1,000 a month caring for his mom — money that went toward her medication and family needs.

But at the beginning of 11th grade, a change to his mom’s insurance ended her personal care benefit, sending him into a runaround with his county’s Medicaid office in Minnesota. “For a solid month I was on my phone, on hold, in the back of the class, waiting for the ‘hello,’” he said. “I’d be in third period, saying, ‘Mr. Stepan, can I step out?’”

A report published in May by the U.S. Government Accountability Office reminded states that National Family Caregiver Support Program grants can be used to assist caregivers under 18. However, the future of those grants remains unclear: They are funded through the Older Americans Act, which is awaiting reauthorization; and the Administration for Community Living, which oversees the grants, was nearly halved in April as part of the reorganization of the Department of Health and Human Services under President Donald Trump.

Additionally, if Congress approves proposed cuts to Medicaid, one of the first casualties likely will be states’ home- and community-based service programs that provide critical financial relief to family caregivers, said Andrew Olenski, an economist at Lehigh University specializing in long-term health care.

Such programs, which differ by state but are paid for with federal dollars, are designed to ensure that Medicaid-eligible people in need of long-term care can continue living at home by covering in-home personal and nursing care. In 2021, they served almost 5% of all Medicaid participants, costing about $158 billion.

By law, Medicaid is required to cover necessary long-term care in a nursing home setting but not all home or community care programs. So, if states are forced to make cuts, those programs are vulnerable to being scaled back or eliminated.

If an aide who makes daily home visits, for example, is no longer an option, family caregivers could step in, Olenski said. But he pointed out that not all patients have adult children to care for them, and not all adult children can afford to step away from the workforce. And that could put more pressure on any kids at home.

“These things tend to roll downhill,” Olenski said.

Some studies show benefits to young people who step into caregiving roles, such as more self-confidence and improved family relationships. Yang said he feels more on top of things than his peers: “I have friends worrying about how to land a job interview, while I’ve already applied to seven or eight other jobs.”

But for many, the cost is steep. Young caregivers report more depression, anxiety, and stress than their peers. Their physical health tends to be worse, too, related to diet and lack of attention to their own care. And caregiving often becomes a significant drag on their education: A large study found that 15- to 18-year-old caregivers spent, on average, 42 fewer minutes per day on educational activities and 31 fewer minutes in class than their peers.

Schools in several states are taking notice. In Colorado, a statewide survey recently included its first question about caregiving and found that more than 12% of high schoolers provide care for someone in their home who is chronically ill, elderly, or disabled.

Rhode Island’s education department now requires every middle and high school to craft a policy to support caregiving students after a study published in 2023 found 29% of middle and high school students report caring for a younger or older family member for part of the day, and 7% said the role takes up most of their day. Rates were higher for Hispanic, Asian, and Black students than their white peers.

The results floored Lindsey Tavares, principal of Apprenticeship Exploration School, a charter high school in Cranston. Just under half her students identified as caregivers, she said. That awareness has changed conversations when students’ grades slip or the kids stop showing up on time or at all.

“We know now that this is a question we should be asking directly,” she said.

Students have shared stories of staying home to care for an ill sibling when a parent needs to work, missing school to translate doctors’ appointments, or working nights to pitch in financially, she said. Tavares and her team see it as their job to find an approach to help students persist. That might look like connecting the student to resources outside the school, offering mental health support, or working with a teacher to keep a student caught up.

“We can’t always solve their problem,” Tavares said. “But we can be really realistic about how we can get that student to finish high school.”

Rhode Island officials believe their state is the first to officially support caregiving students — work they’re doing in partnership with the Florida-based American Association for Caregiving Youth. In 2006, the association formed the Caregiving Youth Project, which works with schools to provide eligible students with peer group support, medical care training, overnight summer camp, and specialists tuned in to each student’s specific needs. This school year, more than 700 middle and high school students took part.

“For kids, it’s important for them to know they’re not alone,” said Julia Belkowitz, a pediatrician and an associate professor at the University of Miami who has studied student caregivers. “And for the rest of us, it’s important, as we consider policies, to know who’s really doing this work.”

In St. Paul, Joshua Yang had hoped to study civil engineering at the University of Minnesota, but decided instead to attend community college in the fall, where his schedule will make it simpler to continue living at home and caring for his mom.

But he sees some respite on the horizon as his sisters, now 12 and 13, prepare to take on a greater share of the caregiving. They’re “actual people” now with personalities and a sense of responsibility, he said with a laugh.

“It’s like, we all know that we’re the most meaningful people in our mom’s life, so let’s all help out,” he said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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On Christmas Day at the WaTiki indoor water park, Hans Wirt was getting winded from following his son up the stairs to the waterslides.

Wirt’s breathing became more labored once they returned to the nearby hotel where they and Wirt’s girlfriend were staying while visiting family in Rapid City, South Dakota.

Then he grew nauseated and went pale. Wirt thought the cause might have been the altitude change between his home in Deltona, Florida — 33 feet above sea level — and Rapid City, at the edge of the Black Hills. But his 12-year-old son was worried and called for an ambulance.

“I could tell by the look in his eyes that there was something a little more to this,” Wirt said. “So I can kind of thank my son for saving my life.”

It turned out the 62-year-old was having a heart attack. A “lousy Christmas present,” Wirt said.

Medics stabilized Wirt before taking him to Monument Health — the only hospital in Rapid City with an emergency room — where he was treated over two days.

Then the bill came.

The Medical Procedure

Paramedics used a defibrillator to restore a normal heart rhythm. Doctors at the hospital gave Wirt various medications, used an electrocardiograph and other diagnostic and monitoring devices, and inserted stents into his arteries to improve blood flow to his heart.

The Final Bill

$95,523.73, including $32,998.90 for medical supplies, mostly related to the stents, and $28,879 for treatment in a cardiac catheterization lab. After unspecified hospital adjustments to the bill, Wirt owed $77,574.44.

The Billing Problem: Medicaid Across State Lines

Wirt is covered by Florida’s Medicaid program through Sunshine Health, a managed-care plan. But the South Dakota hospital refused to submit the bill to his out-of-state Medicaid plan, instead sending it to Wirt and eventually threatening to send the debt to a collection agency.

Medicaid, the government health insurance program primarily for low-income people and those with disabilities, is jointly funded by the federal government and states. States are responsible for administering Medicaid, and most contract with private insurance companies like Sunshine Health.

Federal law says state Medicaid programs must reimburse out-of-state hospitals for beneficiaries’ care in an emergency.

Many hospitals bill out-of-state Medicaid plans in such situations. If they don’t, they risk not being reimbursed at all, since Medicaid recipients probably won’t be able to afford large bills, said Katy DeBriere, who was legal director for the Florida Health Justice Project when she spoke with KFF Health News in April.

But there’s no federal law that requires them to do so, she said.

Federal court opinions have noted that hospitals are not required to bill Medicaid for every individual beneficiary they treat, even if they generally accept Medicaid.

Monument Health didn’t bill Wirt’s insurance because the hospital isn’t enrolled as a health care provider with Florida Medicaid, said hospital spokesperson Stephany Chalberg. She told KFF Health News that Monument bills Medicaid plans only in South Dakota and four bordering states: Wyoming, Montana, Nebraska, and Minnesota.

The hospital’s website says Medicaid patients who are not enrolled in one of those states “are responsible for any charges.”

“Due to the significant credentialing requirements of our multiple hospitals and hundreds of physicians we do not participate with all states,” a hospital representative wrote in a message to Wirt.

According to Florida’s Medicaid website, out-of-state providers who have treated one of its enrollees must submit five documents to bill the program, including a six-page application, a copy of the provider’s license, and a claim form.

The process is different in each state, and many Medicaid programs reimburse out-of-state providers at lower rates than those that are in-state, according to the Medicaid and CHIP Payment and Access Commission, a federal agency that advises Congress.

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Provider enrollment barriers leave “beneficiaries in an untenable situation, preventing them from accessing the coverage to which they are legally entitled,” Chalberg said.

Wirt decided to submit his bill to his Medicaid plan on his own. But he said Sunshine Health told him it can only process bills received directly from providers.

Elizabeth Boyd, a spokesperson for Sunshine Health, told KFF Health News that its staff contacted the hospital on Wirt’s behalf. She did not respond when asked why the plan can’t process bills submitted by patients or what more it could have done to help Wirt.

The Resolution

A few days after KFF Health News emailed officials at Monument Health for this story, Wirt noticed his balance due fell from more than $77,000 to $0.

Chalberg told KFF Health News that Monument Health covered Wirt’s bill through its charity care program. She said that “appropriate patients” are told about the program and that “before any bill is sent to collections, it is evaluated to determine whether the patient may qualify for our financial assistance policy.”

To retain tax-exempt status, nonprofit hospitals must have programs that provide free or discounted care to patients who can’t afford their bills.

But Wirt said that when he first contacted Monument Health after receiving his bill and said he couldn’t afford to pay it, officials didn’t mention the program. He said they didn’t share any resources when he asked whether there were outside groups that could help him pay the bill. Wirt said hospital officials just recommended setting up a payment plan, but the monthly bills were still too high for him to afford. “There’s a reason why I’m on Medicaid,” Wirt said. “It’s just beyond me how they can expect somebody who had Medicaid to come up with that kind of money. It’s unrealistic.”

The Takeaway

Sarah Somers, legal director at the National Health Law Program, said the various “cogs in the Medicaid system” didn’t operate correctly in Wirt’s situation. “Nobody’s exerting themselves enough to just smooth the way for this person.”

States are responsible for managing Medicaid and are therefore the main “cog,” Somers said. She said Medicaid managed-care companies are also supposed to intervene.

Somers and DeBriere said Medicaid recipients who receive bills they don’t think they owe should file a complaint with their state’s Medicaid program and, if they have one, their managed-care plan. They can also ask whether there is a Medicaid or managed-care caseworker who can advocate on their behalf.

The attorneys said patients should also contact a legal aid clinic or a consumer protection firm that specializes in medical debt. DeBriere said those organizations can help file complaints and communicate with the hospital.

DeBriere said that, had she assisted Wirt, she would have immediately sent a letter to Monument Health ordering it to stop billing him and to either register with Florida Medicaid to submit his bill or offer him charity care.

Wirt said the doctors who treated him and the medical care he received at Monument Health were excellent. He said he spoke out about the hospital’s billing practices because he doesn’t want others to endure the same experience.

“If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state,” he joked.

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!

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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GLOBE, Ariz. — Like many residents of this copper-mining town in the mountains east of Phoenix, Debbie Cox knows plenty of people on Medicaid.

Cox, who is a property manager at a real estate company in Globe, has tenants who rely on the safety-net program. And at the domestic violence shelter where she volunteers as president of the board, Cox said, staff always look to enroll women and their children if they can.

But Cox, who is 65, has mixed feelings about Medicaid. “It’s not that I don’t see the need for it. I see the need for it literally on a weekly basis,” she said. “I also see a need for revamping it significantly because it’s been taken advantage of for so long.”

It wasn’t hard to find people in Globe like Cox with complicated views about Medicaid.

Gila County, where Globe is located, is a conservative place — almost 70% of voters went for President Donald Trump in November. And concerns about government waste run deep.

Like many rural communities, it’s also a place where people have come to value government health insurance. The number of Gila County residents on Medicaid and the related Children’s Health Insurance Program has nearly doubled over the past 15 years, according to data from the Georgetown University Center for Children and Families. Today, almost 4 in 10 residents are on one of the plans for low- and moderate-income people or those with disabilities.

So as congressional Republicans consider plans to cut more than $700 billion from Medicaid, the debate over the program hits close to home for many Globe residents, even as some welcome the prospect of tighter rules and less government spending.

For Heather Heisler, the stakes are high. Her husband has been on Medicaid for years.

“We’re ranchers, and there’s not much money in ranching,” said Heisler, who gets her own health care from the Indian Health Service. “Most people think there is, but there isn’t.”

Heisler was selling handicrafts outside the old county jail in Globe on a recent Friday night when the town hosted a downtown street fair with food trucks and live music.

She said Medicaid was especially helpful after her husband had an accident on the ranch. A forklift tipped over, and he had to have part of his left foot amputated. “If anything happens, he’s able to go to the doctor,” she said. “Go to the emergency room, get medicines.”

She shook her head when asked what would happen if he lost the coverage. “It would be very bad for him,” she said.

Among other things, proposed tax legislation written by House Republicans would require working-age Medicaid enrollees to prove they are employed or seeking work. The bill, which passed the House and has advanced to the Senate, would also mandate more paperwork from people to prove they’re eligible.

Difficult applications can dissuade many people from enrolling in Medicaid, even if they’re eligible, researchers have found. And the nonpartisan Congressional Budget Office estimates more than 10 million people will likely lose Medicaid and CHIP insurance under the House Republican plan.

That would reverse big gains made possible by the 2010 Affordable Care Act, which has allowed millions of low-income, working-age adults in places like Globe to get health insurance.

Nationally, Medicaid and CHIP have expanded dramatically over the past two decades, with enrollment in the programs surging from about 56 million in 2005 to more than 78 million last year, according to federal data.

“Medicaid has always played an important role,” said Joan Alker, who runs the Georgetown University Center for Children and Families. “But its role has only grown over the last couple of decades. It really stepped in to address many of the shortcomings in our health care system.”

That’s particularly true in rural areas, where the share of people with disabilities is higher, residents have lower incomes, and communities are reliant on industries with skimpier health benefits such as agriculture and retail.

In Globe, former mayor Fernando Shipley said he’s seen this firsthand.

“A lot of people think, ‘Oh, those are the people that aren’t working.’ Not necessarily,” said Shipley, who operates a State Farm office across the road from the rusted remains of the Old Dominion copper mine. “If you’re a single parent with two kids and you’re making $20 an hour,” he added, “you’re not making ends meet. You’ve got to pay rent; you’ve got to feed those kids.”

Not far away, at the local hospital, some low-wage workers at the registration desk and in housekeeping get health care through Medicaid, chief financial officer Harold Dupper said. “As much as you’d like to pay everyone $75,000 or $80,000 a year, the hospital couldn’t stay in business if that was the payroll,” he said, noting the financial challenges faced by rural hospitals.

The growing importance of Medicaid in places like Globe helps explain why Republican efforts to cut the program face so much resistance, even among conservatives.

“There’s been a shift in the public’s attitude, and particularly voters on the right, that sometimes government plays a role in getting people health care. And that’s OK,” said pollster Bob Ward. “And if you take away that health care, people are going to be angry.” Ward’s Washington, D.C., firm, Fabrizio Ward, works for Trump. He also polls for a coalition trying to protect Medicaid.

At the same time, many of the communities where Medicaid has become more vital in recent years remain very conservative politically.

More than two-thirds of nearly 300 U.S. counties with the biggest growth in Medicaid and CHIP since 2008 backed Trump in the last election, according to a KFF Health News analysis of voting results and enrollment data from Georgetown. Many of these counties are in deep-red states such as Kentucky, Louisiana, and Montana.

Voters in places like these are more likely to be concerned about government waste, polls show. In one recent national survey, 75% of Republicans said they think waste, fraud, and abuse in Medicaid is a major problem.

The actual scale of that waste is hotly debated, though many analysts believe relatively few enrollees are abusing the program.

Nevertheless, around Globe, Republican arguments that cuts will streamline Medicaid seemed to resonate.

Retiree Rick Uhl was stacking chairs and helping clean up after lunch at the senior center. “There’s a lot of waste, of money not being accounted for,” Uhl said. “I think that’s a shame.” Uhl said he’s been saddened by the political rancor, but he said he’s encouraged by the Trump administration’s aggressive efforts to cut government spending.

Back at the street fair downtown, David Sander, who is also retired, said he doubted Medicaid would really be trimmed at all.

“I’ve heard that they really aren’t cutting it,” Sander said. “That’s my understanding.”

Sander and his wife, Linda, were tending a stall selling embroidery that Linda makes. They also have a neighbor on Medicaid.

“She wouldn’t be able to live without it,” Linda Sander said. “Couldn’t afford to have an apartment, make her bills and survive.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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A blockbuster lawsuit from the federal Department of Justice alleges that insurers Aetna, Elevance Health (formerly Anthem), and Humana paid “hundreds of millions of dollars in kickbacks” to large insurance brokerages eHealth, GoHealth, and SelectQuote. The payments, made from 2016 to at least 2021, were incentives to steer patients into the insurer’s Medicare Advantage plans, the lawsuit alleges, while discouraging enrollment of potentially more costly disabled beneficiaries. 

All the insurers and brokers named in the case have denied the allegations and say they will fight them in court. 

Policy experts say the lawsuit, filed May 1, will add fuel to long-running concerns about whether Medicare enrollees are being encouraged to select the coverage that is best for them — or the one that makes the most money for the broker.  

In other Medicare news, The Wall Street Journal last week, citing unnamed sources, reported that a separate insurer, UnitedHealth Group, was being investigated by the Justice Department regarding unspecified potential Medicare violations. UnitedHealth pushed back, calling the article “deeply irresponsible” and saying it had not been notified by the DOJ as to any such investigation. 

Regardless of how this attention shakes out, Medicare Advantage, the private sector alternative to original Medicare, is likely to continue to draw scrutiny because it covers more than half of those enrolled. But the plans, which often include benefits not covered by the traditional government program, cost taxpayers more per enrollee and have drawn criticism for requiring patients to get prior authorization for certain services, something rarely required in original Medicare. 

The DOJ lawsuit alleges insurers made large payments they called “marketing” or “sponsorship” fees to get around rules that set caps on broker commissions. The payments, according to the lawsuit, added incentives — often more than $200 per enrollee — for brokers to direct Medicare beneficiaries toward their coverage “regardless of the quality or suitability of the insurers’ plans.” 

The case joins the DOJ in a previously filed whistleblower lawsuit brought by a then-employee of eHealth, Andrew Shea. The whistleblower’s attorney, Gregg Shapiro, said his client is grateful the DOJ chose to intervene: “People with Medicare must know that when an insurance agent recommends a plan, that recommendation is based solely on the client’s individual needs and preferences,” Shapiro said in an emailed statement. 

While encouraged that the Trump administration filed the case under investigations initiated by the Biden administration, policy experts say Congress and insurers need to do more. 

“What we see in this lawsuit highlights the terrible incentives that desperately need Congress to reform,” said Brian Connell, a vice president at the Leukemia & Lymphoma Society, an advocacy group. 

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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La emblemática legislación del presupuesto del presidente Donald Trump castigaría a 14 estados que ofrecen cobertura de salud a personas que viven en el país sin papeles.

Estos estados, la mayoría liderados por demócratas, dan seguro médico a algunos inmigrantes de bajos ingresos —a menudo niños—, independientemente de su estatus migratorio. Defensores argumentan que la política es humanitaria y que, en última instancia, ahora costos.

Sin embargo, la legislación federal, que los republicanos han denominado One Big Beautiful Bill (Un hermoso gran proyecto de ley), recortaría drásticamente los reembolsos federales de Medicaid a esos estados en miles de millones de dólares anuales en total, a menos que reduzcan esos beneficios.

El proyecto de ley fue aprobado por un estrecho margen en la Cámara de Representantes el jueves 22 de mayo, y ahora pasa al Senado.

Si bien avanza gran parte de la agenda nacional de Trump, incluyendo grandes recortes de impuestos que benefician principalmente a los estadounidenses más ricos, la legislación también realiza recortes sustanciales del gasto en Medicaid que, según los responsables del presupuesto del Congreso, dejará a millones de personas de bajos ingresos sin seguro médico.

De ser aprobados por el Senado, estos recortes representarían un complejo obstáculo político y económico para los estados y Washington, DC, que utilizan sus propios fondos para brindar seguro médico a algunas personas que viven en Estados Unidos sin autorización.

Estos estados verían reducidos en 10 puntos porcentuales los reembolsos federales para las personas cubiertas por la expansión de Medicaid que se realize bajo la Ley de Cuidado de Salud a Bajo Precio (ACA).

Estos recortes le costarían a California, el estado que más tiene que perder, hasta $3 mil millones al año, según un análisis de KFF, una organización sin fines de lucro dedicada a información de salud que incluye a KFF Health News.

En conjunto, los 15 lugares afectados (los 14 estados y DC) cubren a aproximadamente 1.9 millones de inmigrantes sin papeles, según KFF. La entidad indica que la sanción también podría aplicarse a otros estados que cubren a inmigrantes con residencia legal.

Dos de los estados, Illinois y Utah, tienen leyes de “activación” que exigen terminar con sus expansiones de Medicaid si el gobierno federal reduce su aporte de fondos. Esto significa que, a menos que esos estados deroguen sus leyes de activación o dejen de cubrir a las personas sin estatus migratorio legal, muchos más estadounidenses de bajos ingresos podrían quedarse sin seguro.

Si continúan cubriendo a personas sin papeles, a partir del año fiscal 2027, los estados restantes y Washington, DC, tendrían que aportar millones o miles de millones de dólares adicionales cada año, para compensar las reducciones en sus reembolsos federales de Medicaid.

Después de California, Nueva York podría perder la mayor parte de la financiación federal: cerca de 1.600 millones de dólares anuales, según KFF.

El senador estatal de California, Scott Wiener, demócrata y presidente del Comité de Presupuesto del Senado, afirmó que la legislación de Trump ha sembrado el caos mientras los legisladores estatales trabajan para aprobar su propio presupuesto antes del 15 de junio.

“Tenemos que mantenernos firmes”, declaró. “California ha decidido que queremos una atención médica universal y que vamos a garantizar que todos tengan acceso a la atención médica, y que no vamos a permitir que millones de personas indocumentadas reciban atención primaria en salas de emergencia”.

El gobernador de California, el demócrata Gavin Newsom, declaró en un comunicado que el proyecto de ley de Trump devastaría la atención médica en su estado.

“Millones de personas perderán cobertura, los hospitales cerrarán y las redes de seguridad social podrían colapsar bajo ese peso”, dijo Newsom.

En su propuesta de presupuesto del 14 de mayo, Newsom instó a los legisladores a recortar algunos beneficios para inmigrantes sin papeles, citando el aumento desmedido de los costos del programa estatal de Medicaid. Si el Congreso recorta los fondos para la expansión de Medicaid, el estado no estaría en condiciones de cubrir los gastos, afirmó el gobernador.

Newsom cuestionó si el Congreso tiene la autoridad para penalizar a los estados por cómo gastan su propio dinero, y afirmó que su estado consideraría impugnar la medida en los tribunales.

El representante estatal de Utah, Jim Dunnigan, republicano que ayudó a impulsar un proyecto de ley para cubrir a los niños en su estado independientemente de su estatus migratorio, afirmó que Utah necesita mantener la expansión de Medicaid que comenzó en 2020.

“No podemos permitirnos, ni monetaria ni políticamente, que se recorten nuestros fondos federales para la expansión”, declaró. Dunnigan no especificó si cree que el estado debería cancelar su cobertura para inmigrantes si la disposición republicana sobre sanciones se convierte en ley.

El programa de Utah cubre a unos 2.000 niños, el máximo permitido por su ley. Los inmigrantes adultos sin estatus legal no son elegibles. La expansión de Medicaid de Utah cubre a unos 75.000 adultos, quienes deben ser ciudadanos o inmigrantes con residencia legal.

Matt Slonaker, director ejecutivo del Utah Health Policy Project, una organización de defensa del consumidor, afirmó que el proyecto de ley de la Cámara federal deja al estado en una posición difícil.

“Políticamente, no hay grandes alternativas”, declaró. “Es el dilema del prisionero: cualquier movimiento en cualquier dirección no tiene mucho sentido”.

Slonaker apuntó que un escenario probable es que los legisladores estatales eliminen su ley de activación, y luego encuentren la manera de compensar la pérdida de fondos federales para la expansión.

Utah ha financiado su parte del costo de la expansión de Medicaid con impuestos sobre las ventas y los hospitales.

“El Congreso pondría al estado de Utah en posición de tener que tomar una decisión política muy difícil”, declaró Slonaker.

En Illinois, la sanción del Partido Republicano tendría incluso consecuencias más graves. Esto se debe a que podría llevar a que 770.000 adultos perdieran la cobertura médica que obtuvieron con la expansión estatal de Medicaid.

Stephanie Altman, directora de justicia sanitaria del Shriver Center on Poverty Law, un grupo de defensa con sede en Chicago, afirmó que es posible que su estado, liderado por demócratas, derogue su ley de activación antes de permitir que se dé por terminada la expansión de Medicaid.

Agregó que el estado también podría eludir la sanción solicitando a los condados que financien la cobertura para inmigrantes. “Obviamente, sería una situación difícil”, declaró.

Altman indicó que el proyecto de ley de la Cámara de Representantes parece redactado para penalizar a los estados controlados por demócratas, ya que estos suelen brindar cobertura a inmigrantes sin importar su estatus migratorio.

Agregó que la disposición demuestra la “hostilidad de los republicanos contra los inmigrantes” y que “no quieren que vengan aquí y reciban cobertura pública”.

Mike Johnson, el presidente de la Cámara de Representantes de Estados Unidos, declaró en mayo que los programas estatales que brindan cobertura pública a personas sin importar su estatus migratorio actúan como un “felpudo abierto”, invitando a más personas a cruzar la frontera sin autorización. Afirmó que los esfuerzos para eliminar estos programas cuentan con el apoyo de las encuestas públicas.

Una encuesta de Reuters-Ipsos realizada entre el 16 y el 18 de mayo reveló que el 47% de los estadounidenses aprueba las políticas migratorias de Trump y el 45% las desaprueba. La encuesta reveló que el índice de aprobación general de Trump ha caído 5 puntos porcentuales desde que regresó al cargo en enero, hasta el 42%, con un 52% de los estadounidenses desaprobando su gestión.

ACA, también conocida como Obamacare, impulsó a los estados a ampliar Medicaid a adultos con ingresos de hasta el 138% del nivel federal de pobreza, o $21.597 por persona este año. Cuarenta estados y Washington, DC, ampliaron su cobertura, lo que contribuyó a reducir la tasa nacional de personas sin seguro a un mínimo histórico.

El gobierno federal ahora cubre el 90% de los costos de las personas incluidas en Medicaid gracias a la ampliación del Obamacare.

En los estados que cubren la atención médica de inmigrantes sin autorización, el proyecto de ley republicano reduciría la contribución del gobierno federal del 90% al 80% del costo de la cobertura para cualquier persona que se incorpore a Medicaid bajo la expansión de ACA.

Por ley, los fondos federales de Medicaid no pueden utilizarse para cubrir a personas que se encuentran en el país papeles, excepto para servicios de embarazo y emergencias.

Los otros estados que utilizan sus propios fondos para cubrir a personas sin importar su estatus migratorio son: Colorado, Connecticut, Maine, Massachusetts, Minnesota, Nueva Jersey, Oregon, Rhode Island, Vermont y Washington, según KFF.

Ryan Long, director de relaciones con el Congreso del Paragon Health Institute, un influyente grupo político conservador, afirmó que incluso si utilizan sus propios fondos para la cobertura de inmigrantes, los estados aún dependen de los fondos federales para “apoyar sistemas que faciliten la inscripción de inmigrantes indocumentados”.

Long afirmó que la preocupación por que los estados con leyes de activación puedan ver finalizada la expansión de Medicaid es una “pista falsa”, ya que los estados tienen la opción de eliminar sus activadores, como hizo Michigan en 2023.

La sanción por ofrecer cobrtura de salud a personas en el país sin papeles es una de las distintas maneras en que el proyecto de ley de la Cámara de Representantes recorta el gasto federal en Medicaid.

La legislación también trasladaría más costos de Medicaid a los estados al exigirles que verifiquen si los adultos cubiertos por el programa trabajan. Los estados también tendrían que recertificar la elegibilidad de los beneficiarios de la expansión de Medicaid cada seis meses, en lugar de una vez al año o menos, como lo hacen actualmente la mayoría.

El proyecto de ley también congelaría la práctica de los estados de gravar con impuestos a hospitales, residencias de adultos mayores, planes de atención médica administrada y otras compañías de atención médica para financiar su parte de los costos de Medicaid.

En una estimación preliminar del 11 de mayo, la Oficina de Presupuesto del Congreso (CBO) indicó que, según el proyecto de ley aprobado por la Cámara de Representantes, alrededor de 8,6 millones de personas más perderían la cobertura médica en 2034.

Esa cifra aumentará a casi 14 millones, según la CBO, después que la administración Trump finalice las nuevas regulaciones de ACA y, si el Congreso, liderado por los republicanos, como se prevé, se niegue a extender los subsidios mejorados para ayudar a pagar las primas de los planes de salud comerciales vendidos a través de los mercados del Obamacare.

Los subsidios mejorados, una prioridad del ex presidente Joe Biden, eliminaron por completo las primas mensuales para algunas personas que adquirieran planes de Obamacare. Y expiran a fin de año.

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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President Donald Trump’s signature budget legislation would punish 14 states that offer health coverage to people in the U.S. without authorization.

The states, most of them Democratic-led, provide insurance to some low-income immigrants — often children — regardless of their legal status. Advocates argue the policy is both humane and ultimately cost-saving.

But the federal legislation, which Republicans have titled the “One Big Beautiful Bill,” would slash federal Medicaid reimbursements to those states by billions of dollars a year in total unless they roll back the benefits.

The bill narrowly passed the House on Thursday and next moves to the Senate. While enacting much of Trump’s domestic agenda, including big tax cuts largely benefiting wealthier Americans, the legislation also makes substantial spending cuts to Medicaid that congressional budget scorekeepers say will leave millions of low-income people without health insurance.

The cuts, if approved by the Senate, would pose a tricky political and economic hurdle for the states and Washington, D.C., which use their own funds to provide health insurance to some people in the U.S. without authorization.

Those states would see their federal reimbursement for people covered under the Affordable Care Act’s Medicaid expansion cut by 10 percentage points. The cuts would cost California, the state with the most to lose, as much as $3 billion a year, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

Together, the 15 affected places cover about 1.9 million immigrants without legal status, according to KFF. The penalty might also apply to other states that cover lawfully residing immigrants, KFF says.

Two of the states — Utah and Illinois — have “trigger” laws that call for their Medicaid expansions to terminate if the feds reduce their funding match. That means unless those states either repeal their trigger laws or stop covering people without legal immigration status, many more low-income Americans could be left uninsured.

The remaining states and Washington, D.C., would have to come up with millions or billions more dollars every year, starting in the 2027 fiscal year, to make up for reductions in their federal Medicaid reimbursements, if they keep covering people in the U.S. without authorization.

Behind California, New York stands to lose the most federal funding — about $1.6 billion annually, according to KFF.

California state Sen. Scott Wiener, a Democrat who chairs the Senate budget committee, said Trump’s legislation has sown chaos as state legislators work to pass their own budget by June 15.

“We need to stand our ground,” he said. “California has made a decision that we want universal health care and that we are going to ensure that everyone has access to health care, and that we’re not going to have millions of undocumented people getting their primary care in emergency rooms.”

California Gov. Gavin Newsom, a Democrat, said in a statement that Trump’s bill would devastate health care in his state.

“Millions will lose coverage, hospitals will close, and safety nets could collapse under the weight,” Newsom said.

In his May 14 budget proposal, Newsom called on lawmakers to cut some benefits for immigrants without legal status, citing ballooning costs in the state’s Medicaid program. If Congress cuts Medicaid expansion funding, the state would be in no position to backfill, the governor said.

Newsom questioned whether Congress has the authority to penalize states for how they spend their own money and said his state would consider challenging the move in court.

Utah state Rep. Jim Dunnigan, a Republican who helped spearhead a bill to cover children in his state regardless of their immigration status, said Utah needs to maintain its Medicaid expansion that began in 2020.

“We cannot afford, monetary-wise or policy-wise, to see our federal expansion funding cut,” he said. Dunnigan wouldn’t say whether he thinks the state should end its immigrant coverage if the Republican penalty provision becomes law.

Utah’s program covers about 2,000 children, the maximum allowed under its law. Adult immigrants without legal status are not eligible. Utah’s Medicaid expansion covers about 75,000 adults, who must be citizens or lawfully present immigrants.

Matt Slonaker, executive director of the Utah Health Policy Project, a consumer advocacy organization, said the federal House bill leaves the state in a difficult position.

“There are no great alternatives, politically,” he said. “It’s a prisoner’s dilemma — a move in either direction does not make much sense.”

Slonaker said one likely scenario is that state lawmakers eliminate their trigger law then find a way to make up the loss of federal expansion funding.

Utah has funded its share of the cost of Medicaid expansion with sales and hospital taxes.

“This is a very hard political decision that Congress would put the state of Utah in,” Slonaker said.

In Illinois, the GOP penalty would have even larger consequences. That’s because it could lead to 770,000 adults’ losing the health coverage they gained under the state’s Medicaid expansion.

Stephanie Altman, director of health care justice at the Shriver Center on Poverty Law, a Chicago-based advocacy group, said it’s possible her Democratic-led state would end its trigger law before allowing its Medicaid expansion to terminate. She said the state might also sidestep the penalty by asking counties to fund coverage for immigrants. “It would be a hard situation, obviously,” she said.

Altman said the House bill appeared written to penalize Democratic-controlled states because they more commonly provide immigrants coverage without regard for their legal status.

She said the provision shows Republicans’ “hostility against immigrants” and that “they do not want them coming here and receiving public coverage.”

U.S. House Speaker Mike Johnson said this month that state programs that provide public coverage to people regardless of immigration status serve as “an open doormat,” inviting more people to cross the border without authorization. He said efforts to end such programs have support in public polling.

A Reuters-Ipsos poll conducted May 16-18 found that 47% of Americans approve of Trump’s immigration policies and 45% disapprove. The poll found that Trump’s overall approval rating has sunk 5 percentage points since he returned to office in January, to 42%, with 52% of Americans disapproving of his performance.

The Affordable Care Act, widely known as Obamacare, enabled states to expand Medicaid to adults with incomes of up to 138% of the federal poverty level, or $21,597 for an individual this year. Forty states and Washington, D.C., expanded, helping reduce the national uninsured rate to a historic low.

The federal government now pays 90% of the costs for people added to Medicaid under the Obamacare expansion.

In states that cover health care for immigrants in the U.S. without authorization, the Republican bill would reduce the federal government’s contribution from 90% to 80% of the cost of coverage for anyone added to Medicaid under the ACA expansion.

By law, federal Medicaid funds cannot be used to cover people who are in the country without authorization, except for pregnancy and emergency services.

The other states that use their own money to cover people regardless of immigration status are Colorado, Connecticut, Maine, Massachusetts, Minnesota, New Jersey, Oregon, Rhode Island, Vermont, and Washington, according to KFF.

Ryan Long, director of congressional relations at Paragon Health Institute, an influential conservative policy group, said that even if they use their own money for immigrant coverage, states still depend on federal funds to “support systems that facilitate enrollment of illegal aliens.”

Long said the concern that states with trigger laws could see their Medicaid expansion end is a “red herring” because states have the option to remove their triggers, as Michigan did in 2023.

The penalty for covering people in the country without authorization is one of several ways the House bill cuts federal Medicaid spending.

The legislation would shift more Medicaid costs to states by requiring them to verify whether adults covered by the program are working. States would also have to recertify Medicaid expansion enrollees’ eligibility every six months, rather than once a year or less, as most states currently do.

The bill would also freeze states’ practice of taxing hospitals, nursing homes, managed-care plans, and other health care companies to fund their share of Medicaid costs.

The Congressional Budget Office said in a May 11 preliminary estimate that, under the House-passed bill, about 8.6 million more people would be without health insurance in 2034. That number will rise to nearly 14 million, the CBO estimates, after the Trump administration finishes new ACA regulations and if the Republican-led Congress, as expected, declines to extend enhanced premium subsidies for commercial insurance plans sold through Obamacare marketplaces.

The enhanced subsidies, a priority of former President Joe Biden, eliminated monthly premiums altogether for some people buying Obamacare plans. They are set to expire at the end of the year.

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.

USE OUR CONTENT

This story can be republished for free (details).