The Host Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

After all-night markups, two key House committees approved GOP budget legislation that would cut hundreds of billions of dollars from federal health programs over the next decade, mostly from the Medicaid program for people with low incomes or disabilities. The legislation is far from a done deal, though, with at least one Republican senator voicing opposition to Medicaid cuts.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. testified before Congress for the first time since taking office. In sometimes surprisingly combative exchanges with lawmakers in the House and Senate, Kennedy denied cutting programs despite evidence to the contrary and said at one point that he doesn’t think Americans “should be taking medical advice from me.”

This week’s panelists are Julie Rovner of KFF Health News, Julie Appleby of KFF Health News, Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists Julie Appleby KFF Health News @Julie_appleby Read Julie's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories.

Among the takeaways from this week’s episode:

• House Republicans this week released — then quickly ushered through committee — major legislation that would make deep cuts to federal spending while funding President Donald Trump’s domestic priorities, including renewing tax cuts and boosting border security. A preliminary estimate by the Congressional Budget Office found the bill would cut at least $715 billion from federal health spending over 10 years — with most of that money coming from the Medicaid program.
• Overall, the House GOP’s proposal would make it harder to enroll, and stay enrolled, in Medicaid and Affordable Care Act coverage. Among other changes, the bill would impose a requirement that nondisabled adults (with some exceptions) work, volunteer, or study at least 80 hours per month to be eligible for coverage. But Democrats and patient advocates point to evidence that, rather than encouraging employment, such a mandate results in more people losing or dropping coverage under burdensome paperwork requirements.
• Republicans also declined to extend the enhanced tax credits introduced during the covid-19 pandemic that help many people afford ACA marketplace coverage. Those tax credits expire at the end of the year, and premiums are expected to balloon, which could prompt many people not to renew their coverage.
• And Kennedy’s appearances on Capitol Hill this week provided Congress the first opportunity to question the health secretary since he assumed his post. He was grilled by Democrats about vaccines, congressionally appropriated funds, agency firings, and much more.

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

Julie Rovner: The New York Times’ “Elizabeth Holmes’s Partner Has a New Blood-Testing Start-Up,” by Rob Copeland.  

Alice Miranda Ollstein: ProPublica’s “He Became the Face of Georgia’s Medicaid Work Requirement. Now He’s Fed Up With It.” by Margaret Coker, The Current.

Julie Appleby: Scientific American’s “How Trump’s National Weather Service Cuts Could Cost Lives,” by Andrea Thompson.  

Joanne Kenen: The Atlantic’s “Now Is Not the Time To Eat Bagged Lettuce,” by Nicholas Florko.

Also mentioned in this week’s podcast:

• Politico’s “‘Rolling Thunder’: Inside Conservatives’ Strategy To Curb Abortion Pill Access,” by Alice Miranda Ollstein.
• The New York Times’ “Josh Hawley: Don’t Cut Medicaid,” by Sen. Josh Hawley (R-Mo.).
• NPR’s “FDA Moves To Ban Fluoride Supplements for Kids, Removing a Key Tool for Dentists,” by Pien Huang.

click to open the transcript Transcript: GOP Poised To Cut Billions in Health Benefits

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 15, at 9:30 a.m. As always, and particularly this week, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico. 

Joanne Kenen: Hi, everybody. 

Rovner: And my KFF Health News colleague Julie Appleby. 

Julie Appleby: Hi. 

Rovner: No interview this week because so much news, so we will get straight to it. So, quiet week, huh? Just kidding. The House Ways and Means and Energy and Commerce committees completed all-nighter markups on their portions of President [Donald] Trump’s “one big, beautiful” reconciliation bill. And in fact, Ways and Means is officially calling it the “One, Big, Beautiful Bill” in its summary of the measure. 

We will start with Energy and Commerce, which after a 26-hour marathon, one hour short of the record it set in 2017, voted out its part of the bill Wednesday afternoon, including an estimated $715 billion in reductions to health programs, mostly Medicaid, over the next 10 years. Now, the final committee bill does not include the threatened cuts to the 90% match for the Affordable Care Act expansion population, nor does it include the per capita cap for that population. 

Nonetheless, it would represent the biggest cut to Medicaid in the program’s 60-year history. Guys, tell us some of the things that it would do instead to get to that $715 billion amount. 

Kenen: The 715 includes some ACA cuts as well. It’s not 100% Medicaid, but it’s largely Medicaid. The biggest one is the one that we knew was almost inevitable given the current Congress, which is work requirements. It is something the Republicans have wanted a long time. In the prior administration, a few states did pass them. Arkansas got going with them. The courts stopped it. 

The Medicaid statute is pretty clear that it’s about health, not about health for working people. The courts today are different. If I had to guess, I would guess there will be a legal battle and that the courts are likely to uphold work requirements. 

Rovner: We’ll talk more about work requirements in a minute. But what else is in the bill? 

Kenen: There’s lots of extra layers of verification. Supposedly, it’s about fraud. We can get to the Kennedy testimony later, but there were some assertions that did not add up for me. The biggest thing is work requirements, and there’s other things that will make it harder to maintain coverage, that it’s not that tou’re getting kicked off, per se. And there are also some copays. There are some copays for the upper rank. There’s been a lot of information this week. And if I get any details wrong, because we’ve all had to absorb a lot in 48 hours, someone correct me. But my recollection was a $35 copay for certain treatments for the people who are on the higher end of the income. 

Rovner: Right, meaning over 100% of poverty— 

Kenen: Right. 

Rovner: —but still under the level required to qualify for Medicaid. 

Appleby: Right. It would require states actually to impose these cost sharings of up to $35 per service. Although they’re excluding some things like primary care, emergency stuff, that kind of thing, for people in that 100% of poverty to 138% of poverty, and there’s also an upper limit of 5% of the family’s income. But that’s a lot for people in that category. 

Rovner: And we know, there is an enormous body of research that says when you put copays on services, people get fewer of them. And it’s not like people who are just scraping by have a lot of extra money to spend. So we know that one of the ways that they’ll save money is that people won’t get services, presumably needed services. 

Kenen: Although the primary care exemption is important, because primary care, which also usually includes pediatricians, are considered primary care, can deal with a lot of diseases that you don’t always need to see a specialist. I’m not saying it’s a good idea. I’m just saying in terms of an incentive to get basic care, keeping primary care free is an important distinction. 

Rovner: Well, I do want to talk a little bit about that work requirement, which Massachusetts Democratic Rep. Jake Auchincloss called not a work requirement but a paperwork requirement. Once more, for those who haven’t heard us explain this 100 times, it’s not just people who don’t work who lose coverage because of this. I see you nodding, Alice. Please explain this again. 

Ollstein: Yes. So Democrats really hammered over the course of this 26-hour hearing that the only states that have made a foray in this direction so far, Arkansas and Georgia, have seen that these work requirements do not boost employment. They kick people off who should have been eligible because they can’t navigate, like you said, the paperwork. And so it was really striking, over this hearing, where — I watched from 8 a.m. Wednesday to 2 p.m. Wednesday — and during that whole time, every single amendment vote was party-line. Nobody crossed in either direction. So this was really a political exercise in Democrats because they were not able to convince Republicans to change or soften the bill at all. They really focused on branding it, branding it as punishing the poor and threatening their health care. 

And so they were pointing to what happened in Arkansas, what happened in Georgia, where the work requirements really were successful in only that they cut people from the rolls and saved the states money, not successful in helping people find work or helping people get coverage. They also made an effort to brand the copays issue. I heard Democrats calling it a “sick tax.” We’ll see if that phrase sticks around throughout this process. 

Rovner: So kind of in an interesting twist, the work requirements in the bill don’t become mandatory until the year 2029. That suggests to me that those who voted for this don’t really want it to take effect, but they do want to be able to count the savings to pay for other things in the bill. And then, cherry on top of the sundae, if Democrats want to repeal the work requirements later, they would have to find a way to pay for them, because the savings would get built into the budget baseline. Or is that just me being cynical because I’ve only had like five hours of sleep this week? 

Kenen: Well, there are two important dates between now and 2029. One is the 2026 off-year elections, the House elections and some Senate, and then 2028 is the presidential. So there’s several things that have changed politically about Medicaid in recent years, which we can talk to and which I’ve written about quite extensively. One of them is that a lot of people who are Trump’s base are now on Medicaid and particularly that expansion population, and nobody likes having their health care taken away from them, particularly if it’s free or very, very heavily subsidized in the lower ranks of the exchanges. 

So if you’re going to kick your own voters off of their health care, you’re probably more likely to want to do it after they voted for you again. It is not uniquely cynical. We have seen both parties do similar things over the years, either for budgetary game-playing or for political things. It’s quite notable that this goes into effect in 2029. 

Ollstein: It’s just interesting that this is getting criticized from both sides. So Democrats are upset that Republicans want to reap the nominal savings but not have to look like the bad guy. And conservative Republicans are upset that this doesn’t kick in sooner, because they want stricter work requirements even sooner to cut the program even more. So it’s pleasing few. 

Rovner: Well, as Joanne alluded to, it’s not just Medicaid. This bill is also a bit of a stealth assault on the Affordable Care Act, too. Right, Julie? We haven’t talked about it a lot, but this administration seems to be working very hard to make the ACA a lot less effective. And the combination of reductions in Medicaid and changes to the ACA will mean lots more people will be uninsured if this bill becomes law in its current form. Yes? 

Appleby: There are a lot of moving parts to this. So yeah, let’s back up just briefly and look at March, when the Trump administration did propose their first major rule affecting the Affordable Care Act, and it’s called the Patient Protection and Affordable Care Act; Marketplace Integrity … it’s a long-name rule. Anyway, it does a bunch of things. For one, it shortens the open enrollment period by about a month. So open enrollment would end on Dec. 15. And notably, this would apply to all states that run their own state-based marketplaces, as well as the federal marketplace. So there’s 16 plus D.C. that do that. So they would all also be tied to this. So that’s one of the things that the rule would do if it’s finalized in its form. 

It would also end a special enrollment period that allows low-income people to essentially enroll anytime during the year. And people who are automatically reenrolled in a zero-premium plan would instead be charged a $5 premium for reenrollment in that same plan until they confirm their eligibility. Now, the Trump administration says that a lot of these rules are in part to try to combat what they say is fraud and waste, and they point to situations where people are being enrolled without their permission or switched to different plans, generally these zero-premium plans, by unscrupulous brokers who are trying to get commissions. 

We’ve written a lot about that over the past year. So they’re saying that, Oh, we need to do this so that people know they’ve been enrolled. The special enrollment period for low-income people they thought was part of that. That’s disputed by a number of places. And some of the states have pushed back on this, too, and said, Hey, we don’t have this problem with fraud, so why would this now apply to us? Why would the special enrollment period, the shortened enrollment period, etc., etc.? 

So those are things in the proposed rule. And the proposed rule acknowledges that it would reduce enrollment by about up to 2 million people in 2026, with coverage losses concentrated in a bunch of states like Alabama, Florida, Georgia, etc. So that’s the proposed rule. And then if you look at the House bill, like, for example, Energy and Commerce, these would codify some of those proposals from that ACA rule. So it would make it harder for a future president to change the rule and that kind of thing. 

So those things that are codified would be — there’d be more hoops to jump through to verify income, for one thing. That special enrollment period based on income would be barred, and the shorter enrollment period would be in it. And if this goes through, these changes are set to go into effect next year. So a lot of insurers and states would have to scramble to try to get this put in place by then. So that’s just a short thing about what some of the ACA effects would be. 

Rovner: So, it feels like there’s kind of a theme here that’s going to make it harder for people to get on and stay on both the ACA and Medicaid. Is that sort of a fair way to describe this? 

Appleby: Yeah, that’s fair. In the House bills, there are also a lot of things that would bar automatic reenrollment, which a lot of people rely on. People just don’t go back in and sign up for their coverage. They’re automatically reenrolled. The bills differ a little bit. The harshest one would require everybody to sort of verify their income before they can reenroll. There would be a lot more of that. So it would essentially bar reenrollment. And we haven’t even talked about the enhanced tax credits, because that’s also sort of fitting here. 

Rovner: Which was my, yes, my next question. So there’s been a lot of fighting this week about how many people would lose coverage as a result of this bill, and a lot of it is sort of philosophical fighting. We don’t have final CBO [Congressional Budget Office] numbers yet. We may not have them for another week, I am told. But what we do know is one of the things this bill could do but doesn’t do is re-up those additional subsidies that were installed during the Biden administration, during covid, that basically effectively doubled the number of people who enrolled under the marketplaces, right? 

Appleby: It certainly added a lot. Most people who get a subsidy are benefiting from the enhanced subsidies. And remember, these sort of expanded at the lower end and it cut off that cliff at 400% of the poverty level that used to exist where you wouldn’t get a subsidy if you made more than that. So it smoothed all that out. So a lot of people are getting these extra subsidies. 

And a lot of the data I’ve seen have said — I’m looking at an Oliver Wyman report earlier — something like, if these enhanced subsidies are allowed to expire at the end of this year, which they’re poised to do unless Congress acts, that, on average, premiums would go up by about 90%. That will be enough to cause a lot of people not to reenroll. So that’s where we’ve seen some of these estimates of I think it’s around 5 million people may not reenroll as a result of that over time. 

That’s a pretty big number. But like you said, there’s a lot of numbers in the mix, but the enhanced premium subsidies do cost taxpayers. It’s not inexpensive. So if they’re looking for savings, which they are, Congress may decide not to extend them. But at the same time, many people and in a lot of states that are dominated by the GOP and others, people are getting these subsidies, and it would suddenly be a huge hit to many people to have a 90% increase in their premiums, for example. 

Rovner: Yeah, as Joanne said. Which you’re about to say again, right? These are Republican voters now, right? 

Kenen: I think that’s more mixed, the upper income within the ACA. We’ve expected that to go away, because there’s a difference between Congress having to yank something away versus something in the law that expires and they have to proactively renew it. We have always anticipated that enhanced subsidies would decline this year. But I just sort of want to point out, during the first Trump administration, without all this coverage, the uninsurance rate rose in the country. 

And that even before ’29, there are all sorts of things, with shortened enrollment periods, how much outreach they do, there’s lots of things even before 2029 that we can expect a fairly significant erosion of health coverage. Not to what it was in pre-ACA levels — it’s not going to be that extreme, and not all the benefits that those of us with employer-sponsored insurance also get, some things through the ACA. 

So this is not repeal — it’s damage. And it’s more damage than they did in the first Trump administration. All of us would be extremely surprised if there was not a significant drop in the number of insured Americans one, two years from now. 

Rovner: One of the ways conservatives hope to secure the votes for this bill in the House is a provision that would bar Planned Parenthood from the Medicaid program. This would certainly be popular in the House. But when it was in the Affordable Care Act repeal bill in 2017, the Senate parliamentarian ruled that it couldn’t be included in budget reconciliation, because it is not primarily budgetary. Alice, are House leaders just hoping no one will remember that? 

Ollstein: If at first you don’t succeed, try, try again. Yes, I think so. And especially because we just got a new CBO estimate of what the budgetary impact of cutting these funds would be. And it’s, like they have found before, it does not save money. It actually costs the government money because people lose access to contraception and don’t have other sources that they can afford to obtain contraception. And it’s a lot more expensive to have a baby on Medicaid than to access contraception. So I think that also contributes to the parliamentarian problem. 

Rovner: Yes. You can put stuff in reconciliation that costs money, but that was sort of not the intent here. Joanne, you wanted to say something. 

Kenen: And we should point out that this is still at the committee level, right? Is it going to get through the House in this exact form? We can’t be sure yet. Is something going to get through the House at the end of the day? Yes. Yes. But is all of this going to get in? Is this the final draft? Probably not. You have moderates who are still, don’t like some of the things in here, and you have conservatives who think it doesn’t go far enough. 

As we said at the beginning, as far as it does go, it does not go anywhere near as far as the initial, of some of the things that were being discussed, which really would have ended Medicaid as an entitlement. These are big changes. They’re not existential in the same way that a per capita cap or a block grant or blowing up the ACA expansion by changing the rates. There are things they could have done that were far more radical that they don’t have the votes for. And— 

Rovner: But they still can only lose, what, three or four votes and get something through the House. 

Kenen: Right. Right. Because Medicaid is actually quite popular, and people in both parties are covered by it. We still don’t know the pathway, what gets through the House at the end of the day. Something does, right? We all think that they will, somehow or other. Not necessarily by Memorial Day, right? But something at some point will get through the House, and we don’t know exactly what it looks like. 

Rovner: For the record, I’m still shrugging. I think something gets— 

Kenen: And it is a bigger question mark, you know? 

Rovner: Which is my next question. What are the prospects for this bill in the Senate? Do we really believe that the very conservative Missouri Republican Josh Hawley would vote against this? He had a piece in The New York Times this week saying, “Don’t Cut Medicaid.” 

Kenen: He’s been really consistent. Have we seen politicians do huge flip-flops in our years of covering Congress and politics? Yes. He’s really out there on this. It’s sort of hard to see how he just says, Whoops, I didn’t really mean it. But right now in terms of who’s out there in public, we don’t have a critical mass of people who’ve said they can’t vote for this. But we do know there are provisions in this very extensive bill that some people don’t like. It will go through changes in the Senate. 

I don’t have a grasp and I don’t think any of us have a grasp on exactly what’s going to change. I think work requirements, depending on what bells and whistles are attached, could get through the Senate. There might be changes like making it a state option or redefining certain things with it. I think there probably are 51 votes for a work requirement of some type in the Senate. 

That doesn’t mean the way this has been written survives. And there’s just — these are big cuts. And there’s also, remember, we’re only talking about the health stuff. There’s a lot. There’s energy. There’s all sorts of — this is a big bill. This is a big, historic bill. There’s lots and lots of hurdles. We all remember that the ACA repeal, it took several tries. It was really harder than expected. It finally got through the House, and it did die in the Senate. So this is not the last word. We don’t have to shut the podcast. 

Rovner: Yes, long way to go. All right, moving on. Health and Human Services Secretary Robert F. Kennedy Jr. testified before not one but two committees on Wednesday: the House labor, HHS Appropriations subcommittee in the morning and the Senate Health, Education, Labor, and Pensions Committee in the afternoon. And shall we say it didn’t all go swimmingly. Right off the bat, this was the greeting he got from House Appropriations Committee ranking member Rosa DeLauro of Connecticut. DeLauro basically saying, Everything you’re doing is illegal. 

Rep. Rosa DeLauro: Mr. Secretary, this administration is recklessly and unlawfully freezing and stealing congressionally appropriated funds from a wide swath of agencies, programs, and services across the government that serve the American people. And recall that this is a violation of the Constitution. 

The power of the purse resides with the Congress. It’s Article 1, Section 9, Clause 7. Yourself and President Trump and Elon Musk are attacking health programs to pay for tax cuts for billionaires. And by promoting quackery, we are endangering the health of the American people with pseudoscience, fearmongering, and misinformation. 

Rovner: If you want to hear more, we did a live recap of the hearings yesterday afternoon. You can find that on KFF’s YouTube page. But I want to know what you all took away from the hearings. Joanne, you watched most of them, right? 

Kenen: I watched a lot of it. I did not watch every minute of both hearings, but I watched enough. And I thought that very first exchange with DeLauro was really striking because she kept saying, over and over and over again she kept saying: Congress appropriated this money. You don’t have the right to not spend it. And he kept saying, If you appropriate the money, I will spend it. And she said, We have appropriated the money, and you’re not spending it. And he said, If you appropriate the money … 

And she explained. What a continuing wrestle. It was like this endless — well, it wasn’t endless, but it was repeated when she kept saying, We appropriated it, and he kept saying, Huh? And she actually said the first time sort of under her breath, but the mic picked it up, and then she said it again. She said, “Unbelievable.” She’s not known for understatement, but she said, “Unbelievable.” And then she said it again. “Unbelievable.” So that was sort of — the rest of the day was sort of there. 

Rovner: Yeah. I personally found it refreshing that someone finally called out HHS, saying: You know, there was an appropriations bill that got signed by the president, and you are withholding this money. And this is our province. We get to decide how the money is spent. You don’t get to decide how the money is spent. The other big headline that came out of this hearing was when Kennedy said that, after being raked over the coals again about his vaccine comments, he said, Well, you shouldn’t be taking medical advice from me. And I’m like, isn’t that the job of the HHS secretary? 

Ollstein: It was very clear that, like in the markups of the bill, Democrats, unless Republicans are willing to cross the aisle and join them, are just left sort of railing against what’s happening and not really having any power to impact it. We did see some Republicans expressing some concern about the cuts that have happened. But unless that turns into real oversight action, real legislative action, I just imagine we’re set up for this to happen again where Congress appropriates and the cuts happen anyway. 

Rovner: I was surprised at how much Sen. Cassidy, Sen. Bill Cassidy, the chairman of the HELP Committee, didn’t say. He basically said when he voted for Kennedy’s nomination that he was torn. He believes in vaccines. He’s a practicing doctor. He, Cassidy. And he made Kennedy promise that he wasn’t going to change any of these vaccine rules, which he’s already done. And he’s installed anti-vax people at many levels of HHS. And yet Cassidy was incredibly conciliatory in his opening statement. 

And it was left to Chris Murphy of all people, the firebrand Democrat from Connecticut, to basically be Cassidy’s anger manager. And sort of, he said, “If I were the chairman … my head would be exploding,” which I believe is a line that I’ve been saying for the last several months. What’s happening with Cassidy? Do we know? He can’t be happy with what’s happening here. 

Ollstein: This was well previewed by everything Cassidy has sort of put out publicly since the confirmation hearing. If you track his press releases, they’ve been sort of selectively praising HHS for doing certain things and being silent on the things that we imagine he might not like on the vaccine front. And so that dynamic carried forward right into this hearing, which was the first opportunity for Congress to really grill Kennedy since he’s taken office. 

And so many people have pointed out that Cassidy is up for reelection. He is facing a primary challenge from the right. He wants to align himself with the Trump administration and with the sort of “MAGA [Make America great Again]” movement. And he has pushed back on accusations that his treatment of Kennedy is influenced by that, but people can draw their own conclusions. 

Kenen: I also wanted to point out that Kennedy insisted that he hadn’t fired any scientists, and he made that assertion a few times, which I think the Democrats, their jaws collectively dropped in unison. The cuts to NIH [the National Institutes of Health] have been extreme, in the billions. And in addition to the NIH scientists, there are also the ripple effect of training the next generation of scientists, because of the cuts to universities. 

And also Kennedy, I sort of noticed at one point he was saying something about some universities don’t need this money, but then he mentioned specifically but Maine, where Susan Collins is the chair of the Appropriations Committee of the Senate, and Alabama, where Katie Britt has been, Sen. Katie Britt, has been sort of vocal about this, which is also, people don’t think of or may not realize that University of Alabama is a huge scientific center. 

It is a powerhouse, but it is a state-funded university without such a big environment. Kennedy said: You know what? We’re going to make these cuts. But maybe not Maine and Alabama. It was like — talk about politics. But I think that they were really floored when he said over and over again that no scientists have been let go. 

Rovner: You were right. There was also a lot of sort of ad hoc, If you have a particular problem, why don’t you— 

Kenen: Call my office. 

Rovner: —call my office. Yeah. And we can take care of it. Which seemed just sort of mind-blowing to me. It’s like, this is how we’re making policy now. And somebody, I meant to go back and look at who, somebody in the morning at the House hearing, one of the Democrats, said, Is there a special phone number for Democrats to call your office to see if we can get some of these cuts restored? That literally seems to be how HHS is being run right now. 

Ollstein: And I think it’s reflected across the government. When Elon Musk was more involved directly with the DOGE [Department of Government Efficiency] stuff, he was reportedly telling Republican senators the same. Oh, if you have an issue, you know, just text me, just call me. And folks who study government pointed out that this smacks of the kind of personalism that has defined some authoritarian governments in the past where things happen more through favors than through normal government processes that are more transparent. 

Kenen: And a phone call from your senator is not how you should be able to get back into a clinical trial. There was also a lot of exchanges about what’s happening to clinical trials and harm to patients, which he was — there was some gaps there. And you’re watching him saying, Oh yeah, I can get her in. Just, you call me tomorrow. Call my office, to Sen. [Patty] Murray. And the state of him asserting that not much has changed and anything we got wrong we’ll fix versus the fact that huge numbers of things have changed that have affected both patients and future patients. 

One of the Democrats said: What’s wrong with researching cancer and Alzheimer’s, particularly if you’re trying to deal with chronic diseases? These are chronic conditions, and we’re gutting research into them. So there was a lot of disconnects. There was some, also— 

Rovner: It’s not just cuts. They are pushing the “Make America Healthy Again” agenda. Just this week the FDA [Food and Drug Administration] is moving to ban fluoride supplements for kids. These are generally drops, tablets, and lozenges prescribed to kids who live in places that don’t have fluoridated water. 

This move contradicts recommendations from both the CDC [Centers for Disease Control and Prevention] and the U.S. Preventive Health Services Task Force. And RFK was taken to task at the House hearing by Congressman Mike Simpson of Idaho, who’s one of a handful of dentists in the chamber. I have to say I didn’t have eliminating fluoride on my 2025 public health bingo card. 

Ollstein: Yes. And I think that this is raising concerns for a few reasons. One, the public health impact. This goes against decades of research and evidence and the medical community’s consensus. But this also is moving sort of beyond the personal-choice, medical freedom kind of framing that has been used to argue about fluoridating public water. This is taking away a parent’s choice, potentially. If they want these supplements for their kids, they’re not going to be available any longer. And this is exactly what people fear could extend into the vaccine space. It’s not just that it’s going to not have mandates for schools or rules around that, that it won’t even be an option for the people who want it. 

Rovner: All right, well, moving on to abortion, the one piece of potential news out of the Kennedy hearings came in response to a question from the aforementioned Sen. Josh Hawley from Missouri about a new study claiming that the abortion pill mifepristone has way more complications than numerous studies over the past 40 years it’s been in use have found. Alice, tell us about this particular study, which RFK Jr. suggested might prompt the FDA to change the status of the abortion pill. 

Ollstein: So, one, it’s not a study. Even its supporters admit in private that it’s not a study. I obtained a private conversation that a lot of these groups pushing this held recently to talk about how they hoped to use this information to influence government policy. And they noted that because this is something that a conservative think tank just put out themselves, they did not submit it to a medical journal. It did not go through peer review. 

So they said directly that it is not a study in the traditional sense. Still, you have senators and now the secretary of health and human services referring to it as a study and calling for policy changes based on it. So I want people to keep that in mind as this is discussed going forward. These drugs have been available for 25 years now. There have been lots of more rigorous, peer-reviewed studies that have found them to be overwhelmingly safe and effective. 

Some of this new data actually aligns with some of the findings from those previous, more rigorous studies, but their own unique definitions of certain things, calling some things adverse events when the FDA does not consider that to be so, and so medical experts told me, including some from KFF, that this has so many red flags that they think it could never have been published in a credible medical journal. 

Rovner: And just to clarify, while we’re talking about different time periods: It’s been available in the U.S. for 25 years. 

Ollstein: Yes. 

Rovner: It’s been available internationally since the 1980s. 

Ollstein: Right. Right. 

Rovner: So, it has been well studied for quite a long time. Well, in other abortion news this week, the Texas Legislature is moving forward with a new piece of anti-abortion legislation that can’t be challenged in court, this one aimed at the abortion pill. Alice, this is like Chapter 2 in Texas trying to figure out how they can ban abortion-related things without anybody challenging the law, right? 

Ollstein: There’s a lot of different moving parts right now. There’s that. There’s the new case that’s also pending in Texas, brought by three GOP states seeking to impose national restrictions on abortion pills. There’s this new review that the FDA is allegedly going to undertake around dispensing rules. And so this has been an overwhelming focus of the anti-abortion movement since even before Dobbs, but especially now. 

They know that the ability of people to get these pills prescribed online, sent by mail, is the primary way that people are getting around state bans, other than travel, which is not always possible for folks. And so there are just efforts going on in state legislatures, in Congress, in the FDA, in state courts and federal courts, all to impose restrictions. 

And so it’s a very throw-spaghetti-at-the-wall-and-see-what-sticks approach. But that has proven very effective for them over the decades. Arguably that’s how we got to where we are now, where abortion is banned in much of the country. So it’s something to take seriously and watch carefully. 

Rovner: And this is Texas trying again with this. Individuals can sue other individuals who they think have used the abortion pill. It does not require the involvement of the state to prosecute, which has not, I don’t think, spread beyond Texas at this point, but it would be Texas’ second bite at this apple. 

Kenen: But the proposed language in that bill is extraordinary. We at the state legislature of Texas is passing a bill and no court has the right to review whether it is constitutional, etc. It seems pretty extreme, right? 

Rovner: Well, this was how Texas did their first ban. 

Kenen: Right. 

Rovner: Remember that the Supreme Court allowed it to stand because they weren’t quite sure what to do with it. 

Kenen: But that was also because they did unique legal things in terms of, they sort of created a legal structure. This, the language is in the bill — and no court can double-check us. 

Rovner: Yeah. 

Kenen: So, and then what else can they use that for, right? And apparently there are even some Republicans who are a little concerned about that language. And I’m not up on the exact makeup of constitutional views of the entire Texas Legislature. 

Rovner: Yes. We should point out, it hasn’t passed the full legislature yet. 

Kenen: No. It’s proposed. 

Rovner: Just the Texas Senate. It’s passed the Senate. We’re awaiting to see if it will pass the Texas House. All right, well, finally in this incredibly newsy week, just before he left for his overseas trip, President Trump unveiled what he touted as an enormous announcement that turned out to be an executive order basically wishing down drug prices by tying them to other countries’ price-controlled prices. Except this isn’t really going to happen anytime soon. Right, Julie? 

Appleby: Well, it is interesting. It’s this “most favored nations” idea that we would tie drug prices in the United States to what’s paid by other countries where they have much stronger drug negotiation issues. And it’s not clear how it works. So yeah, it’s not clear what the path forward is with that. 

Ollstein: The problem with saying drug prices are coming down is if they do not come down, people might be mad at you for saying they’re coming down. 

Rovner: I would say he did wish down the price of eggs. He said that egg prices were coming down when they weren’t, except now they are, because he had nothing to do with them going up or coming down. It had to do with the bird flu. And so now he can say, See, I got egg prices down. 

Kenen: But they’re still higher than they were when he— 

Rovner: They are still higher than they were. 

Kenen: But they have come down. 

Rovner: But I will say, I was going to say, this is super-clever marketing. This is the one thing that President Trump is really, really good at. He hyped this announcement ahead of time. He actually got headlines insisting that this will really do something. I have had people tell me that they’ve had sort of their grown kids and stuff saying: Oh look, drug prices. He’s going to reduce drug prices. When in fact this is one of those executive orders that just doesn’t really do anything. 

Kenen: We don’t know what’s going to happen to drug prices over the next four years. There’s a law on the books from the Biden administration. In his first administration, I think it might’ve even been a day or two before inauguration, he went on a tear against the drug companies. Remember, he called them killers or something like that. And he also came up with a list of something like 40-odd steps that he could take. And I think half of them had a question mark after them. So he’s been mad at drug prices for a while now. He did not achieve that in the first administration. That’s bipartisan. There’s no Americans who want to pay higher prices for drugs, unless maybe they work for a drug company. People want more— 

Rovner: Right. It’s an 80/20 issue — 80% of people want drug prices down. 

Kenen: Right. 

Rovner: That’s probably more than an 80/20 issue. 

Kenen: There could be some room for bipartisanship on drugs. There’s not a lot of room for bipartisanship, but that’s particularly if he’s not trying to repeal what [President Joe] Biden did, if that stays or gets built on. We don’t know what’s going to happen. But no, you can’t just sign an executive order. It’s not a magic wand. 

Rovner: And I don’t think we’re going to be importing other countries’ price controls anytime soon. I’m going to go on a limb on that one. All right, that is this week’s news. Now it is time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Alice, I want you to go first this week because you have a story that’s directly relevant to something that we talked about in the Medicaid discussion. 

Ollstein: Yeah. So I have this great story from ProPublica [“He Became the Face of Georgia’s Medicaid Work Requirement. Now He’s Fed Up With It.”] about Medicaid work requirements and about how the small-business owner that Georgia decided to make the face of its program, and they filmed a video of him praising it, even he multiple times lost his coverage, even though he tried to do everything right. He logged his work hours. He signed up for alerts. And just because of bureaucratic things and falling through the cracks, two times he lost his coverage and he had to plead for someone to intervene to get him his benefits back. And he has really soured on all of this, even though he was the face of selling it that the governor used. So I think this is a great example of what could happen as this is debated as a national policy. 

Rovner: And I will say, I learned about this ProPublica story from the markup, where a number of members brought it up. He’s now the poster child for what happens when you have work requirements, even if people are working. Joanne. 

Kenen: There’s a great piece in The Atlantic by Nick Florko called “Now Is Not the Time To Eat Bagged Lettuce.” And although it is not in the headline, it’s particularly romaine, which has periodically been in the news as being a source of harmful bacteria. And if you think you can just buy bagged lettuce and wash it yourself and it’ll be safe — no, that doesn’t work, either. 

Basically it goes through like the equivalent of a salad woodchopper and there are all this different lettuce. All this lettuce goes through it. And once one blade gets contaminated, it all gets contaminated. So also, if you are a part of a marriage or one of you likes romaine and the other one would rather have red leaf, this is pretty good ammunition, right? But we should be going back to buying heads of lettuce, washing them yourself. 

And they’re not as safe and sanitary as it sounds, particularly as some issues are going on right now. And of course, we have less public notification and less monitoring and there’s less, less, less of food safety kinds of things coming down the pike at FDA. So it’s even more timely. 

Rovner: It’s a pretty vivid story. Julie. 

Appleby: Thanks. Mine is also, the story I’ve picked is also along the same lines of cuts and what the perhaps unintended consequences were, but the consequences nonetheless. And it’s from the Scientific American. It’s by Andrea Thompson. The headline is “How Trump’s National Weather Service Cuts Could Cost Lives.” 

And it just talks about the National Weather Service with a lot of interesting facts that I didn’t know for sure, that how the improvements have been made in forecasting, why this is important, and how it’s understaffed, and how these cuts are going to just make things worse. And it talks about it costs the average American, it says, about $4 a year for the National Weather Service. “It’s a cup of coffee,” said one person that’s being quoted. 

And it said the National Weather Service provides an overall benefit of $100 billion to the economy. Aside from the fact that you might want a tornado warning ahead of time, that kind of thing, this is also just really important to quantify the overall value at a time when we are seeing a lot of hurricanes and tornadoes and other climate issues going on. So that would be my pick. 

Kenen: But the Sharpie can just make it move. 

Rovner: Yeah, that’s true. All right, my extra credit this week is what Joanne has dubbed “Theranos for Pets,” though the actual headline in The New York Times is “Elizabeth Holmes’s Partner Has a New Blood-Testing Start-Up.” And it’s kind of a scary history-repeats-itself story. Even as Elizabeth Holmes herself remains in jail, having been convicted of fraud over her novel blood-testing company that was really cool but also didn’t work, her partner and the father of her two children, Billy Evans, is raising money for a new blood-testing company. 

He’s called it Haemanthus — I hope I’ve said that right — which is a flower also called the blood lily. And unlike his incarcerated partner, Evans plans to start out by testing the blood of pets, then move to humans. As they say, what could possibly go wrong? 

All right, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our editor, Emmarie Huetteman, and our producer, Francis Yang. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Julie Appleby. 

Appleby: I’m still on X, @Julie_appleby. 

Rovner: Joanne. 

Kenen: I’m only a little on X. I’m more on Bluesky and LinkedIn, @joannekenen. 

Rovner: Alice. 

Ollstein: Mostly on Bluesky, @alicemiranda, and still on X, @AliceOllstein. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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SACRAMENTO, Calif. — Gov. Gavin Newsom on Wednesday proposed that California roll back health care for immigrants without legal status, saying the state needed to cut benefits for some to maintain core services across the board.

It’s a striking reversal for the Democrat, who had promised universal health care and called health coverage for immigrants the moral and ethical thing to do. But a $12 billion state budget deficit, potential federal spending cuts, and larger-than-expected Medi-Cal enrollment have forced him to dial back.

Newsom said he had no other choice but to call for major cost-cutting measures affecting how some immigrants are covered by Medi-Cal, the state’s Medicaid program, which covers about 15 million Californians.

“The challenge that we face this year and the challenge we will face for many years is on growth of our Medicaid system, Medi-Cal,” Newsom told reporters at his budget presentation. “Instead of rolling back the program, cutting people off for basic care, we have to adjust the comprehensive nature of the care.”

California is one of seven states that offer health coverage to low-income adults regardless of immigration status, and that has put the program in the political crosshairs of national Republicans. The latest U.S. House proposal would cut Medicaid funding by 10 percentage points for states that provide coverage for immigrants without legal status — an approach Newsom on Wednesday described as legally questionable. Meanwhile, the Trump administration cited California’s health coverage of noncitizens as an example of states “gaming the system” when it issued a proposed rule Monday to overhaul Medicaid provider taxes.

Some 1.6 million immigrants — most without legal status — are enrolled in Medi-Cal. Federal law prohibits Medicaid dollars from being used to cover unauthorized residents, meaning California must foot the bill for the vast majority of their health care. And those costs have ballooned.

Newsom cautioned that California, like other states, could soon be in a more dire budget situation if Republicans advance their proposal to cut Medicaid. That plan includes work requirements and would cap taxes levied on providers that help states draw additional federal money. However, the governor’s budget proposal was silent on potential federal cuts.

The $321.9 billion budget proposes a freeze in Medi-Cal enrollment for immigrants 19 and older without legal status, starting Jan. 1. Beginning in 2027, immigrants 19 and older in the country illegally, as well as those with legal residency for less than five years, would be required to pay $100 monthly premiums to maintain coverage.

The Newsom administration estimated those two moves would save the state $5.4 billion by the 2028-29 fiscal year. The governor also called for eliminating dental and long-term care benefits for those without legal status and for legal residents who arrived in the U.S. less than five years ago, according to California Department of Finance spokesperson H.D. Palmer.

The changes would not apply to the roughly 217,000 children and young adults without legal status covered by Medi-Cal. Those 18 and under were the first to receive Medi-Cal coverage, in 2016. Children are generally healthier and require less care, and a KFF Health News analysis showed that, in many cases, children lacking legal status were cheaper to cover than citizens.

Maria, a street vendor from Los Angeles, said the monthly premium alone would force her and others to forgo care.

“They say they are one of the largest economies, but they don’t want to help us,” said Maria, who didn’t want to give her full name, out of fear of retaliation from immigration authorities. “We are contributing to the state. It’s not fair that we, the poor, have to pay what we don’t have.”

“Where am I going to get the $100?” Maria asked.

Federal law prohibits charging the poorest Medicaid enrollees a premium, and Newsom’s $100 monthly payment would be considered unaffordable for current beneficiaries, said Laurel Lucia, director of the health care program at the University of California-Berkeley Labor Center.

Newsom is proposing a $194.5 billion Medi-Cal budget for 2025-26. Lawmakers have until June 15 to pass the budget. Democratic leaders signaled their intent to protect health care for the state’s poorest residents.

The governor and Assembly Speaker Robert Rivas blamed fiscal headwinds brought on by President Donald Trump’s tariffs, which they said had led to a massive $16 billion dip in state tax revenue forecasts since April. But Medi-Cal spending surged well before the tariffs took effect. State costs to cover Californians with “unsatisfactory immigration status” — those without status and legal residents who have been here less than five years — is roughly $10.8 billion per year, up from the $6.4 billion officials projected in November. The federal government pays $1.2 billion of that to cover mandated emergency and pregnancy care.

“It’s laughable that he’s trying to blame Trump for anything,” Republican Assembly member Joe Patterson, who sits on the Assembly Budget Committee, said of Newsom. “He overpromised to them, and he’s pulling the carpet out from underneath them.”

Other states that have extended coverage to immigrants are also struggling with escalating costs. Minnesota, for example, originally projected that 5,700 residents without legal status would sign up for the state Medicaid program, known as MinnesotaCare, at a cost of $200 million. Both figures have increased roughly threefold.

Illinois is ending services for adult immigrants, except seniors, on July 1, citing higher-than-anticipated enrollment. The mostly state-funded health plan will stop covering around 30,000 noncitizens ages 42 to 64, including those living in the country without authorization.

Newsom said Wednesday that without a suite of his proposed changes to Medi-Cal, program costs could grow by an additional $10 billion through June 2026 and would “contribute significantly to the structural imbalance in future years.”

But consumer advocates and lawmakers said the move is a betrayal of the governor’s commitment to bring California closer to universal health care and warned it would push immigrants into costly emergency room care. Sen. María Elena Durazo, a Democrat who championed the Medi-Cal expansion, said California shouldn’t single out immigrants to solve its budget deficit.

“I don’t agree that we should be isolating and abandoning and separating a particular group of Californians, as if they are responsible for the problem,” Durazo said. “I don’t care what you call them, they work, they contribute.”

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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SACRAMENTO, California — El gobernador Gavin Newsom no esperaba enfrentarse a otra crisis sanitaria.

En marzo, mientras el presidente Donald Trump y los republicanos del Congreso intensificaban el debate nacional sobre la posibilidad de recortar la atención médica para los estadounidenses pobres y con discapacidades, el gobernador demócrata tuvo que informar a los legisladores estatales que los costos de la atención de salud en California se habían descontrolado.

Esto debido a las grandes iniciativas de Medicaid que él apoyaba, incluyendo la mayor expansión del país de la atención médica financiada con fondos públicos para inmigrantes que viven en Estados Unidos sin papeles.

Sus altos funcionarios del Departamento de Finanzas estatal revelaron con discreción a los legisladores californianos en una carta que el estado había solicitado un préstamo de $3.400 millones para pagar a las aseguradoras, médicos y hospitales que atendían a los pacientes inscritos en el programa estatal del Medicaid, conocido como Medi-Cal.

Ante el aumento de los costos de la atención en medio de una crisis presupuestaria estatal cada vez más profunda, Newsom ahora debe considerar la posibilidad de reducir la cobertura y los beneficios.

El gobernador, en su segundo mandato, se enfrenta a una difícil decisión política: no cumplir su promesa de lograr una atención médica universal y retirar la cobertura a millones de inmigrantes sin estatus legal, o buscar recortes presupuestarios en otros lugares.

Con casi 15 millones de residentes inscritos en Medi-Cal, California tiene más que perder en materia de atención médica que cualquier otro estado. Sin embargo, aunque Newsom ha condenado la estrategia de Trump sobre los aranceles y las políticas ambientales, se ha mantenido hermético en materia de política de salud.

Para complicar su situación política, las encuestas muestran que brindar cobertura médica a inmigrantes sin papeles cuenta con escaso apoyo. Y cualquier problema presupuestario resultante podría perjudicar su legado político si se postulara a la presidencia en 2028.

“Todos sabemos que los recortes definitivamente se avecinan”, dijo Carlos Alarcón, analista de salud y beneficios públicos del California Immigrant Policy Center, que ha ayudado a impulsar una campaña de una década en el estado para expandir Medicaid a los inmigrantes elegibles sin documentos.

“El gobernador debe cumplir su compromiso; nos decepcionaremos mucho si vemos recortes y reducciones. En tiempos difíciles, siempre son nuestras comunidades marginadas y desatendidas las que salen perdiendo”, agregó.

California permite a cualquier adulto de bajos ingresos inscribirse en Medi-Cal si gana el 138% del nivel federal de pobreza, o $21.597 al año o menos, independientemente de su estatus migratorio. Sin embargo, los costos han sido mucho más altos de lo esperado.

El gobernador demócrata Jerry Brown amplió Medi-Cal a las personas de 19 años o menos sin estatus legal, pero expresó su reticencia a extenderlo más allá de ese grupo debido a los posibles costos.

Newsom promulgó leyes que incluyen a las personas de 20 años o más. Se estima que 1.6 millones de inmigrantes sin estatus legal ahora están cubiertos, y los costos se han disparado a $9.500 millones al año, en comparación con los $6.400 millones estimados en noviembre. El gobierno federal aporta aproximadamente $1.1 mil millones de ese total para atención médica del embarazo y emergencias.

“Podemos expandirnos por pura generosidad a todas partes, pero en cuanto estos recursos se agoten, todos perdemos. Estamos llegando a un punto crítico”, dijo el asambleísta de California David Tangipa (republicano de Fresno). “O asumimos la responsabilidad fiscal, o no habrá servicios para nadie, incluyendo a los californianos y a los inmigrantes indocumentados”.

Los líderes demócratas responsables de aprobar el presupuesto estatal no aceptaron entrevistas. En un comunicado, la senadora estatal María Elena Durazo (demócrata de Los Ángeles) quien defendió la expansión en la Legislatura, declaró: “Revertir este progreso sería una decisión perjudicial y obtusa”.

Los legisladores están considerando congelar la inscripción de inmigrantes sin estatus legal, imponer medidas de costos compartidos como copagos o primas sobre ls medicamentos, o restringir los beneficios, según personas familiarizadas con el tema, que pidieron no ser identificadas para proteger sus relaciones en el Capitolio estatal.

Sin embargo, es poco probable que Newsom recorte drásticamente los fondos en su revisión presupuestaria, publicada el 14 de mayo. En cambio, los recortes se producirían si los republicanos del Congreso aprueban un acuerdo presupuestario con importantes reducciones en el gasto federal en Medicaid.

“Esto va a ser muy problemático para el gobernador. Los recortes del presupuesto afectarán la vida de millones de inmigrantes que recién comienzan a tener atención médica, pero el gobernador tiene que hacer algo, porque esto no es sostenible”, dijo Mark Peterson, experto en atención médica y política nacional de la UCLA. “La posibilidad de recortar otros gastos para apoyar a los inmigrantes que viven en el país sin autorización sería una estrategia política difícil; no creo que eso suceda”.

Si Newsom, junto con la Legislatura controlada por los demócratas, se viera obligado a realizar recortes, podría argumentar que no tenía otra opción. Trump y los republicanos del Congreso han amenazado a estados como California con la última propuesta de la Cámara de Representantes de EE.UU. de recortar la financiación de Medicaid en 10 puntos porcentuales para los estados que ofrecen coberturas a inmigrantes sin papeles.

Para Newsom, Trump podría ser un chivo expiatorio fácil, dicen analistas.

“Puede culpar a Trump; el dinero disponible es limitado”, dijo Mike Madrid, analista político republicano anti-Trump en California, especializado en temas latinos. “Esto está haciendo que la gente vea la atención médica que no puede pagar y se pregunte: ‘¿Por qué demonios se la damos gratis a quienes están aquí sin documentos?’”.

El costo exorbitante ha sido una sorpresa.

En la primera propuesta presupuestaria de Newsom como gobernador, en la que propuso ampliar Medi-Cal a los adultos jóvenes sin documentos, su administración estimó que extender los beneficios a todas las personas elegibles, independientemente de su estatus, costaría aproximadamente $2.4 mil millones anuales. Pero la última cifra reportada a los legisladores fue casi cuatro veces mayor.

Newsom se negó a responder preguntas de KFF Health News, y en su lugar hizo referencia a comentarios anteriores que dejan la puerta abierta a la posibilidad de reducir Medi-Cal. El gobernador destacó las conversaciones “serias” con los legisladores y afirmó que recortar el programa es una “pregunta abierta” en la que el presidente influirá considerablemente.

“¿Cuál es el impacto de Donald Trump en muchos de estos temas? ¿Cuál es el impacto del vandalismo federal en muchos de estos programas?”, se preguntó Newsom retóricamente en diciembre, sugiriendo que no está claro si podrá sostener la expansión para los inmigrantes sin papeles en los próximos años.

Newsom expandió Medi-Cal en tres fases, comenzando con los inmigrantes de 19 a 25 años, quienes se volvieron elegibles en 2020, resistiendo la presión de los defensores de la atención médica para una expansión grande y costosa. Argumentó que hacerlo de forma gradual, en última instancia, ahorraría dinero a California.

“Es lo correcto moral y éticamente”, dijo Newsom en 2020. “También es lo financieramente responsable”.

Los superávits presupuestarios récord de los últimos años permitieron que los demócratas continuaran. Los adultos mayores de 50 a 64 años comenzaron a ser elegibles en 2022, y Newsom cerró la brecha al año siguiente, aprobando la cobertura para el grupo más numeroso, el de 26 a 49 años a partir de 2024.

Sin embargo, los costos han aumentado muchísimo, mientras que el panorama presupuestario se ha deteriorado, según un análisis de KFF de los registros más recientes de 2023 disponibles del Departamento de Servicios de Atención Médica del estado, que administra Medi-Cal.

Por fuera de los niños, fue más caro brindar cobertura de Medicaid a los inmigrantes sin estatus legal que a los residentes legales. Por ejemplo, Medi-Cal pagó a L.A. Care, una gran aseguradora de salud en Los Ángeles, un promedio de $495.32 mensuales por brindar atención a un adulto sin hijos sin papeles, y $266.77 por un residente legal sin hijos.

No solo fue más caro para los inmigrantes sin estatus legal, sino que California asumió la mayor parte del costo.

El estado pagó aproximadamente entre el 60% y el 70% de los costos de atención médica para un inmigrante adulto sin hijos cubierto por L.A. Care, y alrededor del 10% para un residente legal sin hijos. Estos costos no abarcan el costo total de la atención, que puede variar según en donde viven los pacientes de Medi-Cal, y aumentar al surtir recetas, ir al dentista o buscar atención de salud mental.

Estos pagos también varían según la aseguradora, pero la tendencia se mantiene en todos los planes de Medi-Cal. En la mayor parte del estado, los pacientes pueden elegir entre más de un plan de salud.

En muchos casos, la cobertura para los niños sin estatus legal fue más económica que la de los niños con residencia legal. Generalmente, los niños son más saludables y necesitan menos atención.

Mike Genest, quien se desempeñó como director de finanzas durante el gobierno del ex gobernador republicano Arnold Schwarzenegger, argumentó que el estado debería haber previsto el enorme costo.

“La idea de que a largo plazo podamos pagar la atención médica para todas estas personas indocumentadas es insostenible”, dijo Genest.

Si bien ahora los costos son altos, la expansión de Medi-Cal generará ahorros a largo plazo para los contribuyentes y el sistema de salud, afirmó Anthony Wright, quien anteriormente presionó a favor de la expansión como director de la organización sin fines de lucro Health Access y ahora lucha contra los recortes a Medicaid como director ejecutivo de Families USA, con sede en Washington, D.C.

“De todas formas, seguirán acudiendo a nuestro sistema de salud”, afirmó Wright. “Dejarlos sin seguro médico solo resultará en salas de emergencia más congestionadas y costará aún más. No tiene sentido económico que no tengan seguro; eso les quita ingresos cruciales a clínicas y hospitales, lo que solo causa más problemas”.

Esta historia fue producida por KFF 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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SACRAMENTO, Calif. — Gov. Gavin Newsom didn’t expect to be reckoning with another health care crisis.

In March, as President Donald Trump and congressional Republicans escalated a nationwide debate over whether to slash health care for poor and disabled Americans, the Democratic governor had to tell state lawmakers that California’s health care costs had spiraled out of control due to major Medicaid initiatives he backed — including the nation’s largest expansion of taxpayer-financed health care for immigrants living in the U.S. without legal permission.

His top officials at the state Department of Finance quietly disclosed to California lawmakers in a letter that the state had borrowed $3.4 billion to pay health insurers, doctors, and hospitals caring for patients enrolled in California’s Medicaid program, known as Medi-Cal. Facing rising health care costs amid a deepening state budget crisis, Newsom now must contemplate rolling back coverage and benefits.

The second-term governor faces a tough political decision: renege on his promise to achieve universal health care and strip coverage from millions of immigrants who lack legal status or look elsewhere for budget cuts. With nearly 15 million low-income or disabled residents enrolled in Medi-Cal, California has more to lose on health care than any other state. Yet even as Newsom has condemned Trump’s approach to tariffs and environmental policies, he has been tight-lipped on health policy.

Complicating his political tightrope: Polling shows that providing health care coverage for immigrants without legal status has tepid support. And any resulting budget trouble could harm his political legacy should he run for president in 2028.

“We all know that the cuts are definitely coming,” said Carlos Alarcon, a health and public benefits analyst with the California Immigrant Policy Center, which has helped spearhead a decade-long campaign in California to expand Medicaid to eligible immigrants without legal status. “The governor should keep his commitment — we’ll be very disappointed if we see cuts and rollbacks. When times get hard, it’s always our marginalized and underserved communities that lose out.”

California allows any low-income adults to enroll in Medi-Cal if they earn 138% of the federal poverty level, or $21,597 a year or less, regardless of immigration status. But the costs have been dramatically higher than expected.

Democratic Gov. Jerry Brown expanded Medi-Cal to people age 19 and younger without legal status, but he expressed reluctance to go further because of potential costs. Newsom signed bills into law adding people age 20 and older. An estimated 1.6 million immigrants without legal status are now covered, and costs have soared to $9.5 billion per year, up from $6.4 billion estimated in November. The federal government chips in roughly $1.1 billion of that total for pregnancy and emergency care.

“We can expand out of the graciousness of our heart to everywhere and anywhere, but the moment these resources run out, now everybody loses. We’re hitting that breaking point,” said California Assembly member David Tangipa, a Fresno Republican. “Either we get fiscally responsible, or there’s not going to be services for anybody — and that includes the Californian and the undocumented immigrant.”

Democratic leaders responsible for approving the state budget declined interviews. In a statement, state Sen. María Elena Durazo, a Los Angeles Democrat, who championed the expansion in the legislature, said, “Rolling back this progress would be a harmful and shortsighted decision.”

Lawmakers are considering freezing enrollment for immigrants without legal status, imposing cost-sharing measures such as drug copays or premiums, or restricting benefits, according to people familiar with the matter, who asked not to be identified to protect relationships at the state Capitol.

However, it’s unlikely Newsom will slash funding in his budget revision set for release on May 14. Instead, cuts would follow if congressional Republicans approve a budget deal with major reductions in federal spending on Medicaid.

“This is going to be very problematic for the governor. Budget cuts will disrupt the lives of millions of immigrants who just got health care, but the governor has got to do something, because this is not sustainable,” said Mark Peterson, an expert on health care and national politics at UCLA. “The prospect of cutting other places in order to support immigrants living in the country illegally would be a hard political sale; I don’t see that happening.”

Should Newsom, along with the Democratic-controlled legislature, be forced to make cuts, he could argue he had no choice. Trump and congressional Republicans have threatened states like California with the latest U.S. House proposal cutting Medicaid funding by 10 percentage points for states that provide coverage for immigrants without legal status.For Newsom, political analysts say, Trump could make an easy scapegoat.

“He can blame Trump — there’s only so much money to go around,” said Mike Madrid, an anti-Trump Republican political analyst in California who specializes in Latino issues. “It’s making people look at the health care that they can’t afford and ask, ‘Why the hell are we giving it for free to people who are here illegally?’”

The exorbitant cost has come as somewhat of a surprise.

In Newsom’s first budget proposal as governor — in which he called for expanding Medi-Cal to young adults without legal status — his administration estimated it would cost roughly $2.4 billion annually to extend benefits to all eligible people regardless of status. But the latest figure reported to legislators was nearly four times as much.

Newsom declined to respond to questions from KFF Health News, instead referencing previous comments that leave the door open to scaling back Medi-Cal. The governor noted “sober” discussions with lawmakers and said cutting Medi-Cal is “an open-ended question” that the president will heavily influence.

“What’s the impact of Donald Trump on a lot of these things? What’s the impact of federal vandalism to a lot of these programs?” Newsom asked rhetorically in December, suggesting it’s unclear whether he’ll be able to sustain the expansion to immigrants without legal status in future years.

Newsom expanded Medi-Cal in three phases, starting with immigrants ages 19 to 25, who became eligible in 2020, resisting pressure from health care advocates for one big, costly expansion. He argued doing it incrementally would ultimately save California money.

“It is the right thing morally and ethically,” Newsom said in 2020. “It is also the financially responsible thing to do.”

Record budget surpluses in recent years allowed Democrats to continue. Older adults ages 50 to 64 became eligible in 2022, and Newsom closed the gap the following year, approving coverage starting in 2024 for the biggest group, those ages 26 to 49.

But the costs have grown tremendously while the budget picture has soured, according to a KFF analysis of the most recent 2023 records available from the state Department of Health Care Services, which administers Medi-Cal.

Aside from children, it was more expensive to provide Medicaid coverage to immigrants without legal status than to legal residents. For instance, Medi-Cal paid L.A. Care, a major health insurer in Los Angeles, an average of $495.32 monthly to provide care for a childless adult without legal status and $266.77 for a legal resident without kids.

Not only were immigrants without legal status more expensive, California footed most of the cost. The state paid roughly between 60% and 70% of health care costs for a childless adult immigrant covered by L.A. Care, and about 10% for a legal resident without kids. Those costs don’t encapsulate the entire cost of providing care, which can vary depending on where Medi-Cal patients live, and grow higher when filling prescriptions, going to the dentist, or seeking mental health care.

These payments also differ by insurer, but the trend holds across the state’s Medi-Cal health insurance plans. Patients in most of the state can choose from more than one health plan.

Children without legal status in many cases were cheaper to cover than children who were legal residents. Generally, kids are healthier and require less care.

Mike Genest, who served as finance director under former Republican Gov. Arnold Schwarzenegger, argued that the state should have planned for the immense price tag.

“The idea that we’d be able to afford in the long run paying for health care for all these undocumented people — it’s beyond unsustainable,” Genest said.

While costs are high now, the expansion of Medi-Cal will result in long-term savings to taxpayers and the health care system, said Anthony Wright, who previously lobbied for the expansion as the head of the nonprofit Health Access and is now fighting Medicaid cuts as the executive director of Families USA, based in Washington, D.C.

“They’re going to be showing up in our health care system regardless,” Wright said. “Leaving them without health insurance is just going to end in more crowded emergency rooms, and it’s going to cost even more. It doesn’t make any sense economically for them to be uninsured; that takes critical revenue from clinics and hospitals, just causing more problems.”

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The Trump administration must soon make a decision that will affect millions of Americans’ ability to access and afford mental health and addiction care.

The administration is facing a May 12 deadline to declare if it will defend Biden-era regulations that aim to enforce mental health parity — the idea that insurers must cover mental illness and addiction treatment comparably to physical treatments for ailments such as cancer or high blood pressure.

Although a federal parity law has been on the books since 2008, the regulations in question were issued last September. They represent the latest development in a nearly two-decade push by advocates, regulators, and lawmakers to ensure insurance plans cover mental health care equitably to physical health care.

Within the dense 166-page final rule, two provisions have garnered particular attention: first, that insurers provide “meaningful benefits” — as defined by independent medical standards — for covered mental health conditions if they do so for physical conditions. For example, if insurers cover screening and insulin treatment for diabetes, then they can’t cover screening alone for opioid addiction; they must also cover medications to treat opioid use disorder.

Second, insurers must go beyond the written words of their policies to measure how they work in practice. For example, are patients having to seek out-of-network care more often for mental than physical care? If so, and it relates to an insurer’s policies, then those policies must be adjusted.

In January, a trade association representing about 100 large employers sued the federal government, claiming the regulations overstepped the administration’s authority, would increase costs, and risked reducing the quality of care. The ERISA Industry Committee represents several Fortune 500 companies, such as PepsiCo and Comcast, which sponsor health insurance plans for their employees and would be directly affected by the new regulations.

ERIC’s lawsuit, filed days before President Donald Trump’s inauguration, puts the onus on the new administration to decide whether to defend the regulations. If it chooses not to, the rules could be scrapped.

Mental health clinicians, patients, and advocates are urging the administration to fight back.

“What we’re trying to do is make the spirit of parity a practical reality,” said Patrick Kennedy, a Democratic former U.S. representative who sponsored the 2008 parity law in the House and co-founded the Kennedy Forum, which advocates on mental health issues. This is “an existential issue for the country, public health, for every aspect of our society.”

A 2023 national survey found that more than 6 million adults with mental illness who wanted treatment in the past year were unable to receive it. Cost was one of the most common barriers.

This lack of treatment harms people’s physical health too, with research suggesting that undertreating depression can complicate chronic conditions, such as diabetes.

Kennedy hopes that connection will prompt support from the Trump administration, which has made chronic disease a central focus of its “Make America Healthy Again” agenda.

“You’re never going to get MAHA if you don’t integrate mental health,” Kennedy said, mentioning the broad health movement embraced by his cousin HHS Secretary Robert F. Kennedy Jr.

But James Gelfand, president and CEO of ERIC, said the regulations are a misguided attempt to solve the nation’s mental health care crisis.

People’s difficulty accessing therapy or medication has less to do with insurance policy and more to do with a severe shortage of mental health care providers, he said, adding, “No amount of penalties on employers” or new parity regulations “is going to change that dynamic until we get more of these providers.”

This point is at the heart of debate about parity issues. Is mental health care difficult to access because there are few providers, or are providers not accepting insurance because of low reimbursement rates? A recent study by the research institute RTI International suggests it has more to do with payment.

The departments of Justice, Labor, and Health and Human Services declined to comment for this article. The Treasury Department, which is also involved in the lawsuit, did not respond to requests for comment.

‘They Bank on You Just Giving Up’

Psychiatric nurse practitioner Gabrielle Abelard employs about 40 clinicians in her therapy practice, which serves about 2,500 clients across Massachusetts each year.

One of the programs she’s most proud to offer is intensive in-home therapy for children with serious behavioral challenges, such as intergenerational trauma, aggressive outbursts, and self-harm. Two clinicians visit the child’s home over months and work with the family, the child’s doctors, and school staff.

“A big part of the work being done is helping to keep children in school, helping to keep them out of the hospital and even out of jail,” Abelard said.

But insurance barriers sometimes hinder the services.

Abelard’s staff has to obtain prior authorization from insurers before they can provide care. Then they have to reapply for authorization every two, three, or six months, depending on the insurer. When that reauthorization is delayed, Abelard faces a dilemma: continue seeing clients knowing insurers may not pay for those services or leave clients without care until the reauthorization comes through.

Continuing services has cost her tens of thousands of dollars, she said, and months of bureaucratic hurdles to obtain back payments from insurers.

“They bank on you just giving up,” she said.

A goal of the landmark 2008 Mental Health Parity and Addiction Equity Act was to decrease dilemmas such as Abelard’s.

But the bipartisan law primarily emphasized easy-to-measure treatment limits, saying insurers could not impose higher deductibles or copays for mental health care than they did for physical health care. What received less attention was how insurers should handle other limitations, such as prior authorization or fail-first requirements for patients to try certain therapies before they would be eligible for others.

As a result, true parity remained elusive, said Deborah Steinberg, a senior health policy attorney at the nonprofit Legal Action Center.

In 2020, Congress tried to address this through a new law, signed by Trump in his first term. The law required insurance plans to systematically analyze differences in certain treatment limitations for mental and physical health care and submit those analyses upon request to states and the federal governments.

As the federal government reviewed some of those analyses, it discovered numerous parity violations. In a 2022 report, it detailed how some insurance plans covered nutritional counseling for diabetes, but not for anorexia or bulimia. Another plan required precertification for all outpatient mental health and addiction services but only for a select few outpatient medical and surgical services.

The regulations issued in September aimed to provide insurers more guidance on the 2020 law and close loopholes that allowed such disparities, Steinberg said.

‘Supply Is the Biggest Problem’

One of the biggest changes in the new regulations was the focus on outcomes, such as how often patients go out of network for mental versus physical care.

Steinberg called the provision “a really important change.” But Gelfand, president of the employer association suing to stop the regulations, said it ignores the complexity of mental health care.

Many factors outside employers’ and insurers’ control affect how often a patient goes out of network, he said, including the availability of providers in the area, regional variations in clinical practices, and the patient’s personal preference.

Mental health clinicians know there’s high demand for their services, so they have a lot of market power. That “is creating the bad behavior from these providers,” Gelfand said, such as refusing to accept insurance and not submitting out-of-network bills on clients’ behalf.

“Supply is the biggest problem,” Gelfand said.

However, the RTI International study challenged that premise, with the authors noting that primary care physicians are in shorter supply than behavioral health providers yet have much lower out-of-network use.

The authors point to insurance reimbursements as the culprit instead. The study found that insurance reimbursements for behavioral health visits are, on average, 22% lower than for medical or surgical office visits. The low pay creates a disincentive for psychologists and psychiatrists to join insurance networks.

But the fix may not be as easy as raising reimbursement rates. Companies are already paying increasingly high premiums for employees’ health insurance and many are concerned about sustaining these benefits.

ERIC has championed other strategies, such as reforming medical education and residency programs to produce more mental health care providers, increasing telehealth services, and training primary care doctors to address basic mental health concerns. The organization often lobbies state and federal lawmakers, writes letters to regulatory agencies, and testifies before Congress on these issues.

Narrowly focusing on insurance regulations could have unintended consequences, Gelfand said. Increased costs for health plans may get passed on to consumers. Or, in an attempt to keep costs down, insurers may narrow the size of their physical health care networks to match the mental health ones. In a worst-case scenario, employers could stop providing mental health benefits altogether.

Advocates say that’s unlikely, since many employees have come to expect this type of coverage, and employers recognize that providing mental health benefits can increase worker productivity and retention.

Patrick Kennedy also pointed to the bigger picture around these issues: If people do not have insurance coverage for mental health care, they’re more likely to end up in crisis at the hospital or in the criminal justice system, he said. Their children may be sent to foster care. Taxpayers finance those systems.

“We all end up picking up the tab for not enforcing parity,” he said.

But what calculation the Trump administration makes — and whether it defends or drops the new regulations — remains to be seen.

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SACRAMENTO, Calif. — State Sen. Akilah Weber Pierson anticipates that California’s sprawling Medicaid program, known as Medi-Cal, may need to be dialed back after Gov. Gavin Newsom releases his latest budget, which could reflect a multibillion-dollar deficit.

Even so, the physician-turned-lawmaker, who was elected to the state Senate in November, says her priorities as chair of a budget health subcommittee include preserving coverage for the state’s most vulnerable, particularly children and people with chronic health conditions.

“We will be spending many, many hours and long nights figuring this out,” Weber Pierson said of the lead-up to the state’s June 15 deadline for lawmakers to pass a balanced budget.

With Medicaid cuts on the table in Washington and Medi-Cal running billions of dollars over budget due to rising drug prices and higher-than-anticipated costs to cover immigrants without legal status, Weber Pierson’s dual responsibilities — maintaining a balanced budget and delivering compassionate care to the state’s poorest residents — could make her instrumental in leading Democrats through this period of uncertainty.

President Donald Trump has said GOP efforts to cut federal spending will not touch Medicaid beyond “waste, fraud, and abuse.” Congressional Republicans are considering going after states such as California that extend coverage to immigrants without legal status and imposing restrictions on provider taxes. California voters in November made permanent the state’s tax on managed-care health plans to continue funding Medi-Cal.

The federal budget megabill is winding its way through Congress, where Republicans have set a target of $880 billion in spending cuts over 10 years from the House committee that oversees the Medicaid program.

Health care policy researchers say that would inevitably force the program to restrict eligibility, narrow the scope of benefits, or both. Medi-Cal covers 1 in 3 Californians, and more than half of its nearly $175 billion budget comes from the federal government.

One of a handful of practicing physicians in the state legislature, Weber Pierson is leaning heavily on her experience as a pediatric and adolescent gynecologist who treats children with reproductive birth defects — one of only two in Southern California.

Weber Pierson spoke to KFF Health News correspondent Christine Mai-Duc in Sacramento this spring. She has introduced bills to improve timely access to care for pregnant Medi-Cal patients, require developers to mitigate bias in artificial intelligence algorithms used in health care, and compel health plans to cover screenings for housing, food insecurity, and other social determinants of health.

This interview has been edited for length and clarity.

Q: You’re a state senator, you practice medicine in your district, and you’re also a mom. What does that look like day to day?

A: When you grow up around someone who juggles a lot, that just kind of becomes the norm. I saw this with my mom [former state Assembly member Shirley Weber, who is now secretary of state].

I’m really happy that I’m able to continue with my clinical duties. Those in the health care profession understand how much time, energy, effort, and money we put into becoming a health care provider, and I’m still fairly early in my career. With my particular specialty, it would also be a huge void in the San Diego region for me to step back.

Q: What are the biggest threats or challenges in health care right now?

A: The immediate threats are the financial issues and our budget. A lot of people do not understand the overwhelming amount of dollars that go into our health care system from the federal government.

Another issue is access. Almost everybody in California is covered by insurance. The problem is that we have not expanded access to providers. If you have insurance but your nearest labor and delivery unit is still two hours away, what exactly have we really done for those patients?

The third thing is the social determinants of health. The fact that your life expectancy is based on the ZIP code in which you were born is absolutely criminal. Why are certain areas devoid of having supermarkets where you can go and get fresh fruits and vegetables? And then we wonder why certain people have high blood pressure and diabetes and obesity.

Q: On the federal level, there’s a lot of conversation happening around Medicaid cuts, reining in the MCO tax, and potentially dropping Affordable Care Act premium subsidies. Which is the biggest threat to California?

A: To be quite honest with you, all of those. The MCO tax was a recognition that we needed more providers, and in order to get more providers, we need to increase the Medi-Cal reimbursement rates. The fact that now it is at risk is very, very concerning. That is how we are able to care for those who are our most vulnerable in our state.

Q: If those cuts do come, what do we cut? How do we cut it?

A: We are in a position where we have to talk about it at this point. Our Medi-Cal budget, outside of what the federal government may do, is exploding. We definitely have to ensure that those who are our most vulnerable — our kids, those with chronic conditions — continue to have some sort of coverage. What will that look like?

To be quite honest with you, at this point, I don’t know.

Q: How can the state make it the least painful for Californians?

A: Sometimes the last one to the table is the first one to have to leave the table. And so I think that’s probably an approach that we will look at. What were some of the more recent things that we’ve added, and we’ve added a lot of stuff lately. How can we trim down — maybe not completely eliminate, but trim down on — some of these services to try to make them more affordable?

Q: When you say the last at the table, are you talking about the expansion of Medi-Cal coverage to Californians without legal status? Certain age groups?

A: I don’t want to get ahead of this conversation, because it is a very large conversation between not only me but also the [Senate president] pro tem, the Assembly speaker, and the governor’s office. But those conversations are being had, keeping in mind that we want to provide the best care for as many people as possible.

Q: You’re carrying a bill related to AI in health care this year. Tell me what you’re trying to address.

A: It has just exploded at a speed that I don’t know any of us were anticipating. We are trying to play catch-up, because we weren’t really at the table when all of this stuff was being rolled out.

As we advance in technology, it’s been great; we’ve extended lives. But we need to make sure that the biases that led to various discrepancies and health care outcomes are not the same biases that are inputted into that system.

Q: How does Sacramento policy impact your patients and what experience as a physician do you bring to policymaking?

A: I speak with my colleagues with actual knowledge of what’s happening with our patients, what’s happening in the clinics. My patients and my fellow providers will often come to me and say, “You guys are getting ready to do this, and this is why it’s going to be a problem.” And I’m like, “OK, that’s really good to know.”

I work at a children’s facility, and right after the election, specialty hospitals were very concerned around funding and their ability to continue to practice.

In the MCO discussion, I was hearing from providers, hospitals on the ground on a regular basis. With the executive order [on gender-affirming care for transgender youth], I have seen people that I work with concerned, because these are patients that they take care of. I’m very grateful for the opportunity to be in both worlds.

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In his March address to Congress, President Donald Trump honored a Texas boy diagnosed with brain cancer. Amid bipartisan applause, he vowed to drive down childhood cancer rates through his “Make America Healthy Again” initiative.

A few days later, the administration quietly dropped a lawsuit to cut emissions from a Louisiana chemical plant linked to cancer.

At first glance, Trump appears to have fully embraced the MAHA movement championed by Health and Human Services Secretary Robert F. Kennedy Jr. From proclaiming in his congressional speech a goal to “get toxins out of our environment” to launching a new commission to study cancer and other ailments, Trump has vowed to end what he calls an epidemic of chronic disease.

But even as he extols MAHA, Trump has unleashed a slew of policies likely to make Americans less healthy. He’s slashing 20,000 full time positions from HHS and cutting more than $4 billion in indirect costs related to health research grants, including studies into treatment for Alzheimer’s and cancer. He also supported a GOP plan likely to kneecap Medicaid, a joint federal-state program that covers about 72 million Americans.

The contradictions raise doubts about the sincerity of Trump’s support for the MAHA agenda and his administration’s commitment to making a dent in chronic disease — conditions that afflict about 133 million Americans and account for roughly 90% of the $4.5 trillion spent annually in the U.S. on health care.

The administration’s attention to chronic disease is also notable for its lack of focus on expanding health insurance. Research shows people with coverage have lower death rates; insurance provides free or low-cost preventive care that can help manage chronic disease and reduce risks of serious complications.

“The layoffs at HHS, cuts to Medicaid, and reduction in research could all end up resulting in less healthy Americans,” said Larry Levitt, executive vice president for health policy at KFF. “They’re talking about getting at the root causes of chronic disease. Less research and protections will undermine that goal.” KFF is a health information nonprofit that includes KFF Health News.

HHS leaders have said that they focused personnel cuts at agencies on redundant or unnecessary administrative positions. The administration has said the job cuts will save money and make HHS more responsive.

“Streamlining bureaucracy and eliminating redundancies is how we deliver on the mission of Making America Healthy Again — not by preserving a bloated system that’s failed to improve outcomes despite record spending,” HHS spokesperson Vianca Rodriguez Feliciano said in an email.

Public health advocates say the staffing cuts run counter to the promise of a MAHA agenda dedicated to reducing chronic disease.

“HHS declared that their mission is to Make America Healthy Again,” said Sharon Gilmartin, executive director of Safe States Alliance, on a press call. The alliance is a nonprofit focused on preventing injury and violence. “How can we do that when the people who have spent decades of their life combating the health issues of our nation are being tossed out with no notice?”

The HHS workforce reductions decimated divisions focused on chronic disease.

Gone is most of the Centers for Disease Control and Prevention’s population health division, which conducted research and developed public health programs on chronic disease. Gone, too, are staffers at the National Institutes of Health who focused on Alzheimer’s research. After HHS staffers working on Alzheimer’s projects were put on administrative leave, the Alzheimer’s Association sounded the alarm about the cuts, saying in an April 1 statement that the reductions “could cause irreversible damage.”

And gone is the CDC’s Office on Smoking and Health, which worked to protect the public from the harmful effects of tobacco use. The administration also gutted the FDA’s Center for Tobacco Products, which enforces advertising restrictions. Tobacco use is the leading preventable cause of disease, disability, and death in the country.

“Cuts to CDC and FDA tobacco control programs are devastating,” Tom Frieden, who served as director of the CDC from 2009 to 2017, said April 18 on the social media platform Bluesky.

According to administration fact sheets and press releases, the staffing cuts will save $1.8 billion a year and shrink HHS’ workforce from 82,000 to 62,000 full-time employees. HHS will be retooled to focus on “safe, wholesome food, clean water, and the elimination of environmental toxins,” according to a March 27 press statement. The restructuring will improve Americans’ experience with HHS by making the agency more responsive and efficient, the statement said.

Roger Severino, a lawyer who led the HHS Office for Civil Rights during the previous Trump administration, said the job cuts are necessary because the HHS budget has grown while American health has declined.

“If you want to Make America Healthy Again, you have to make HHS healthy again. You have to trim the bureaucratic fat,” said Severino, who is now vice president of domestic policy at the Heritage Foundation, a conservative policy group. “We haven’t seen chronic disease go down or obesity go down, while autism rates are up. If this were a private company, it would have gone bankrupt years ago.”

But many public health experts question how the federal government will be able to respond to existing problems, as well as new health issues, with fewer employees and resources.

Infectious diseases are one area of concern.

Trump, on the first day of his second term in office, withdrew the nation from the World Health Organization, which detects, monitors, and responds to emerging health threats. The U.S. has been the largest financial contributor to the organization.

Without membership, the U.S. may remain in the dark if the WHO identifies an emerging threat that could ultimately spread and become global. Spillover can happen: In 2014, an Ebola outbreak in West Africa led to 11 reported cases in the U.S. The WHO played a central role in developing infection-prevention protocols and provided logistical support to affected countries.

The evisceration of the U.S. Agency for International Development could also leave the nation more vulnerable because the agency worked with countries such as Vietnam on early detection of diseases including bird flu. The agency typically would have aided in the response to a current Ebola outbreak in Uganda, providing support that doctors say helped prevent spread in past outbreaks.

The staffing reductions and frozen or canceled grants are having an immediate impact on the ability to respond to infectious outbreaks. Right now, for instance, Texas is in the throes of a measles outbreak, with more than 500 confirmed cases.

But the administration’s funding cuts forced the Dallas County health department to lay off 11 full-time workers and 10 part-time staffers responsible for responding to such outbreaks, Philip Huang, director and health authority for the Dallas County Health and Human Services Department, said at a press event.

The administration has also imperiled ongoing research, including studies and trials related to chronic disease.

Trump ended hundreds of research projects at the National Institutes of Health totaling more than $2 billion, including projects on HIV prevention drugs and Alzheimer’s disease research.

“Patients enrolled in NIH studies led by Plaintiffs face abrupt cancellations of treatment in which they have invested months of time with no explanation or plan for how to mitigate the harm,” according to a federal lawsuit filed in Massachusetts by scientists and researchers.

The research being cut could potentially have supported Trump’s pledge, when he honored the boy with brain cancer, to drive down rates of the disease. In the weeks since, however, Trump’s administration announced plans to weaken automobile tailpipe emission standards. Trump slashed more than 400 grants to Columbia University, including millions earmarked for a cancer center.

“It’s making people sicker again. Now that would be a more honest bumper sticker,” said Leslie Dach, a former Obama administration official who is the executive chair of Protect Our Care, which advocates for the Affordable Care Act. “They’re stopping research on vaccines and gutting health care programs that keep 100 million Americans healthy. It’s all show. It’s a bunch of junk.”

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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CRESTWOOD, Mo. — The prospect of sweeping federal cuts to Medicaid is alarming to some Missourians who remember the last time the public medical insurance program for those with low incomes or disabilities was pressed for cash in the state.

In 2005, Missouri adopted some of the strictest eligibility standards in the nation, reduced benefits, and increased patients’ copayments for the joint federal-state program due to state budget shortfalls totaling about $2.4 billion over several prior years. More than 100,000 Missourians lost coverage as a result, and the Federal Reserve Bank of Philadelphia reported that the changes led to increases in credit card borrowing and debt in third-party collections.

A woman told NPR that year that her $6.70-an-hour McDonald’s job put her over the new income limits and rendered her ineligible, even though she was supporting three children on about $300 a week. A woman receiving $865 a month in disability payments worried at a town hall meeting about not being able to raise her orphaned granddaughter as the state asked her to pay $167 a month to keep her health coverage.

Now, Missouri could lose an estimated $2 billion a year in federal funding as congressional Republicans look to cut at least $880 billion over a decade from a pool of funding that includes Medicaid programs nationwide. Medicaid and the closely related Children’s Health Insurance Program together insure roughly 79 million people — about 1 in 5 Americans.

“We’re looking at a much more significant impact with the loss of federal funds even than what 2005 was,” said Amy Blouin, president of the progressive Missouri Budget Project think tank. “We’re not going to be able to protect kids. We’re not going to be able to protect people with disabilities from some sort of impact.”

At today’s spending levels, a cut of $880 billion to Medicaid could lead to states’ losing federal funding ranging from $78 million a year in Wyoming to $13 billion a year in California, according to an analysis from KFF, a health information nonprofit that includes KFF Health News. State lawmakers nationwide would then be left to address the shortfalls, likely through some combination of slashing benefits or eligibility, raising taxes, or finding a different large budget item to cut, such as education spending.

Republican lawmakers are floating various proposals to cut Medicaid, including one to reduce the money the federal government sends to states to help cover adults who gained access to the program under the Affordable Care Act’s provision known as Medicaid expansion. The 2010 health care law allowed states to expand Medicaid eligibility to cover more adults with low incomes. The federal government is picking up 90% of the tab for that group. About 20 million people nationwide are now covered through that expansion.

Missouri expanded Medicaid in 2021. That has meant that a single working-age adult in Missouri can now earn up to $21,597 a year and qualify for coverage, whereas before, nondisabled adults without children couldn’t get Medicaid coverage. That portion of the program now covers over 329,000 Missourians, more than a quarter of the state’s Medicaid recipients.

For every percentage point that the federal portion of the funding for that group decreases, Missouri’s Medicaid director estimated, the state could lose $30 million to $35 million a year.

But the equation is even more complicated given that Missouri expanded access via a constitutional amendment. Voters approved the expansion in 2020 after the state’s Republican leadership resisted doing so for a decade. That means changes to Medicaid expansion in Missouri would require voters to amend the state constitution again. The same is true in South Dakota and Oklahoma.

So even if Congress attempted to narrowly target cuts to the nation’s Medicaid expansion population, Washington University in St. Louis health economist Timothy McBride said, Missouri’s expansion program would likely stay in place.

“Then you would just have to find the money elsewhere, which would be brutal in Missouri,” McBride said.

In Crestwood, a suburb of St. Louis, Sandra Smith worries her daughter’s in-home nursing care would be on the chopping block. Nearly all in-home services are an optional part of Medicaid that states are not required to include in their programs. But the services have been critical for Sandra and her 24-year-old daughter, Sarah.

Sarah Smith has been disabled for most of her life due to seizures from a rare genetic disorder called Dravet syndrome. She has been covered by Medicaid in various ways since she was 3.

She needs intensive, 24-hour care, and Medicaid pays for a nurse to come to their home 13 hours a day. Her mother serves as the overnight caregiver and covers when the nurses are sick — work Sandra Smith is not allowed to be compensated for and that doesn’t count toward the 63-year-old’s Social Security.

Having nursing help allows Sandra Smith to work as an independent podcast producer and gives her a break from being the go-to-person for providing care 24 hours a day, day after day, year after year.

“I really and truly don’t know what I would do if we lost the Medicaid home care. I have no plan whatsoever,” Sandra Smith said. “It is not sustainable for anyone to do infinite, 24-hour care without dire physical health, mental health, and financial consequences, especially as we parents get into our elder years.”

Elias Tsapelas, director of fiscal policy at the conservative Show-Me Institute, said potential changes to Medicaid programs depend on the extent of any budget cuts that Congress ultimately passes and how much time states have to respond.

A large cut implemented immediately, for example, would require state legislators to look for parts of the budget they have the discretion to cut quickly. But if states have time to absorb funding changes, he said, they would have more flexibility.

“I’m not ready to think that Congress is going to willingly put us on the path of making every state go cut their benefits for the most vulnerable,” Tsapelas said.

Missouri’s congressional delegation split along party lines over the recent budget resolution calling for deep spending cuts, with the Republicans who control six of the eight House seats and both Senate seats all voting for it.

But 76% of the public, including 55% of Republicans, say they oppose major federal funding cuts to Medicaid, according to a national KFF poll conducted April 8-15.

And Missouri Sen. Josh Hawley, a Republican, has said that he does not support cutting Medicaid and posted on the social platform X that he was told by President Donald Trump that the House and Senate would not cut Medicaid benefits and that Trump won’t sign any benefit cuts.

“I hope congressional leadership will get the message,” Hawley posted. He declined to comment for this article.

U.S. House Republicans are aiming to pass a budget by Memorial Day, after many state legislatures, including Missouri’s, will have adjourned for the year.

Meanwhile, Missouri lawmakers are poised to pass a tax cut that is estimated to reduce state revenue by about $240 million in the first year.

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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Faced with potential federal spending cuts that threaten health coverage and falling childhood vaccination rates, Monica Soni, the chief medical officer of Covered California, has a lot on her plate — and on her mind.

California’s Affordable Care Act health insurance exchange covers nearly 2 million residents and 89% of them receive federal subsidies that reduce their premiums. Many middle-income households got subsidies for the first time after Congress expanded them in 2021, which helped generate a boom in enrollment in ACA exchanges nationwide.

From the original and enhanced subsidies, Covered California enrollees currently get $563 a month on average, lowering the average monthly out-of-pocket premium from $698 to $135, according to data from Covered California.

The 2021 subsidies are set to expire at the end of this year unless Congress renews them. If they lapse, enrollees would be on the hook to pay an average of $101 a month more for health insurance — not counting any premium hikes in 2026 and beyond. And those middle-income earners who did not qualify for subsidies before would lose all financial assistance — $384 a month, on average — which Soni fears could prompt them to drop out.

At the same time, vaccination rates for children 2 and under declined among 7 of the 10 Covered California health plans subject to its new quality-of-care requirements. Soni, a Los Angeles native who came to Covered California in May 2023, oversees that program, in which health plans must meet performance targets on blood pressure control, diabetes management, colorectal cancer screening, and childhood vaccinations — or pay a financial penalty.

Lack of access to such key aspects of care disproportionately affects underserved communities, making Covered California’s effort one of health equity as well. Soni, a Harvard-trained primary care doctor who sees patients one day a week at an urgent care clinic in Los Angeles County’s public safety net health system, is familiar with the challenges those communities face.

Covered California reported last November that its health plans improved on three of the four measures in the first year of the program. But childhood immunizations for those under 2 declined by 4%. The decline is in line with a national trend, which Soni attributed to postpandemic mistrust of vaccines and “more skepticism of the entire medical industry.”

Most parents have heard at least one untrue statement about measles or the vaccine for it, and many don’t know what to believe, according to an April KFF poll.

Health plans improved on the other three measures, but not enough to avoid penalties, which yielded $15 million. The exchange is using that money to fund another effort Soni manages, which helps 6,900 Covered California households buy groceries and contributes to over 250 savings accounts for children who get routine checkups and vaccines. Some of the penalty money will also be used to support primary care practices around California.

In addition to her bifurcated professional duties, Soni is the mother of two young children, ages 4 and 7. KFF Health News senior correspondent Bernard J. Wolfson spoke with Soni about the impact of possible federal cuts and the exchange’s initiative to improve care for its enrollees. This interview has been edited for length and clarity.

Q: Covered California has record enrollment of nearly 2 million, boosted by the expanded federal subsidies passed under the Biden administration, which end after this year. What if Congress does not renew them?

A: Our estimates are that it will approach 400,000 Californians who would drop coverage immediately. We hear every day from our folks that they’re really living on the margins. Until they got some of those subsidies, they could not afford coverage.

As a primary care doctor, I am the one to treat folks who show up with preventable cancers because they were too afraid to think about what their out-of-pocket costs would be. I don’t want to go back to those days.

Q: Congress is considering billions in cuts to Medicaid. How would that affect Covered California and the state’s population more broadly, given that more than 1 in 3 Californians are on Medi-Cal, the state’s version of Medicaid?

A: Those are our neighbors, our friends. Those are the people working in the restaurants we eat at. Earlier cancer screenings, better chronic disease control, lower maternal mortality, more substance use disorder treatment: We know that Medicaid saves lives. We know it helps people live longer and better. As a physician, I would be hard-pressed to argue for rolling back anything that saves lives. It would be very distressing to watch that come to California.

Q: Why did Covered California undertake the Quality Transformation Initiative?

A: We were incredibly successful at covering nearly 2 million, but frankly we didn’t see improvements in quality, and we continue to see gaps for certain populations in terms of outcomes. So, I think the question became much more imperative: Are we getting our money’s worth out of this coverage? Are we making sure people are living longer and better, and if not, how do we up the ante to make sure they are?

Q: There’s a penalty for not meeting the targets, but no bonuses for meeting them: You meet the goals or else, right?

A: We don’t say it like that, but that is true. And we didn’t make it complicated. It’s only four measures. It’s things that as a primary care doctor I know are important, that I take care of when I see people in my practice. We said get to the 66th percentile on these four measures, and there’s no dollars that you have to pay. If you don’t, then we collect those funds.

Q: And you use the penalty money to fund the grocery assistance and child savings accounts.

A: That’s exactly right. We had this opportunity to think about what would we use these dollars for and how we actually make a difference in people’s lives. So, we cold-called hundreds of people, we sent surveys out to thousands of folks, and what we heard overwhelmingly was how expensive it is to live in California; that folks are making trade-offs between food and transportation, between child care and food — just impossible decisions.

Q: You will put up to $1,000 a child into those savings accounts, right?

A: That’s right. It’s tied to doing those healthy behaviors, going to child well visits and getting recommended vaccines. We looked at the literature, and once you get to even just $500 in an account, the likelihood of a kid going to a two- or four-year school increases significantly. It’s actually because they’re hopeful about their future, and it changes their path of upward mobility, which we know changes their health outcome.

Q: Given the rise in vaccine skepticism, are you worried that the recent measles outbreak could grow?

A: I am very concerned about it. I was actually reading some posts from a physician colleague who trained decades earlier and was talking about all the diseases that my generation of physicians have never seen. We don’t actually know how to diagnose and take care of a number of infectious diseases because they mostly have been eradicated or outbreaks have been really contained. So, I feel worried. I’ve been brushing off my old textbooks.

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 principal organismo no partidista de control gubernamental del país ha confirmado que está examinando los costos de operar el único programa de Medicaid activo con requisito de trabajo, mientras legisladores republicanos estatales y federales consideran requisitos similares.

La Oficina de Responsabilidad Gubernamental de Estados Unidos (GAO) informó a KFF Health News que su análisis del programa Georgia Pathways to Coverage podría publicarse este otoño.

En sus primeros 100 días, la administración Trump ha dicho que su prioridad era eliminar el despilfarro en los programas federales, lo que ha permitido al multimillonario Elon Musk y al recién creado Departamento de Eficiencia Gubernamental (DOGE) un amplio margen de maniobra para modificar radicalmente las operaciones de las agencias federales.

La idea de un mandato nacional que requiera que los beneficiarios de Medicaid trabajen, estudien o realicen otras actividades que cumplan los requisitos para mantener la cobertura está ganando terreno a medida que los republicanos del Congreso evalúan propuestas para recortar $880 mil millones del déficit federal a lo largo de 10 años.

Estos ahorros buscan compensar los costos de las prioridades del presidente Donald Trump, incluyendo la seguridad fronteriza y los recortes de impuestos que beneficiarían en gran medida a los más ricos.

La mayoría del público, independientemente de su orientación política, se opone a los recortes de fondos a Medicaid, según una encuesta publicada el 1 de mayo por KFF, una organización sin fines de lucro dedicada a la información sobre salud que incluye a KFF Health News.

La investigación de la GAO llega en un momento crítico, afirmó Leo Cuello, profesor de investigación del Centro para Niños y Familias de la Universidad de Georgetown.

“El Congreso parece estar implementando recortes a Medicaid de forma frenética y apresurada”, afirmó. El informe de la GAO podría explicar al Congreso la magnitud de los problemas con los requisitos de trabajo “antes de que se apresuren y lo hagan sin pensar”.

Las experiencias de Georgia y Arkansas, los dos únicos estados que han implementado programas similares, demuestran que los requisitos de trabajo reducen la inscripción en Medicaid y agregan costosas capas de burocracia.

Ahora, más estados intentan obtener la aprobación de la administración Trump para aprobar los requisitos de trabajo para Medicaid, el programa estatal-federal que ofrece cobertura médica a millones de estadounidenses con bajos ingresos y discapacidades.

Los Centros de Servicios de Medicare y Medicaid (CMS), que aprueban programas piloto de Medicaid, como los de requisitos de trabajo, no respondieron a una solicitud de comentarios.

La GAO halló en 2019 que la gestión de los programas de requisitos laborales puede resultar costosa para los estados —cientos de millones de dólares, en algunos casos— y que los funcionarios federales no consideraron esos costos al aprobarlos, lo que no puede aumentar el gasto de Medicaid.

Aun así, la administración Trump ha apoyado los requisitos laborales. Estos programas exigen que los empleados estatales verifiquen manualmente si los beneficiarios cumplen con los requisitos de elegibilidad, y supervisen su cumplimiento continuo.

En 2023, más del 90% de los adultos estadounidenses elegibles para la expansión de Medicaid ya trabajaban o podrían estar exentos de los requisitos, según KFF.

Durante su audiencia de confirmación para dirigir los CMS, Mehmet Oz afirmó estar a favor de los requisitos laborales, pero no creía que debieran utilizarse como “un obstáculo, un intento engañoso de impedir que las personas accedan a Medicaid”.

La primera administración Trump aprobó los requisitos laborales en 13 estados. Casi todos los programas fueron bloqueados por la administración Biden o por tribunales federales.

Georgia es uno de los 10 estados que no ha expandido completamente Medicaid a casi todos los adultos de bajos ingresos.

El estado lanzó Pathways to Coverage el 1 de julio de 2023. Ha sido una prioridad política del gobernador republicano Brian Kemp, cuya oficina se vio envuelta en una larga batalla legal con la administración Biden cuando intentó bloquear el programa.

El programa costó más de $57 millones estatales y federales hasta finales de 2024, gran parte de los cuales se destinaron a administrarlo. Al 25 de abril, 7.410 personas estaban inscritas, un pequeño porcentaje de las que estarían cubiertas por una expansión total de Medicaid. Pathways también ha ralentizado los tiempos de procesamiento para otros programas de beneficios en el estado.

Al ser consultado sobre los costos y beneficios de Pathways, Garrison Douglas, vocero de Kemp, señaló el reciente mercado estatal de Obamacare en Georgia. El mercado de seguros registró una inscripción récord debido, en parte, a la mejora de los subsidios aprobada por la administración Biden.

“Estamos cubriendo a más georgianos de lo que habría cubierto la expansión tradicional de Medicaid, y por menos dinero”, dijo Douglas, refiriéndose a la parte estatal, no federal, del gasto.

Los subsidios mejorados que impulsaron la inscripción expirarán este año. La Oficina de Presupuesto del Congreso estima que extenderlos costaría al gobierno federal alrededor de $335 mil millones en 10 años.

En marzo, Arkansas solicitó a la administración Trump que relanzara su programa de requisitos de trabajo de Medicaid. El período federal de comentarios públicos sobre el programa finaliza el 10 de mayo. Una versión anterior fue suspendida por una orden judicial en 2019, pero no antes de que más de 18.000 personas perdieran su cobertura en menos de un año.

Georgia planea solicitar a la Casa Blanca que renueve su programa con cambios modestos, incluyendo la reducción de la frecuencia con la que los inscritos deben demostrar al estado que están trabajando o participando en otras actividades calificadas.

La investigación de la GAO sobre el programa de requisitos de trabajo de Georgia se produce después de que tres senadores demócratas nacionales —Jon Ossoff y Raphael Warnock, de Georgia, y Ron Wyden, de Oregon— solicitaran a la GAO en diciembre una investigación sobre los costos del programa. Su solicitud citaba un informe de KFF Health News.

“Impulsé este informe de la GAO porque confío en que sus hallazgos respaldarán aún más lo que ya sabemos: Pathways to Coverage cuesta más dinero a los contribuyentes y cubre a menos personas que si el estado simplemente se uniera a otros 40 estados para cerrar la brecha en la cobertura médica”, declaró Warnock en un comunicado.

La GAO afirmó que su objetivo es determinar cuánto ha gastado Georgia en la gestión del programa, cuánto de ese dinero fue federal y cómo se está monitoreando ese gasto.

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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Carmen Aiken of Chicago made an appointment for an annual physical exam in July 2023, planning to get checked out and complete some blood work.

The appointment was at a family medicine practice run by University of Illinois Health. Aiken said the doctor recommended they undergo a Pap smear, which they hadn’t had in more than a year, and testing for sexually transmitted infections. Aiken, who works for a nonprofit and uses the pronoun they, said they were also encouraged to get the HPV vaccine.

They’d tested positive for HPV in 2019 and eventually cleared the virus but had not received the vaccine to prevent future infections.

“Sounds like a good idea,” Aiken, 37, recalled telling the doctor.

They also needed some lab work done, part of routine monitoring for one prescription. After being examined, Aiken said, they were directed to a different part of the office building to get blood drawn and receive the first dose of the vaccine before leaving.

Then the bill came.

The Medical Procedure

Services at Aiken’s appointment included a pelvic exam, a vaccination, and blood work, checking, in part, glucose levels and liver function.

An annual physical exam typically includes a variety of services, many of which insurers are required to cover under the Affordable Care Act, such as reviewing the patient’s health history, screening for high cholesterol, or performing a Pap smear, a procedure to check the cervix for signs of cancer.

Updating immunizations is also a common, covered service at checkups. The vaccine for HPV, or the human papillomavirus, provides protection against an infection that can cause several types of cancer. Federal health officials recommend being immunized for HPV at age 11 or 12, though the vaccine also can be administered later in life.

The Final Bill

$1,430.13: $1,223.22 for lab services and pathology, plus $206.91 for “professional services,” which included a charge for a 40-minute “High Mdm” outpatient visit — indicating a high level of “medical decision-making” — as well as charges for immunization administration and vaccines.

The Billing Problem: Diagnostic Blood Work With a Hospital Price Tag

Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.

A patient who needs blood work for a specific medical concern — as Aiken did, for medication monitoring — could be required to pay part of the bill. That’s the case even if the blood work is performed during a checkup alongside preventive services. Some health insurers pay for standard blood work as part of a preventive visit, but that’s not always the case.

Aiken had purchased a health insurance plan on the federal marketplace and said they were confident the visit would be covered at no cost to them.

When they got a bill for more than $1,400, Aiken thought, “How did this happen?” They said they called their insurer, BlueCross BlueShield of Illinois, then filed an appeal for the $1,223.22 amount they owed for lab services after their initial inquiry went nowhere. “Surely this is a misunderstanding.”

But their insurer sided with UI Health’s position that the blood work rendered during the appointment was not preventive. In a letter denying Aiken’s appeal, BlueCross BlueShield of Illinois decided that “the labs were billed correctly as diagnostic.”

Under the plan’s parameters, the insurer determined Aiken remained on the hook for 50% of the cost of outpatient labs performed in a hospital setting.

Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, would not discuss Aiken’s bill with KFF Health News.

Francesca Sacco, a spokesperson for UI Health, said in an emailed statement that Aiken scheduled the appointment for “medication monitoring and to obtain a vaccine.”

“Medication monitoring is not considered a wellness benefit under the Affordable Care Act,” she said.

Sacco also said Aiken’s labs were sent for processing to University of Illinois Hospital, more than a mile away from the family medicine practice.

That left Aiken owing more. Hospitals typically charge much more than physicians’ offices or independent commercial labs for the same tests.

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More from Bill of the Month

The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who’s on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles — or even charged for two separate appointments.

Patients may not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.

Confusion still persists 15 years after the ACA’s preventive services protections took effect, said Sabrina Corlette, a founder and co-director of the Center on Health Insurance Reforms at Georgetown University.

“This is an outrageous bill for what should have been routine care,” Corlette said. “People just don’t have this kind of money lying around.”

The Resolution

After the insurer denied their appeal, they “fell down a hole into despair about it for a while,” Aiken said.

“And then someone really wise was like, ‘You can pay it and then just stop thinking about it.’”

So that’s what Aiken did: “I put it on my credit card.”

UI Health’s Sacco said the hospital system is committed to working with insurers to resolve cost-sharing disputes.

“However, it is the insurance company’s sole discretion whether a service is fully covered or subject to cost sharing,” she said. “In this case, the insurer determined that cost sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health.”

The experience left its mark on Aiken. Last year, they said, they walked out of an urgent-care visit after a doctor recommended a Pap smear — fearing they’d incur another large bill.

The Takeaway

Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure patients generally would pay nothing for preventive services, such as immunizations, under the ACA.

Annual checkups are a key element of preventive care. For instance, most adults who never received the HPV vaccine do not know they are still eligible, so it’s critical to inform them of their options, said Verda Hicks, a gynecologic oncologist based in Kansas City, Missouri.

The vaccine offers protection against nine types of HPV, she said. It also prevents HPV-related cancers in men, so the Centers for Disease Control and Prevention recommends boys receive the immunization, too.

“Get vaccinated,” Hicks said. “We just do not have the same tools for many other cancers.”

Keep in mind that your coverage may vary — some insurance companies won’t cover the cost of the vaccine for some older patients — and the same services may be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.

Also, prices can vary depending on where care is delivered and tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab. Patients may not realize that labs drawn at a clinic may be sent to a hospital for testing, exposing them to greater costs.

There has been a push in Congress to eliminate this price variation through “site-neutral” payment policies. Regardless of location, the price for routine care would be reimbursed at the same amount.

“Site-neutral reforms could potentially have significantly reduced Carmen’s expenses,” said Christine Monahan, an assistant research professor at Georgetown’s Center on Health Insurance Reforms.

Meanwhile, a case before the Supreme Court could upend the health system by eliminating the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. The high court heard oral arguments April 21.

If the justices side with the plaintiffs this term, Georgetown’s Corlette said, “then we all potentially lose access to free, high-value preventive care, and that would be a real shame.”

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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For nearly three agonizing years, Mariah Freschi and her husband have been trying to have a second baby. The California mother recently underwent surgery to remove her blocked fallopian tubes, leaving in vitro fertilization as her only option to get pregnant. But the cost quoted by her Sacramento-area clinic was $25,000 — out of reach for Freschi, a preschool teacher, and her husband, a warehouse worker.

“When we first found out IVF was our only option, it just felt so overwhelming,” said Freschi, who has insurance through the California marketplace. “No one sets aside 20, 30 grand to grow your family.”

The Freschis are far from alone in requiring medical assistance to have children: About 13% of women and 11% of men in the U.S. experience infertility, while others are in a same-sex relationship, single, or want to preserve their eggs or sperm before undergoing various medical treatments.

And, like the Freschis, many Americans do not have health insurance that pays for IVF.

During his campaign, President Donald Trump vowed that the government would cover IVF or require insurers to cover it. In February, he signed an executive order seeking policy recommendations on expanding IVF access, dubbing himself the “fertilization president” a few weeks later.

Whether the administration’s efforts will change policy remains unknown, but state-level attempts to mandate fertility coverage reveal the gauntlet of budgetary and political hurdles that such initiatives face — obstacles that have led to millions of people being left out.

“There are economic opponents, and there are ideological opponents,” said Sean Tipton, a lobbyist for the American Society for Reproductive Medicine. “It is a tough lineup of opponents. And that’s very consistent from state to state.”

Twenty-two states have passed legislation requiring insurers to cover at least some fertility care, and 15 of those require coverage for IVF. The laws vary widely, though, when it comes to who and what gets covered, largely because of debates over cost. Fertility services can range from diagnostic testing and ovulation-enhancing drugs to IVF, widely considered the most effective but also the most expensive treatment, during which one or more lab-fertilized eggs are transferred to a uterus.

It’s mostly those footing the bill amid rising health care costs and state deficits that have voiced opposition. State insurance mandates “factor in significantly” when it comes to whether employers continue to provide coverage at all because of financial concerns, according to Chris Bond, a spokesperson for AHIP, which represents health insurers, who also said employers “want to have flexibility with how these benefits are structured.”

States cite concerns about higher premiums and the budget impact of having to cover government workers. In the past few years, infertility coverage bills in Minnesota, North Dakota, and Louisiana, for example, failed largely over cost.

IVF advocates, however, cite data from a decade ago showing that fertility care in states with mandates has accounted for less than 1% of total premium costs, a figure similar to estimates for newer mandates. And advocates often argue that building a family is a human right, though fertility care is disproportionately used by wealthy, white women. Covering IVF for the Medicaid population, which includes more than 70 million Americans, rarely works its way into legislative proposals.

The California Example

California is a case study in how many of these conversations play out. Cost concerns sank IVF legislation in the state for several years before lawmakers approved a mandate last year. SB 729 goes into effect July 1 and requires large employers with state-regulated health insurance to cover infertility diagnosis and treatment, including IVF. State employees will get coverage in 2027.

California’s mandate is considered one of the most comprehensive and inclusive in the country, said Barbara Collura, president of Resolve: The National Infertility Association, making same-sex couples and single parents eligible for coverage. But it still leaves out most of the state’s insured population, including those covered by Medicaid, the Affordable Care Act marketplace, and self-insured companies, which account for the majority of workers and are federally regulated.

Mimi Demissew, executive director of Our Family Coalition, an LGBTQ+ rights nonprofit that co-sponsored SB 729, said her group envisioned the broadest possible mandate, which would have included people covered by small employers, the marketplace, and other privately purchased plans. “We dreamed big,” she said. “But the pushback and the whittling down was because of the budget.”

Gov. Gavin Newsom’s finance department opposed SB 729 over concerns about the state’s budget and higher premiums. And groups representing the state’s health plans and employers cited costs in their opposition, with the California Chamber of Commerce calling health care “one of the most formidable expenses a business experiences,” per a legislative analysis.

The law going into effect this year is estimated to cover around 9 million people, 5 million fewer than originally proposed. Annual premiums, whose cost is typically shared by employers and employees, are projected to increase for people with state-regulated health insurance by approximately $40 per person covered in the first year.

Mandates Vary Widely by State

More than 10 states — including California — have what fertility experts call “comprehensive” coverage, which requires some insurers to cover IVF with minimal restrictions. But even in those states, large swaths of the population miss out.

In Massachusetts, which has one of the country’s oldest, broadest mandates for infertility coverage, including IVF, only about 30% of women were eligible as of 2019.

Those covered by these mandates, however, are grateful. Luisa Lopez, a nonprofit executive, credited the three IVF cycles that New York’s mandate covered with allowing her and her husband to have a baby after 10 years of trying.

“I feel very lucky to live in a state that prioritized this,” Lopez said. Still, she said, she was on the hook for thousands of dollars in copays and other costs.

In states with narrow mandates, coverage is elusive. With limited exceptions, only state employees have qualified for IVF coverage through Utah’s mandate, for example. Joseph Letourneau, a University of Utah fertility specialist who successfully lobbied for fertility preservation coverage for Medicaid patients and state employees with cancer, said he couldn’t recall ideological opposition to fertility coverage but that some legislators were concerned about raising costs.

Oklahoma and Kentucky limit coverage requirements to patients who wish to preserve their fertility because of specific medical conditions.

Pushback Beyond Costs

Some opponents of IVF coverage say life begins at the moment of conception and have expressed concerns about the disposal of embryos during the IVF process.

Chieko Noguchi, a spokesperson for the U.S. Conference of Catholic Bishops, said the Catholic Church teaches that IVF is morally wrong because it “involves the death or freezing of embryonic children and treats human beings like products that can be bought and ordered.”

In Republican-controlled-Georgia, some advocates say the proposal of abortion restrictions has distracted from efforts to mandate fertility coverage. SisterSong, a reproductive justice nonprofit, supports two bills that would require private insurers and Medicaid to cover IVF in Georgia. But, the organization’s director of maternal health and birth equity initiatives, Leah Jones, acknowledged a steep uphill battle given the costs and anti-abortion legislation that some advocates fear could criminalize IVF. Having to fight just for the legality of IVF, she said, detracts from expanding access.

“We’re always on the defense,” Jones said.

Several states, including Georgia, are weighing or have passed bills that would protect access to IVF after Alabama’s state Supreme Court ruled that embryos created through IVF should be considered children, leading to temporary suspension of those services. Zemmie Fleck, executive director of Georgia Right to Life, said the Georgia anti-abortion bill would not make IVF illegal.

This fissure in Trump’s base over protecting versus restricting or even prohibiting IVF has raised questions about how his executive order will play out. Letourneau of Utah said some of his patients have asked if the order will cover their treatment costs.

The White House did not respond to requests for comment.

An Uncertain Road Ahead

While a growing number of companies provide IVF coverage as a health benefit, most patients are left to find ways to pay on their own. Some have turned to loans — IVF financing startups such as Gaia and Future Family have raised millions in venture funding.

The Freschis have applied for grants, are crowdfunding, and have put their upcoming cycle on a credit card.

“It’s so scary,” said Freschi, describing worries about potential unexpected IVF costs. “It just feels like you’re constantly walking around with a weight on you.”

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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SACRAMENTO, Calif. — Medi-Cal, California’s complex, $174.6 billion Medicaid program, provides health insurance for nearly 15 million residents with low incomes and disabilities. The state enrolls twice as many people as New York and more than three times as many as Texas — the two states with the largest number of Medicaid participants after California.

Enrollment is high because California goes beyond federal eligibility requirements, opening Medi-Cal to more low-income residents. The state also provides a broad range of benefits, such as vision, dental, and maternity care — some of which is largely paid for by federal dollars but which also affects state spending.

But lately, Medi-Cal has found itself in political crosshairs.

Democrats say the biggest threat to Medi-Cal is $880 billion in GOP budget cuts being mulled in Washington, D.C., which health experts say would require eligibility restrictions, such as work requirements, or program cuts to yield enough savings over a decade. Republicans argue that Medicaid costs have spiked due to fraud and abuse and they criticize state Democrats for making the benefit available to immigrants regardless of legal status.

In March, Gov. Gavin Newsom’s administration borrowed $3.4 billion to cover an unexpected overrun in Medi-Cal, and lawmakers in April appropriated an additional $2.8 billion for the rest of the fiscal year. Although the Democratic governor acknowledged a need for adjustments, he has defended the state’s efforts to get more people covered. In 2022, California’s uninsured rate for residents under age 65 hit a record low of 6.2%, according to the California Health Care Foundation.

As lawmakers debate funding for the safety net program, here’s what’s at stake for California’s largest health program.

Who’s Covered?

More than a third of Californians depend on Medi-Cal or the closely related Children’s Health Insurance Program to see a doctor, therapist, or dentist. They rely on the program to get medicine and access treatment. It can also be a lifeline for families by allowing people with disabilities and seniors to stay in their homes and providing coverage to their caregivers. It also funds nursing care for seniors.

The overwhelming majority of enrollees qualify because they earn 138% or less of the federal poverty level: $21,597 annually for an individual person or $44,367 for a family of four. While that’s low for a state where the median household income tops $96,000, it’s far more generous than Alabama’s family eligibility limit, which is 18% of the federal poverty level, or Florida’s, at 26%.

Unlike Alabama or Florida, California extends coverage to low-income adults without dependents. The state also covers more people with disabilities who work, inmates, and other residents who wouldn’t qualify for the benefit program if California lawmakers hadn’t expanded the program beyond what the federal government requires.

According to state estimates, Medi-Cal covers about 7.3 million low-income families and an additional 5 million adults, most of whom don’t have dependents. An additional million people with disabilities rely on the program.

Medi-Cal also picks up the tab for 1.4 million residents 65 and older for benefits not covered by Medicare, such as long-term care and dental, hearing, and vision care.

The majority of adult Medi-Cal recipients under 65 work, according to a KFF review of March 2024 census data. In California, about 42% of nondisabled adults on Medi-Cal work full time and an additional 20% work part time. Those not employed were most commonly caring for a family member, attending school, or ill.

Just over half of Medi-Cal recipients are Latino, about 16% white, 9% Asian or Pacific Islander, and 7% Black, according to state enrollment data. That differs from the nation as a whole, where about 40% of people under age 65 who use Medicaid are white, 30% Hispanic, 19% Black, and 1% Indigenous people.

Where Does the Money Come From?

The federal government pays for about 60% of the Medi-Cal program. Of its nearly $175 billion budget this fiscal year, Washington, D.C., is expected to contribute $107.5 billion.

An additional $37.6 billion comes from the state’s general fund. The final $29.5 billion comes from other sources including hospital fees, a managed-care organization tax, tobacco tax revenue, and drug rebates.

California receives 50% in matching federal dollars for core services, such as coverage to children and low-income pregnant women. But it gets a 90% match for the roughly 5 million Californians it has added to rolls under the Medicaid expansion authorized by the Affordable Care Act.

Where Does It Go?

On average, Medi-Cal costs $8,000 per recipient, but costs vary widely, according to a March analysis by the California Legislative Analyst’s Office.

For instance, people with disabilities account for 7% of enrollees but 19% of Medi-Cal’s spending, with an average annual cost of $21,626.

Meanwhile, the cost to cover seniors averages roughly $15,000. And senior enrollment, at 1.4 million, has skyrocketed, increasing 40% since 2020 as lawmakers eased the rules for how many assets people 65 and older could have and still qualify for the program.

California also foots much of the bill to cover about 1.6 million immigrants without legal status — roughly $8.4 billion of the $9.5 billion, Department of Finance program budget manager Guadalupe Manriquez said during a recent Assembly Budget Committee hearing.

What Could Get Cut?

President Donald Trump in March said that he would not “touch Social Security, Medicare, Medicaid” but focus on getting the “fraud out of there.” However, health experts say Medicaid services would be gutted if Congress follows through on massive spending reductions to pay to extend Trump’s tax cuts.

Congressional Republicans have discussed implementing work requirements for nondisabled adults, which could affect at least 1 million Medicaid enrollees in California, the most of any state, according to an analysis by the Urban Institute.

Lawmakers also could roll back the Medicaid expansion under the Affordable Care Act, also known as Obamacare, which passed in 2010 and allowed more people to qualify for Medicaid based on income. California, 39 other states, and Washington, D.C., have chosen to adopt “Medicaid expansion,” in which the federal government pays for 90% of coverage for those enrollees.

Such a move would cost California billions each year if it opted to continue coverage for the roughly 5 million additional enrollees who have gained coverage under the expansion.

Republicans could also make it tougher for states such as California to continue to draw federal aid through provider taxes such as the MCO tax, something the first Trump administration proposed but later dropped. The tax on managed care plans brings in about $5 billion a year and was endorsed by voters in a ballot initiative last fall, but the federal government has been complaining for years about how states levy such taxes on insurance plans and hospitals. If it restricts how states collect these taxes, it would likely cause a funding gap in California.

If federal cuts occur, Newsom officials acknowledge, the state couldn’t absorb the cost of existing programs. Republicans are pressuring Democrats who control the legislature to end Medi-Cal coverage of residents without legal status — something neither Newsom nor Democratic legislative leaders have expressed a willingness to do.

State leaders also could be faced with cutting optional benefits such as dental care and optometry, trimming services aimed at enhancing recipients’ quality of life, or reducing payments to managed care plans that cover 94% of Medi-Cal recipients.

That’s what California lawmakers did during the Great Recession, cutting reimbursement rates to providers and eliminating benefits including eye and dental care for adults. The governor at the time, Republican Arnold Schwarzenegger, went a step further, chopping $61 million from counties’ Medi-Cal funding in a budget bloodletting that he said contained "the good, the bad, and the ugly."

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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They’re the fixers, the ones who step in when Affordable Care Act enrollees have a problem with their coverage, like a newborn incorrectly left off a policy or discovering that a rogue broker had signed them up or switched their plan without consent.

Specially trained caseworkers help resolve such issues, which might otherwise cause consumers to rack up large doctors’ bills or prevent them or their family members from getting care. Now, though, the broad federal reduction in force set in motion by the Trump administration has cut the ranks of those caseworkers, slashing two out of six divisions of caseworkers, according to one affected worker and a former Centers for Medicare & Medicaid Services official familiar with the situation, Jeffrey Grant.

Currently, the number of ACA enrollees is at an all-time high of 24 million. The ACA — known as Obamacare — has long drawn disfavor from Republicans and Trump himself. The health law faces additional changes next year that, if adopted, could sow confusion and more problems. Consumers would face a new learning curve with extra paperwork and rules. And the caseworker cuts might extend the time needed to resolve any difficulties.

“It impacts not only our jobs, but all these people we serve,” said one New York City-based caseworker, who was let go in a Feb. 14 purge affecting federal employees in their probationary periods. “Usually, we would have on average 14 days to take care of a case that was very difficult, although the urgent cases would be solved within two to three business days. It will now be delayed so much more. Whole teams got wiped out completely.”

NPR and KFF Health News are not naming the two affected workers in this article because they fear professional or personal repercussions for speaking to the media.

The two teams of caseworkers were dismantled in a haphazard fashion that left some workers without an official notice but locked out of their computers.

The cuts have demoralized caseworkers, whose jobs demand a grasp of complex and arcane health insurance rules in a little-known government department that most consumers don’t interact with — CMS’ Exchange Customer Solutions Group — until they need help.

“The loss in staffing is going to reduce the ability for people to get through” to caseworkers after contacting the marketplace or other organizations for help, said Jackie Kiger, executive director of Pisgah Legal Services, a nonprofit that provides legal and ACA help for North Carolina consumers and is facing a budget reduction under a separate effort by the Trump administration to cut “navigator” funding by 90%. Navigators are government-funded nonprofits that help people enroll in the ACA or resolve problems with coverage.

The federal force reduction aims to decrease the number of employees at agencies within the Department of Health and Human Services from 82,000 to 62,000, including the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, and CMS.

CMS, which oversees the ACA and other government health programs, will lose about 300 workers, including about 30 caseworkers scattered nationwide. The cuts come amid thousands of other federal job losses, including front-line workers across an array of agencies, from Social Security field offices to the National Park Service.

In a press release, HHS estimated its reduction in force will save taxpayers $1.8 billion a year. No one from CMS responded to KFF Health News’ questions about the caseworker reductions.

What Will Be Affected?

When consumers have a problem with their ACA plan, their first step is usually to call the federal or state marketplace on which they purchased coverage.

Those call centers can handle basic questions about plans purchased on the federal exchange, which serves 31 states. (State marketplaces handle their own complex cases and don’t rely on federal caseworkers.)

When someone calls the federal marketplace 800 number with coverage problems, the inquiry probably winds up on a caseworker’s desk, said one affected caseworker. That employee received a reduction-in-force notice several days after losing access to their work computer on April 1.

Caseworkers usually don’t speak directly with consumers, the worker said. Using information sent over by the federal marketplace — including notes taken when consumers called in with problems, as well as ACA applications — they handle or oversee consumer requests, such as canceling a plan or adding a member.

One of the last problems handled by that caseworker involved a child born in November who was not added correctly to the family’s plan for 2024, meaning any care the child received during the last two months of the year was not covered and the family risked being stuck with the bills.

“This person did everything right, including calling the marketplace within 60 days to report the birth and add the newborn to their coverage,” said the worker, who was quickly able to resolve it because it was a marketplace error.

The worker, who is now soured on federal employment and will look for a new job in the private sector, said caseworkers handled an average of 30 issues a day, but that in recent months the number kept climbing, heading past 45, and grew even more intense after the Feb. 14 dismissal of probationary employees.

“It’s not an easy job,” the worker said, noting the challenge of constantly evolving rules and policies governing health plans.

Ferreting Out Fraud

In the past year, caseworkers have dealt with cases involving unauthorized enrollments or switching, a problem that ticked up in late 2023, according to KFF Health News investigations, and continued through much of last year, resulting in at least 274,000 complaints to CMS through August. The complaints centered on practices by rogue brokers who enrolled or switched coverage for consumers without their express knowledge. That could leave them without access to their health provider networks or drug coverage, or even facing a tax bill.

Though it is unclear how many such complaints fell to a federal caseworker, some improperly switched consumers want to be restored into plans they had originally chosen, while others want them canceled.

“I have seen people who were enrolled and every two or three months a broker would switch them to a different plan,” said the caseworker who was locked out in early April. “The more health plans they were enrolled in, the more difficult it was to handle on the back end.”

New hires spend months learning the ropes.

The New York-based worker let go in February during her probationary period said she had joined CMS in October and spent three months in training. Just about a month after completing that training, she was let go — a bitter irony, she said, because she had sought stability in a job with the federal government, having experienced a layoff during her private-sector career.

“I took a huge pay cut — over $40,000 — when I went from the private sector into the government,” said the mother of three whose husband serves in the military. Her federal salary was about $76,000, which is not high for an expensive market like the New York metropolitan area. “But I took it as an opportunity to get in the door and move up. Then, boom, I get hit with another layoff.”

“I can only imagine how hard it is for people with 10 to 15 years with the government who are banking on it for retirement,” she said.

Starting next year, the Trump administration has proposed several changes to the ACA, including ending year-round eligibility for very low-income applicants, requiring additional financial and eligibility documentation, and charging some people a monthly $5 fee when auto-reenrolled in coverage until they confirm their eligibility.

Such changes will “make things harder, so there you will have more things that go wrong,” said Grant, the former CMS official, who founded Schedule F Healthcare Strategies after leaving CMS. “You will then also have fewer caseworkers to handle the work.”

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

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

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This story can be republished for free (details).