WALHALLA, S.C. — Nestled in the foothills of the Blue Ridge Mountains, a small primary care clinic run by Clemson University draws patients from across the region. Many are Hispanic and uninsured, and some are willing to travel from other counties, bypassing closer health care providers, just to be seen by Michelle Deem, the clinic’s bilingual nurse practitioner.

“Patients who speak Spanish really prefer a Spanish-speaking provider,” Deem said. “I’ve gotten to know this community pretty well.”

Clemson doesn’t operate an academic medical center, nor does it run a medical school. Arguably, the public university is best known for its football program. Yet, with millions of dollars earmarked from the state legislature, it has expanded into delivering health care, with clinics in Walhalla and beyond. School leaders are attempting to address gaps in rural and underserved parts of a state where health outcomes routinely rank among the worst in the country.

“Some of these communities have such high need,” said Ron Gimbel, director of Clemson Rural Health, which operates four clinics and a fleet of mobile health units as part of the university’s College of Behavioral, Social and Health Sciences. “They have so many barriers that impact their ability to be healthy.”

Clemson Rural Health is one of several programs attempting to meet this need in the state.

“Rural health is trendy,” said Graham Adams, CEO of the South Carolina Office of Rural Health.

State lawmakers nationwide are spending millions of dollars to address a rural health care crisis long in the making. For more than a decade, though, Republican-controlled legislatures in most Southern states have refused billions in federal funds that would provide public health insurance coverage to more low-income adults. These are the same states where racial health disparities and health outcomes are often worse than in other regions.

Nearly every state has extended Medicaid coverage for women in the months after they give birth. But 10 states haven’t fully expanded Medicaid coverage with federal money made available under the 2010 Affordable Care Act. Seven of these states — Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee, and Texas — are in the South. With few exceptions, adults without children in these states don’t qualify for Medicaid coverage, regardless of their income level.

Georgia Gov. Brian Kemp and South Carolina Gov. Henry McMaster, both Republicans, recently announced plans to expand Medicaid in limited ways to include some parents. The South Carolina plan would impose work requirements on some of these newly eligible Medicaid beneficiaries, while the Georgia plan would allow some parents of young children to skirt the state’s existing Medicaid work rules. Both plans require federal approval.

Jonathan Oberlander, a professor and health policy scholar at the University of North Carolina, said he doesn’t expect to see any of the remaining states rushing to fully expand Medicaid. Before Donald Trump took office on Jan. 20, Republicans in Washington had already expressed their intention to dramatically cut spending for Medicaid, which covers 72 million people at a cost of nearly $900 billion.

“There’s a large gray cloud hanging over Medicaid expansion right now, and that’s because there’s so much uncertainty about what the Trump administration and congressional Republicans are going to do,” Oberlander said.

Even so, in South Carolina this year the advocacy group CoverSC plans to lobby the General Assembly to pass a bill to adopt Medicaid expansion, said Beth Johnson, regional government relations director for the American Cancer Society Cancer Action Network and a CoverSC board member. The state’s legislative session began Jan. 14.

If such a measure were approved, the federal government would cover 90% of the state’s Medicaid expansion costs and South Carolina would be expected to pay 10%, or an estimated $270 million during the first year, according to a 2024 report by the Milken Institute School of Public Health at George Washington University.

Across all 10 non-expansion states — which, outside the South, also include Kansas, Wisconsin, and Wyoming — about 1.5 million people fall into a coverage gap, according to 2024 estimates from KFF, the health information nonprofit that includes KFF Health News. That means they do not qualify for Medicaid coverage or financial assistance to buy insurance through the federal marketplace.

Many of the people who would qualify for Medicaid if these states were to expand eligibility are gig workers, Johnson said. They play music, drive for Uber, or deliver pizza, and they typically don’t qualify for health insurance through their jobs.

“They are providing services that we all appreciate,” she said. “And they simply can’t afford health insurance.”

In some South Carolina communities, Clemson Rural Health attempts to fill this gap by providing primary care, cancer screenings, nutrition education, and diabetes management for uninsured patients free of charge or at reduced rates. Only about half of the patients seen by Clemson Rural Health have health insurance, Gimbel said, compared with 92% of the U.S. population.

During the current state fiscal year, Clemson Rural Health has been underwritten by a $2.5 million contract, its largest source of funding, from the state Department of Health and Human Services, which administers Medicaid in South Carolina and operates with a budget approved by state lawmakers.

That’s a relatively small amount of money compared with the $47.5 million the state legislature has given to the Medical University of South Carolina in recent years to move into rural communities. MUSC has served Charleston for most of its 200-year history, but since 2019 it has expanded across the state by purchasing, building, or partnering with seven rural hospitals — some on the brink of closure — and one freestanding emergency department. MUSC is set to open an additional rural hospital this year.

Other states have made similar investments. The University of Georgia, for example, has established a new medical school, partly to send more physicians into underserved and rural areas. The Georgia General Assembly kicked in half the cost of a new $100 million building for medical education and research in Athens.

Meanwhile, the Tennessee General Assembly passed a budget last year that included $81 million for a variety of rural health initiatives.

Outside the South, state legislatures in Colorado, Nevada, West Virginia, and elsewhere have made recent investments in rural health, in addition to expanding Medicaid eligibility.

Some of this spending has been prompted by a wave of rural hospital closures — more than 100 since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

It’s not yet clear what long-term impact some of these initiatives will have — for instance, whether the Clemson program will “reduce premature mortality, decrease preventable hospitalizations, and improve overall quality of life,” as it aims to do, according to its website. Some public health experts point out that bolstering the number of rural clinics, hospitals, and doctors in the South won’t matter much if patients can’t afford to make an appointment.

“Lack of ability to pay is one of the greatest barriers,” said Adams, the Office of Rural Health chief.

Oberlander said conservative lawmakers often consider projects such as building new rural clinics more politically palatable than expanding Medicaid coverage.

“The further away you get from the ACA, the less polarized the politics of health care,” he said.

South Carolina Senate President Thomas Alexander, a Republican who lives in Walhalla, said the General Assembly is willing to invest in some rural health initiatives to improve health care access.

“Just because you expand Medicaid doesn’t mean you’ve expanded access to the services,” Alexander said. “I want to focus on expanding access to the services.”

Gimbel would not comment on Medicaid expansion in South Carolina, and he said it’s too soon to know how federal Medicaid changes under the Trump administration might affect funding for Clemson Rural Health, which currently receives money from the state’s Medicaid agency. But making the Clemson program financially solvent might take several more years, he said.“If rural health was profitable,” he said, “we wouldn’t have a rural health problem.”

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

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The Host Julie Rovner KFF Health News @jrovner 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.

Robert F. Kennedy Jr., President Donald Trump’s nominee to lead the Department of Health and Human Services, came under sharp questioning from Democrats and some Republicans at his confirmation hearings this week before two Senate committees. Of particular interest were the doubts about Kennedy’s qualifications and past anti-vaccination positions raised by Sen. Bill Cassidy (R-La.), who is a physician — and, notably, a member of the Senate Finance Committee, which is expected to vote next week on whether to advance Kennedy’s nomination to the Senate floor.

 Meanwhile, a federal government memo temporarily freezing a lot of federal grant and loan funding touched off confusion and recriminations at the new Trump administration for its sudden, sweeping actions.

This week’s panelists are Julie Rovner of KFF Health News, Sandhya Raman of CQ Roll Call, and Sarah Karlin-Smith of the Pink Sheet.

Panelists Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.

Among the takeaways from this week’s episode:

• During appearances before two Senate committees, Kennedy assured lawmakers he would follow science and defer to Trump’s policy preferences. But he also made mistakes that are notable for someone vying to lead the nation’s top health agency, such as confusing the Medicaid and Medicare programs.
• As Kennedy’s second hearing concluded, it was not immediately clear whether he would earn the votes needed to be confirmed by the full Senate — especially as at least one key Republican, Cassidy, seemed less than convinced. If every Democrat and independent votes against him, Kennedy could lose just a few GOP votes and still be confirmed.
• Much of the nation’s health system — alongside many, many other entities that rely on federal funding — experienced a kind of whiplash early this week, as the Trump administration’s Office of Management and Budget issued a memo freezing federal grants and loans until they could be reviewed for adherence to Trump’s priorities. A federal judge temporarily blocked the freeze from taking effect, and OMB revoked the memo — but the White House said Trump’s recent executive orders affecting funding “remain in full force and effect, and will be rigorously implemented.”
• In other Trump administration news, Trump fired a slew of inspectors general late last week — including the one who oversees HHS and the nation’s health system. And an executive order affecting health care for trans children has many parents and advocates on edge.

Also this week, Rovner interviews Nicholas Bagley, a University of Michigan law professor, who explains how the federal regulatory system is supposed to operate to make health policy.

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

Julie Rovner: 404 Media’s “Medical Device Company Tells Hospitals They’re No Longer Allowed to Fix Machine That Costs Six Figures,” by Jason Koebler.

Sandhya Raman: ProPublica’s “Dozens of People Died in Arizona Sober Living Homes as State Officials Fumbled Medicaid Fraud Response,” by Mary Hudetz and Hannah Bassett.

Sarah Karlin-Smith: CBS News’ “Wind-Blown Bird Poop May Help Transmit Bird Flu, Minnesota’s Infectious Disease Expert Warns,” by Mackenzie Lofgren.

Also mentioned in this week’s podcast:

KFF Health News’ “Trump’s Funding ‘Pause’ Throws States, Health Industry Into Chaos,” by Phil Galewitz.

Click to open the transcript Transcript: RFK Jr. in the Hot Seat

[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, Jan. 30, at 1:30 p.m. As always, 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 Sandhya Raman of CQ Roll call. 

Sandhya Raman: Hi, everyone. 

Rovner: And Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi there. 

Rovner: Later in this episode, we’ll have my interview with University of Michigan law professor Nicholas Bagley, who will break down for us how the federal regulatory system is supposed to work when it comes to health. But first, how is it still January? 

We are coming to you a little later than usual today because we have been watching hearings on Capitol Hill, where Health and Human Services Secretary-designate Robert F. Kennedy Jr., who was called a “predator” in a video earlier this week posted by his cousin Caroline Kennedy, appeared for his confirmation hearings. On Wednesday, he was at the Senate Finance Committee. Earlier today, he was at the Senate Health, Education, Labor, and Pensions Committee. A reminder, only the Finance Committee actually gets to vote on whether to send this nomination to the floor. I think it’s safe to say there was a lot to chew over in these two days of hearings. But first, do we have any idea how likely he is to be confirmed by the full Senate? 

Karlin-Smith: It seems like it’s going to be close. Yesterday, I didn’t hear any notable concerns necessarily from Republicans. It seemed like all the Senate Finance Republicans didn’t have any huge issues with his nomination, although I guess I should say one of the people on that committee is the chair of the one we saw today, and he didn’t quite make his opinion known. 

And then today the Senate health committee chair, Bill Cassidy, who is a doctor, made it very clear that he is not happy with Kennedy’s views on vaccines, and that he talks about some very personal moments in his career where he experienced the death of a particular young woman who was unvaccinated and it could have been prevented if she was. And Cassidy didn’t quite indicate where he’s going, but it seems like it may be hard for Kennedy to get him to a yes, because it seemed like Cassidy was giving him a lot of chances today, and oftentimes Kennedy was kind of saying the wrong answer of what Cassidy wanted to hear on vaccinations. And there’s a few other Republicans, I think, in a similar boat there, so it’s probably going to be close, but— 

Rovner: Yeah, and of course Cassidy, who’s the chairman of the health committee, is one of the Republican votes on the Finance Committee, too. There are several members who are on both committees. It was interesting, sort of, to watch what they said yesterday compared to what they said today in terms of questioning. But certainly there don’t seem to be any Democrats who are leaning his way, which is, I mean, we saw when he was officially nominated there were a lot of Democrats, not necessarily in the Senate but around the country, who agree with some of the things he says about regulatory capture by the drug industry and the food industry and ultra-processed foods. He does say a lot of things that are of interest and agreed to by Democrats, right? 

Karlin-Smith: Yeah, there were a few people I was watching because there were some inklings again that maybe they would vote to confirm him. One was Sen. [Raphael] Warnock from Georgia, who there was no indication, again, in his remark that he had interest in supporting him. The other was [Sen.] Sheldon Whitehouse, who apparently was Kennedy’s law school roommate and friend. And again, there was no indication of support or openness, not that we actually know how he was going to vote. And then the third person actually was Sen. Bernie Sanders, who at the hearings, both days, he did express some of his interest in some of the ideas that Kennedy has espoused. But yet again, I think the things they disagree on sort of outweigh the things where they can see agreement. And I think they’re seen as so problematic that they just totally cancel out any place where they could work together. 

Rovner: Just a reminder, Cassidy is super important here because RFK Jr. can’t afford to lose more than three Republican votes, assuming all the Democrats and independents vote against him, which is not necessarily what we know. And we assume but don’t know that the three senators who voted against [now-Defense Secretary] Pete Hegseth — Sen. Lisa Murkowski, [Sen.] Susan Collins of Maine, and Sen. Mitch McConnell, who’s a polio survivor and has said things about Kennedy’s vaccine statements — we assume those are likely to be no votes. So Cassidy would be the fourth and therefore decisive one. And I think that’s why everybody’s been watching him so closely. Sandhya, I see you nodding. 

Raman: I think even if [the] health [committee] is not voting on this, he’s the head of health, he’s a doctor, and if he votes no, that gives other Republicans who might be saying yes or leaning yes cover to kind of switch if they want to. Once you have one fall, then it’s easier for others in a lot of cases. So I think that after this weekend we’ll have more information. Cassidy’d said he wanted to ask additional questions, whatever those might be, and if those, where the cards may fall. 

Rovner: Yes. I believe Cassidy’s parting words in the hearing were, You might be hearing from me this weekend. Of course, if I were Cassidy and I were thinking about voting no, I don’t think I would blast it out right now to give time for everybody to come back at him, so you could see how he might want to play his cards a little bit closer to the chest. 

Well, for those who did not sit through the hearings like we did, I will say — I went back and counted — this is my 11th HHS secretary confirmation set of hearings that I have watched. And I could say that RFK Jr. is easily the least knowledgeable nominee that I have ever seen, at least in how the Department of Health and Human Services works. At both committees he was asked pretty easy questions about Medicare and Medicaid and showed that he does not understand either program, which together cover more than a hundred million Americans. What stood out to each of you? 

Raman: I think those, definitely, especially given that he’d fumbled on that the first hearing, the fact that that comes up again from Sen. [Maggie] Hassan asking questions on that in both hearings, that he stumbles again on the issues within the CMS [Centers for Medicare & Medicaid Services] umbrella. And I think yesterday he’d had some questions about EMTALA [the Emergency Medical Treatment and Active Labor Act] and emergency pregnancies, and again he— 

Rovner: Yeah, going to ask about abortion separately in a second. 

Raman: Yeah, so I think the fact that there have been major issues within the HHS umbrella that seemed new to him doesn’t bode well for what I saw. 

Karlin-Smith: One of the things that stood out to me was that he often got caught in lies or semi-lies and stuff around some of his past statements. And again, that just seems like a failure of the various staff in the Trump organization to really prepare him to know how to handle this. Because if you have such a public record like that, you know these things are going to come up. And even there was one exchange that happened yesterday, and the same comment was brought up today with Warnock, about comments he made comparing the effects of giving people vaccines to actions of the Nazis or abusive priests. And he says, I didn’t say it. And then he sort of says, But this is what I said, which is basically the same thing. 

And then the other thing I was going to say is I’ve noticed sort of a shift, since [Donald] Trump officially won the election and was getting closer to being in office, of the drug industry, some head CEOs really being like, You know, actually, we think [President] Trump will be positive for the industry. And they seem to be kind of ignoring some of the anti-vaccine sentiment and other things, including Trump’s populist appeal on drug pricing. 

Just some of the comments of Kennedy actually surprised me. We sort of know he’s skeptical of a lot of drugs, prescription drugs, being overused in the U.S. But again, both days he made a comment suggesting there’s a study that says prescription drugs are the third-leading cause of death in the U.S., which is not correct, and having a hard time finding what study he was referencing. But the CDC [Centers for Disease Control and Prevention] does have sort of accidental and unintentional injuries as the third-leading cause of death. But that includes a lot of stuff beyond just things that may impact prescription drugs, like opioid overdose deaths. So that’s going to include every car crash in the U.S. that causes a fatality. It’s going to include drownings, a lot of things that have nothing to do with prescription drugs. And that just seems like a big thing to both get wrong as an HHS nominee and also, again, something that’s kind of concerning for people that are interested in medical research and believe there is a positive benefit to pharmaceuticals. 

Rovner: One of the things that he said a lot, which is a safe thing for a nominee to say when being questioned by senators on both sides, is that he would be in line with what the president wants. Of course, in this case, there’s a lot about Trump that we don’t know what he wants, particularly on issues that are not his very top priorities like immigration. So on health care — on Will you continue the drug negotiations that were started under the Biden administration? — he’s like, I’m going to carry out President Trump’s policies. And this is where, Sandhya, I was going to ask about abortion, because he’s obviously, and we’ve talked about this a lot, a lot of anti-abortion groups who are very suspect of him because he was a Democrat until last year and he was very much pro-abortion-rights, and now he says that he will basically do what he is told. Is that essentially how you took it? 

Raman: Yeah. And I think the interesting thing was when in some of that questioning, the way he answered wasn’t I’d had a change of heart or I had a conversation with someone that shifted my perspective or anything like that. He just said: I will do what the president says. But yes, I made those statements. There was no bridge between those. And kind of like you said, if we don’t have clarity on some of those things from Trump, it’s hard to know which way he might go, how high that could be a priority for him. 

I mean, there were certain things that we can kind of expect if he’s confirmed that he might do, just because they have been happening throughout the years under Republican administrations and some of those commitments that were kind of made. But I think this has not really been a top issue for him in general. Like what we were saying before, he wasn’t familiar with EMTALA. That has been a huge thing over the past couple years. The federal government is involved with lawsuits and into kind of upholding that law and making sure that hospitals give emergency care to pregnant women that might need an abortion. 

Rovner: And there’s a Supreme Court case pending on this. 

Raman: It’s surprising that that would be unfamiliar for him given how big of an issue that is. And I think him not being familiar is not even just an issue for Democrats. For Republicans that want that assurance, they would likely want him to be familiar so that when we have HHS implementing guidance later on, that it would go in line with how they would want to interpret EMTALA. So that was one that just really stood out to me. 

Rovner: Yeah, I think I was taken aback, just the idea that he didn’t know what it was and he didn’t even know that the Medicare program basically has the ability to enforce rules for hospitals because it gives so much money to hospitals. Of the many things that made me kind of raise my eyebrows, that made me raise my eyebrows a little bit. I think I put this on social media. Whoever prepped him for these hearings did not do a very good job, because there was some really, really basic stuff any nominee for this job should have known, for much lower jobs should have known, that he appeared not to. 

Well, that was hardly the only news this week. It’s been pretty crazy. It is still Thursday, I think. We’re going to go back a little bit to what I’m calling the “funding freeze fiasco.” When we left off last week, much of science at the Department of Health and Human Services had been “paused,” she puts in air quotes, to use the administration’s word. Meaning no outside communication, no official travel, not much purchasing, and lots of panicked scientists at National Institutes of Health, the FDA [Food and Drug Administration] and the CDC, just to name a few of the agencies. 

Well, it turns out that was just a preview. Monday night, the Office of Management and Budget, whose nominated leader, Russell Vought, has not been confirmed by the Senate yet, issued a memo calling for a halt to all federal grants and loans, with the named exceptions of Social Security and Medicare, starting at 5 p.m. Tuesday. On Tuesday morning, the White House tried to say that the freeze wasn’t supposed to affect programs that provide benefits to individuals, things like food stamps or welfare. But by midday, reports were coming out from around the country about state officials shut out of Medicare payment portals and grantees of various other health programs, including community health centers and federal family planning clinics, unable to access payment systems as well. 

Tuesday afternoon, a federal judge delayed the freeze until Monday, meaning a few days from now. But on Wednesday morning, OMB issued a memo repealing the earlier memo. Shortly after that, White House press secretary Karoline Leavitt said the freeze was actually still on for programs that may violate Trump’s executive orders trying to stop diversity, equity, and inclusion programs, as well as many programs created by the Inflation Reduction Act. A judge cited that confusion and Leavitt’s tweet and blocked the entire effort Wednesday afternoon. So where are we now? And bigger question, does the president really have the authority to just stop payment of so many federal programs? 

Raman: It’s confusing to every single person that I have talked to in different swaths of health care in that this is very unprecedented. They don’t know how to react. And that has been on different days of the week depending on which part of the timeline that we’ve been in. And a concern that I’ve heard from multiple folks has been that despite whatever is kind of written at the time, there’s the chilling effect of the confusion making something sort of overimplemented, even if it only applies to some pocket of funding or some programming. It’s just people being scared and avoiding it just so that their whole program or whole whatever doesn’t get targeted in something. And I’m not a lawyer. I can’t tell you what falls as legal or not legal. But I think that the legal experts that I’ve heard from have really questioned that they have the authority to do all of this. 

Rovner: I have a friend who works for a nongovernmental organization that works with many governmental organizations, and she said last night, “We have 13 different stop-work orders.” 

Karlin-Smith: I was going to say the other thing about the situation besides the legality of it was when they put out the initial order, it was unclear whether Medicaid was a part of it. It wasn’t specifically exempted as Medicare and Social Security were. And then the next day, all these state Medicaid portals were down and they issued this other memo that says, No, no, sorry, we didn’t mean to not accept Medicaid and SNAP [the Supplemental Nutrition Assistance Program] and these other programs that provide critical health food benefits. And it seems like part of what might have been going on is that they just don’t understand how all of this funding works and that Medicaid sort of operates through grants, right? The states get the money, and then it goes to people. And similarly with a lot of other programs, it’s not a direct payment to a person or a direct distribution of goods. 

And again, I think it’s similar to the experience of listening to RFK. It does make you wonder how much of the people that are running the government understand what the government is, what it entails, and how to operate a government appropriately and think about the consequences ahead of time. And now again, I think as Sandhya mentioned initially, maybe I think some of this confusion and chaos is just the point. They don’t care. But if they break things, it is concerning that when they’re making policy, they don’t seem to know what they’re doing. And then that federal workers feel like they have to follow these unclear policies and maybe doing almost too much because of it. And we’ve seen that maybe with some of the rollbacks of NIH spending after they froze certain spending, and they’ve allowed some of the HIV treatment distribution to go on worldwide. But the fact that people felt like they had to freeze it initially signals the policy wasn’t appropriately written or communicated or something like that. 

Rovner: Yeah, and I also saw some arguments that it was just a coincidence that all these portals were down, that they were literally down for maintenance, not because the funding was being frozen, that was just sort of an accidental thing. Although it seems very odd to take them down for maintenance in the first week of the administration. There’s a lot. So whatever happens with the broader order, and we still don’t really know, at HHS, there is still lots of upheaval going on even without any Senate-confirmed officials installed yet. Sarah, we talked a lot about what’s happening at NIH last week. What’s happening at the FDA? 

Karlin-Smith: So, in some ways, I think, from what I’ve heard, the FDA is like a little bit more protected. And I’m going to say it’s a relative thing, but drug approvals are still happening because drug approvals come from user fee funding. They’re still able to have meetings related to that. They’re still doing inspections of food facilities, manufacturing facilities, things like that that help keep people safe, even though there’s travel bans. The things that I’ve seen that seem most impactful and concerning at this point, besides just, I think, a lot of federal government workers are just a little bit nervous about their jobs and stability and so forth. 

Rovner: A little bit. 

Karlin-Smith: Yes. Right now as part of Trump’s diversity, equity, and inclusion executive order, which seemed to my read to be about really how those issues are handled in hiring and staffing, but it seems like it’s being applied very broadly, including at FDA. So a big thing is the FDA took down a lot of webpages and a key guidance document around increasing diversity in clinical trials. And that’s really important. And it’s important for minorities. It’s important for women. It wasn’t very long ago that we didn’t know a lot about how drugs worked in women vs. men because we didn’t include women. And it turns out that is a big difference sometimes. It’s things like that where key programs that I think are seen as scientifically important are in question over, again, an order that is not clear whether it’s supposed to impact that type of stuff. 

Rovner: Yeah, I noticed at the Finance Committee hearing for Kennedy yesterday, one of the senators asked him about clinical trials including more Native Americans, and he said, Oh yes, absolutely. And I thought: “Oh, I don’t think you’re supposed to say that right now. I think that’s all part of what the Trump administration is trying to get rid of.” But obviously, Sarah, as you said, Trump seems to be taking the tech phrase “Move fast and break things” very much to heart, basically doing whatever he wants and daring someone to stop him, which so far nobody really has except maybe that one judge. 

Another example of where this is happening is the World Health Organization, which Trump ordered the U.S. to leave as one of his Day 1 executive orders. But leaving the WHO is supposed to be a year-long process, and this year’s funding is supposed to be honored, yet already officials at the CDC have been ordered to stop all work with the WHO on things like Ebola and Marburg and mpox, as well as bird flu. That includes virtual as well as in-person work. Is anybody pushing back on these things? 

Raman: In a sense, if you looked at earlier this week when we were getting a lot of the pushback on the foreign-aid aspect and not for things like PEPFAR [the President’s Emergency Plan for AIDS Relief], we had even the WHO put out a statement critiquing the U.S. saying this is a bad idea. So even coming from them critiquing the actions that the U.S. is taking, even if the U.S. is kind of withdrawn. But I think this was one of the things that we kind of saw coming a lot more than some of the others, just because in the latter half of the first Trump administration there was gaining animosity towards WHO and just different things there. You could see it in Congress. It was not unexpected for them to want to amp up calls for that. 

Rovner: But my bigger question is, just throwing away some of the things that Congress has said that, Yes, if you want to pull out of the WHO, here’s how you do it, and he’s like, Nope, we’re just doing it. 

Karlin-Smith: Well, I think, and there’s sort of technicalities in how they wrote the order, but Congress does have to actually approve that or at least sign off on that. But in terms of pushback, I guess I think the sentiment I’ve seen from people is: Where are Democrats? Why are they not making a big deal about some of this stuff? Because it is so unprecedented. This is not a kind of what you typically expect in a transition. Which obviously, again, right? We transitioned from a Democratic to Republican president. There are differences in policy ideas and so forth, and they’re putting their people in charge. You sometimes maybe expect a little bit of changes, even certain types of pauses. But the scope and the potential harm and even questionable legality of some of this is different. And Democrats have been fairly quiet, and I think people are looking for that, like, Well, how do we react? And if you don’t have the leadership reacting and helping guide you, then you end up in a kind of quiet space. 

Rovner: I feel like Democrats were trying to, and they said this, that, We don’t want to be like the last Trump administration, where they reacted to every little thing. But now there seems to be the, Why are they not reacting at all? 

So I’m going to add another thing to this along some of these same lines. Trump late Friday night fired about a dozen and a half inspectors general from most of the executive departments, including several he himself had installed. Included in that group was a Health and Human Services inspector general, Christi Grimm, a career employee who had been in the IG’s office since 1999 and was in fact the acting IG during the last year of Trump’s first term in 2020. These firings of what are supposed to be nonpartisan fraud and abuse watchdogs are irregular, shall we say, because Congress passed a law requiring that a president give Congress 30 days’ notice of any IG firing and to state a cause, neither of which has happened. In fact, the Agriculture Department’s IG, Phyllis Fong, was marched out of her office after refusing to leave quietly, pointing out her termination did not follow protocol, which it did not. Is this Trump thumbing his nose at Congress or just trying to do so much so fast that nobody has time to react? 

Raman: To me, I think it’s trying to do so much so fast that people don’t have to react. Because even if you think of the HHS inspector general, what does the HHS inspector general do? A lot of oversight on Medicare and Medicaid to reduce fraud there. And that is such a big, I think, talking point for Republicans, every year in Congress, just, what are different guardrails we can add to reduce fraud. That is such a big thing for them. And to just strip that without having something else set up, it doesn’t seem in line with — I mean, I don’t know. I think that it really is part of the causing chaos. 

Rovner: Yeah. 

Karlin-Smith: I think I read last night they usually recover something in the not quite $10 billion a year or something like that. So that’s a lot of money. And we think of, again, a party, and Trump in particular, has been really focused on creating a more efficient government and reducing waste, particularly in HHS, where the primary role I think of the OIG [Office of Inspector General] and where they spend most of their time is recovering money that wasn’t properly spent. It doesn’t seem to line up with their political positions and views, and it’s just creating a lot of concern in spaces about that he’s sort of pushing the limits of the law to put his people in charge. 

Rovner: Right, because he wouldn’t want an IG who’s nonpartisan to call out fraud and waste and potential corruption from people within HHS, which is part of what the IG’s job is in all of these departments, not just HHS. So we’re going to have to watch how that plays out. Well, one thing that is pretty common to see early in a new administration is lots of executive orders, because the departments haven’t been fully staffed up yet. A lot of those executive orders this week have been aimed at transgender people. Executive orders directed an end to trans people serving in the military, seek to bar doctors from treating minors even with reversible treatments like puberty blockers, and threatened to pull federal funding from schools where teachers call students by their preferred names. Is it just me or does this feel pretty far-reaching? 

Raman: I think what part of this is, we’ve seen them kind of messaging on this issue for a while. This has been a big social issue that has been brought up. So I wouldn’t say that it is surprising that this comes up now. I think it’s part of that flood. We’re not used to having Monday, the executive order, Tuesday and Wednesday that are so broad in scope. And I think that is part of it, that it’s hard to go through it all and kind of see what are the ramifications that this could all have. I would say that the one Tuesday, the one that’s health-based, is pretty broad in that we’re seeing things that we haven’t really seen before, just because I think a lot of the expansions of gender-affirming care on the state level have been happening within the last four years, so there hasn’t really been an opportunity for if they were able to do that. 

But I think the thing that kind of sticks out is that with a lot of the trans health stuff geared at children, the age is not necessarily 18. The executive order is 19 and below, and it’s sometimes older than that in some of the states. But I think for something that’s national and just kind of what, all the rulemaking that he’s directing to not cover gender-affirming care for youth under Tricare, and just changing the provisions in the Postal Service and federal employee plans, it’s pretty wide-ranging. And I think the part that I would definitely be most curious about are the things related to the Justice Department and what they can enforce on other states, just because we do have states that have pretty progressive policies for gender-affirming care, and that folks that live in more restrictive states have kind of moved there to be able to access that for their kids, and just what they’ll be able to do on that level to tamp down on that. I think that will be a big thing to watch. 

Rovner: Well, moving on to reproductive health. Last week at this time, we were talking about how the first flurry of executive actions did not include anything about abortion. The anniversary of Roe v. Wade came and went on Wednesday, and the annual March for Life by anti-abortion forces came and went with both the president and the vice president speaking on Friday, and still nothing. And then Friday night, Trump issued the orders we’d been kind of expecting all along since Monday. Sandhya, this was kind of a return to Republican administrations past, right? 

Raman: Yeah. So he reinstated the Mexico City policy, which we’ve had every Republican administration since [President Ronald] Reagan, and it restricts the funding that we can give to foreign organizations that even if they with their other funds do anything in the abortion realms. Similar to what we’ve done with Title X in the U.S. but for foreign aid. And then I think another important piece is they in a separate document rejoined us into this document known as the Geneva Consensus Declaration, where countries kind of pledge that they’re going to be against abortion and advance women and children’s health efforts. And I think those things were pretty expected. I wasn’t expecting it to come that much later after the March for Life rather than kind of timed with that. And then the other important thing was that he rescinded two of the executive orders under [President Joe] Biden to be more in line with Hyde-level restrictions, so not using federal funding for abortion in most circumstances. 

Rovner: So then on Monday we saw things go even a little bit further. Acting Health and Human Services Secretary Dorothy Fink put out a document that looked pretty routine, except it quietly said that not only could HHS programs not pay for abortion, which they haven’t been able to because of the Hyde Amendment, but also that they could not, quote, “promote” abortion, which has been interpreted to mean talk about the procedure in anything except the most negative terms. Now, this is a big change. For decades, the Hyde Amendment that bars funding coexisted side by side with a requirement in the Title X family planning program that women with unintended pregnancies be counseled on all their options, including abortion, and be referred for abortion if they ask. This is most definitely not current law, but I guess if you’ve been following the rest of this week’s theme, that seems not to matter to this administration, right? 

Raman: Yeah. And I think also, within that same statement, she kind of said they were going to reevaluate their guidance about conscience and religious protections within the Office of Civil Rights. And that also kind of brought me back to we had a lot of rulemaking in Trump 1 related to that. And I think some of those were more directly related to abortion, gender-affirming care, things like that within that umbrella. So I would expect more on that front to also kind of come back. But yeah, I think this is another one where it’s another step more, another step more. 

Rovner: Another flood the zone and dare everybody to keep up with it. All right, one final thing this week, one of the big administration priorities we haven’t talked about is immigration. And yes, immigration is a health care issue. One of the changes the Trump administration is making is allowing ICE [Immigration and Customs Enforcement] officers to raid hospitals and other health care facilities. The reason that’s always been taboo is that you don’t want people with potentially contagious diseases to shy away from seeking medical care because they’re afraid of encountering immigration authorities, and then they end up spreading those diseases far and wide instead. Are we just going to have to learn this lesson the hard way again? 

Karlin-Smith: It seems potentially likely, and it’s at a concerning time with bird flu, avian flu circulating, and a lot of farmworkers in this country being immigrants and migrants who may or may not have legal status officially, because we need to know to actively protect everybody and figure out where the disease is spreading, what we need to do in reaction to that and keep everybody safe. We need to know if people have bird flu or don’t have bird flu. And so you want people to be comfortable getting medical care and treatment and getting tested and not feel like they’re risking being separated from their family, their livelihood, and all of that stuff. 

The other thing I thought, again, some of the rhetoric that’s used around this is sort of people are taking services from Americans and they’re not giving anything in return, and a lot of these people contribute to our tax system and stuff and don’t actually get any benefits back from that. So again, I think some of the logic around that. But it’s certainly been interesting to see hospitals figure out how they can deal with this or what they need to do to train their staff to kind of protect their patients and figure out how they comply with these policies. 

Rovner: And encourage sick people to come forward and get medical care. All right, well, that’s as much news as we have time for this week. Now we will play my interview with Nick Bagley, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Nicholas Bagley, the Thomas G. Long professor of law at the University of Michigan Law School. In addition to being an expert on all things health-law-related, in his day job Nick teaches administrative law. So I’ve asked him here to give us a refresher on how the federal regulatory process is supposed to work. Nick, thank you so much for joining us. 

Nicholas Bagley: I am thrilled to be here, and go blue. 

Rovner: Before we get to our main topic, this administration is off to a bit of a different start, if I can call it that, in terms of go fast and break things. Just how different has the start of this Trump administration been? 

Bagley: Well, in one respect, I think it’s pretty different. They’re coming out, rhetorically at least, extremely strong in a whole flurry of executive orders that say that they’re going to make enormous changes to the regulatory state. They’ve promoted this “Department of Governmental Efficiency” that Elon Musk heads. They’re making lots of claims that they’re going to cut back on all the red tape that makes it hard for Americans to get stuff done. So in that sense, it is a little bit different, a kind of shock-and-awe offensive. 

But when you drill down to details, there’s a little less there than meets the eye. So an executive order, they sound really fancy, but they’re really just gussied-up internal memoranda telling one of your subordinates to do something. And so they make big promises, and then when you drill down to the details they say, And follow through as practicable and consistent with law and make sure you take your time and talk to all the relevant stakeholders, etc., etc., etc. And so for a lot of the initiatives, we’re still waiting on details, and that’s very consistent with past administrations, because it takes a long time to make big regulatory changes. 

Rovner: So at her first briefing earlier this week, presidential press secretary Karoline Leavitt said that Trump had already repealed a number of President Biden’s regulations, and reporters I have seen use similar language. But that hasn’t really happened yet, right? 

Bagley: It hasn’t happened. And I’ve spent a lot of time trying to get across just how little these executive orders do on their own. They’re important in that they set a tone, they offer instructions, they tell us about where the president would like to go, and his subordinates will take that seriously. But the president can’t undo a regulation just by waving his pen around. There’s a process, and that process takes time. 

Rovner: What’s the difference between congressional power and executive power? I mean, President Trump seems to think that he can pretty much do anything he wants with the executive branch. That’s not really the case, right? 

Bagley: No, it’s a big misunderstanding. The executive branch is really dependent for all of its authority and all of its funding on Congress. The core of Article 2 power under the U.S. Constitution says that the president “shall take Care” that the laws are faithfully executed. That’s the president’s responsibility. And if he hasn’t been given power by Congress, he has precious few powers on his own. There’s really not much conferred in the Constitution itself. So all of the president’s awesome powers, they derive from laws that Congress can adopt and that Congress can amend and that Congress can repeal. And so this claim that he’s going to go it alone is really a claim that he’s going to work with the statutes that are on the books. And some of those statutes give him a lot of authority, and he’s going to have a lot of room to run. And others of those statutes are going to constrain him quite a bit. And we’ve seen his claims about what he wants to do, and now we’re going to have to test how much he’s going to be allowed to do. 

Rovner: Can you talk very broadly about what power the president has through rulemaking authority and what he, at least in theory, can’t do? 

Bagley: Yeah. When an agency moves to adopt a rule, a rule is something that says to the regulated community, these are the kinds of things you have to do in order to continue an operation. So if you’re a power plant, you’ve got to install this scrubber. If you’re a meat processing facility, you’ve got to abide by these safety regulations. And on and on and on. When agencies adopt those rules, there’s a law that requires them to work through a pretty intensive process. So what they’ve got to do is they’ve got to offer notice about the rule that they’re thinking of adopting. They’ve got to allow the public to comment on that rule. And then the agency has got to respond in detail to all of those comments. 

And that’s a process. It doesn’t sound that intensive, but it takes usually in the order of somewhere between one and three years to get a regulation through that process. And you can do it quicker if you really have to, but of course that takes some resources, too. So when President Trump’s press secretary says he’s gotten rid of a bunch of regulations, she’s just misstating the law. That’s not true. Now, the processes will start and many of those rules will eventually be undone, but it will take time. 

Rovner: And the same thing in terms of his doing rules. These are all about, what can he do as compared to Congress? He can’t just make up rules, right? 

Bagley: Yeah, he can’t just make up rules. There are a bunch of really important legislative constraints that are easy to forget about. The first one, and really the most important one, is the appropriations power. He can’t mint money. But the second is when he exercises power, he’s got to abide by the rules that Congress has laid out on how he exercises that power. And it turns out that Congress has never been comfortable telling the president, Go be the lord of the manner in this particular space and just rule by decree. Congress says: There’s got to be a process to make sure that all stakeholders are heard and to make sure that we get these right. And if you don’t go through the requisite process, we’ve told the courts to come in and stop you. 

And sometimes President Trump assumes that because the judiciary leans to the right, they’re going to be passive when it comes to his abuses of regulatory power, and I think is misreading how the courts think about this problem. In the first Trump administration, we saw a lot of Republican judges push back hard on sloppy regulatory choices, and I expect to see the same pattern emerge here. 

Rovner: So where do things like guidance and executive orders fit into this? He’s got power there, but not as much power as he does through the regulatory process, right? 

Bagley: That’s exactly right. So when you adopt a rule, that rule has what they call the “force of law.” It’s basically like a law even though it’s adopted by the executive branch. And that means that if you violate the rule, you can be punished for violating the rule. When you’re talking about executive orders or guidance documents, they’re kind of easy come, easy go. You can adopt them with a stroke of a pen, but they can’t actually create any new binding legal obligations. So for example, a guidance document, might hear about these sometimes, they’re just telling the world how the agency thinks about a particular rule or a particular law. It says, This is how we understand what this rule or what this law means. But that’s not binding on the courts. It’s not binding on adjudicators. It’s just the agency’s opinion. And because it’s just the agency’s opinion, it doesn’t carry that kind of weight. So if you really want to make big regulatory changes, there’s really no substitute to going through the full dress process. 

Rovner: So to add one more level of confusion to this, last year there was a very important Supreme Court case that we talked about a lot on the podcast that threw out a 40-year-old precedent known as Chevron deference that basically instructed judges to trust the expertise of federal agencies, at least in most cases. Will the elimination of Chevron make it easier or harder for the Trump administration to carry out its agenda through the regulatory process? 

Bagley: Yeah. Well, if you ask the Trump administration, they think this is great. They think it’s going to make their job easier because the United States Supreme Court is clipping the wings of these left-leaning agencies that are imposing rules willy-nilly. But actually, the truth is that losing Chevron deference is a real blow to the Trump administration’s priorities. And the reason is really simple. Chevron doctrine gave the executive branch flexibility in how it interpreted statutes. It allowed them to interpret those statutes kind of how they thought best, so long as what they offered was a reasonable interpretation. But now the courts are going to get to decide what the statutes mean. And if the Trump administration likes a particular interpretation, and the courts say, That’s not the best reading of the statute. We think the best reading of the statute is a different one, the Trump administration might have won under Chevron, but it’s going to lose under Loper Bright. And so I think they’re going to find themselves handcuffed to a much greater extent than I think they appreciate. 

Rovner: So basically, it’s going to cut both ways. 

Bagley: It’s going to cut both ways. These big changes to administrative law often have that effect. The Supreme Court, when it issues Loper Bright, what it’s saying is, We want the courts to be more important in this regulatory process. But the courts being more important means that the executive branch is a little less important, and that’s true for Democratic presidents and it’s true for Republican presidents. 

Rovner: We’re going to have to learn a lot more about health law in this coming four years. Nick Bagley, thank you so much. 

Bagley: Very happy to do it. Thank you. 

Rovner: OK, we are back. Now it’s 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 will put the links in our show notes on your phone or other mobile device. Sandhya, you were first to choose this week, so why don’t you go first? 

Raman: So I chose “Dozens of People Died in Arizona Sober Living Homes as State Officials Fumbled Medicaid Fraud Response,” and it’s by Mary Hudetz of ProPublica and Hannah Bassett of the Arizona Center for Investigative Reporting. So the story is about how at least 40 Native American residents in some sober living homes in Phoenix died when state Medicaid officials weren’t able to respond to the fraud scheme targeting Native Americans. And their investigation found that half of the deaths were happening when officials were ignoring the calls about the oversight issues that were getting reported. And the Medicaid agency even found that the fraud cost taxpayers up to like $2.5 billion. It’s a really sobering story. 

Rovner: Sarah. 

Karlin-Smith: So I took a look at a piece this week from CBS News, “Wind-blown bird poop may help transmit bird flu.” It’s about a possibility that Michael Osterholm talked about this week on his podcast, which is we have some reason to believe that bird flu may be spreading in bird poop, and it sort of can basically transmit in the air into a point where somebody, a human being including, may end up getting infected with bird flu and they didn’t have any direct contact with an animal or something like that. And so it raises concerns about the ability for it to spread much more differently. 

And also, he mentioned it raises concerns just for control of the virus, because of the way chickens are sort of housed. If they’re on farms and so forth, it would be very difficult to sort of refit their homes, if you will, to sort of prevent them from getting bird flu from outside wild birds. So if they can show this is happening, this would be kind of a big complication in our ability to track, control, and contain the virus, and of course, as they were talking about in this story, get the price of eggs down, which everyone’s very focused on. 

Rovner: That’s right. Well, my extra credit this week is from an independent news outlet called 404 Media. It’s called “Medical Device Company Tells Hospitals They’re No Longer Allowed to Fix Machine That Cost Six Figures” by Jason Koebler. It’s about a machine used in open-heart surgeries and a company that used to offer hospital maintenance staff certification classes to teach workers how to maintain and repair the machines. But now the company has decided instead to require those hospitals to purchase maintenance contracts. Hospitals are now considering not only that it’s going to cost them more but that they may have to wait longer for an authorized repair person rather than rely on their own personnel. This is part of the broader right-to-repair debate, except this one could have life-or-death consequences. 

OK, that’s 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 ace producer and editor, Francis Ying, also to our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and increasingly at Bluesky, @julierovner. Where are you guys these days? 

Karlin-Smith: I’m mostly at Bluesky at @sarahkarlin-smith but still hanging around X a little bit and trying to post on LinkedIn, too. 

Rovner: Sandhya? 

Raman: On Bluesky and on X, @SandhyaWrites. 

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

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A few years before the covid-19 pandemic, Dale Rice lost a toe to infection.

But because he was uninsured at the time, the surgery at a Reno, Nevada, hospital led to years of anguish. He said he owes the hospital more than $20,000 for the procedure and still gets calls from collection agencies.

“It can cause a lot of anxiety,” Rice said. “I can’t give you what I don’t have.”

Rice, 62, was born and has spent his life in Nevada. He said he fell through a gap in the tribal health care system because he lives 1,500 miles from the Prairie Band Potawatomi Nation home area in eastern Kansas, where he’s an enrolled member.

He receives primary care at the Reno-Sparks Indian Colony tribal health clinic in Nevada, but structural barriers in the federal Indian Health Service left him without coverage for specialty care outside of the clinic. Rice might have been eligible for specialty services referred by his tribe’s health system in Kansas, but he lives too far from the tribe’s delivery area to utilize the tribal health program that helps pay for services outside of the IHS.

“I shouldn’t need to move to Kansas City to be fully covered,” Rice said.

A new tribal sponsorship program rolled out last year in Nevada is aimed at getting tribal citizens like Rice covered and protecting them from incurring debt for uninsured care. It allows tribes to buy health insurance through the state’s Affordable Care Act marketplace for people living in their service area, including Native Americans from other tribes.

Tribal leaders and Nevada officials say the sponsorship model increases access to coverage and care for tribal citizens and their families by allowing them to seek medical care outside the tribal health care system.

A few dozen tribes have moved to set up the insurance programs since the ACA authorized them more than a decade ago.

“It’s not widespread,” said Yvonne Myers, an ACA and Medicaid consultant for Citizen Potawatomi Nation Health Services in Oklahoma.

Native American adults are enrolled in Medicaid at higher rates than their white counterparts and have long faced worse health outcomes, higher incidences of chronic disease, and shorter life expectancy. Many rely on the IHS, a division within the Department of Health and Human Services responsible for providing care to Native Americans, but the agency is chronically underfunded.

In Nevada, tribes can sponsor their community members’ health coverage through aggregated billing, a method for paying the premiums for multiple individuals in a single monthly payment to the insurer. Another part of the program includes collaboration between Nevada Health Link, the state health insurance marketplace, and tribes to certify staffers at tribal health clinics so they can enroll community members in health plans. Program officials also said they are committed to providing further education to tribes about the accommodations available to them under the ACA.

Health agencies in Washington state and Nevada have helped set up tribal sponsorship programs. Independently, tribes in Alaska, Wisconsin, Idaho, Michigan, Montana, and South Dakota have rolled out individual programs, as well.

It’s already making a difference for Native American patients in Nevada, said Angie Wilson, tribal health director for the Reno-Sparks Indian Colony and an enrolled member of the Pit River Tribe in California. Wilson said patients have shown up at her office in tears because they couldn’t afford services they needed outside of the tribal clinic and were not eligible for those services to be covered by the IHS Purchased/Referred Care program.

The Reno-Sparks Indian Colony, with more than 1,330 members in 2023, is one of two tribes that participate in Nevada’s tribal sponsorship program and aggregated billing. Russell Cook, executive director of Nevada Health Link, said he expects more tribes to come aboard as the agency works to build community trust in tribes often wary of government and corporate entities.

The Fort McDermitt Paiute and Shoshone Tribe, with a reservation that spans Nevada’s northwestern border, was the first tribe to pilot the program. There are about 125 households on the reservation.

As of December, 30 tribal members had been enrolled into qualified health plans through Nevada Health Link as part of the tribal sponsorship program, according to state officials, and more than 700 of those enrolled through the state marketplace self-reported American Indian and/or Alaska Native status for last year.

Through sponsorship, tribes may use their federal health care funding to pay the premium costs for each participating person. That, combined with cost-sharing protections in the ACA for American Indian and Alaska Natives enrolled in marketplace health plans, means beneficiaries face very low to no costs to receive care outside of tribal clinics. The American Rescue Plan also expanded eligibility for premium tax credits, making purchasing a health plan more affordable.

Because sponsorship in some tribes isn’t limited to enrolled tribal citizens, it can help the whole community, said Jim Roberts, senior executive liaison for intergovernmental affairs with the Alaska Native Tribal Health Consortium and an enrolled member of the Hopi Tribe in Arizona.

Since Alaska first allowed sponsorship in 2013, Roberts said, it has not only increased the access to care for Native Americans but also significantly lowered the costs of care, “which is equally as important, if not for some tribes more important.”

In Washington state, where sponsorship in ACA plans began in 2014, 12 of 29 tribes participate.

Cook said the state exchange is seeing interest in the part of the sponsorship program that trains staff at tribal clinics to become certified exchange representatives, a role similar to that of a navigator who helps inform people about health coverage options.

He said the agency is working on a marketing campaign to spread awareness among Native Americans in the state about the sponsorship program. It will include translating resource guides and other materials from the agency into Native languages spoken in the state, such as Northern and Southern Paiute, Washoe, and Western Shoshone.

Cook said he’s surprised more states haven’t taken the initiative to create sponsorship programs in collaboration with tribes.

Nevada Health Link patterned its approach by looking at Washington state’s program, Cook said. Since launching its own program, the Nevada agency has been approached by officials in California who are exploring the option.

But leaders like Wilson are concerned that under the Trump administration the enhanced tax credits for ACA marketplace enrollees implemented during the pandemic will end. The credits are set to expire at the end of this year if Congress doesn’t act to extend them. Without the credits, nearly all people enrolled through the marketplace will see steep increases in their premium payments next year.

If tribal citizens or other community members become ineligible for the premium tax credits, that could jeopardize the tribe’s financial ability to continue sponsoring health plans, Roberts said.

“Whatever side of the fence people fall on, it does not take away that there’s a federal trust responsibility by the United States of America to its First Nations people,” Wilson said.

Wilson, who has been an advocate for sponsorship since the ACA was approved in 2010 and led the effort to establish the program in Nevada, said she is happy with the tribal sponsorship program but wishes it would have happened sooner.

“We’ve lost so much in Indian Country over time,” she said. “How many more Indian people could have gotten access to care? How much more of a difference could that have made in sustaining health care for tribes?”

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

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La expectativa de vida entre los nativos americanos en el oeste de Estados Unidos ha caído por debajo de los 64 años, una edad cercana a las de la República Democrática del Congo y Haití. Para muchos estadounidenses de origen asiático, es de alrededor de 84 años, similar a las de Japón y Suiza.

La salud de los estadounidenses ha sido desigual durante mucho tiempo, pero un nuevo estudio muestra que la disparidad entre las expectativas de vida de diferentes grupos poblacionales casi se ha duplicado desde el año 2000. “Esto es como comparar países muy distintos”, dijo Tom Bollyky, director del programa de Salud Global en el Council of Foreign Relations, y autor del estudio.

El análisis, llamado “Ten Americas” (10 Américas), publicado a fines del año pasado en The Lancet, halló que “la expectativa de vida de una persona varía drásticamente dependiendo de en dónde vive, las condiciones económicas en ese lugar y la identidad racial y étnica de la persona”.

Que la salud de algunas poblaciones específicas haya empeorado es una razón clave por la que la expectativa de vida general del país (75 años para los hombres y 80 para las mujeres) sea la más corta entre las naciones ricas.

Para cumplir con las promesas de la nueva administración Trump de que Estados Unidos vuelva a ser saludable, los responsables de las políticas tendrán que solucionar los problemas que socavan la expectativa de vida en todas las poblaciones.

“Mientras tengamos estas disparidades realmente graves, tendremos una expectativa de vida muy baja”, dijo Kathleen Harris, socióloga de la Universidad de Carolina del Norte. “No debería ser así para un país tan rico como Estados Unidos”.

Desde el año 2000, la expectativa de vida promedio de muchos indígenas americanos y nativos de Alaska ha estado disminuyendo de manera constante. Lo mismo ha sucedido desde 2014 con las personas negras en los condados de bajos ingresos del sureste del país.

“Algunos grupos en Estados Unidos enfrentan una crisis de salud”, dijo Bollyky, “y debemos responder porque está empeorando”.

Las enfermedades cardíacas, los accidentes de tránsito, la diabetes, covid-19 y otras causas comunes de muerte son responsables directos. Pero las investigaciones muestran que las condiciones de vida de las personas, sus comportamientos y sus entornos influyen en gran medida para que algunas poblaciones corran un mayor riesgo que otras.

Los nativos americanos del oeste (región que en el estudio “Ten Americas” abarca más de una docena de estados, excluyendo California, Washington y Oregon) estuvieron entre los más pobres del análisis, viviendo en condados donde el ingreso anual promedio de un individuo es inferior a los $20.000. Los economistas han demostrado que las personas con bajos ingresos suelen vivir menos.

Estudios también han vinculado el estrés de la pobreza, el trauma y la discriminación con conductas de riesgo para confrontarlos como el tabaquismo y las adicciones. Y las reservas a menudo no tienen mercados y agua potable, lo que dificulta comprar y cocinar alimentos saludables.

Aproximadamente uno de cada 5 nativos americanos del suroeste no tiene seguro médico, según un informe de KFF. Aunque el Servicio de Salud Indígena ofrece cobertura, el informe indica que el programa es frágil debido a la falta crónica de fondos. Esto significa que las personas pueden retrasar o saltearse tratamientos para afecciones crónicas. El posponer la atención médica contribuyó al enorme número de víctimas de covid entre los nativos americanos: aproximadamente uno de cada 188 navajos murió de la enfermedad en el pico de la pandemia.

“La combinación de un acceso limitado a la atención médica y mayores riesgos para la salud ha sido devastadora”, dijo Bollyky.

En el otro extremo del espectro, la categoría de estadounidenses de origen asiático en el estudio mantuvo la expectativa de vida más larga desde el año 2000. En 2021, era de 84 años.

La educación puede ser en parte la base de las razones por las que ciertos grupos viven más.

“Las personas con más educación tienen más probabilidades de pedir, y seguir, consejos de salud”, dijo Ali Mokdad, epidemiólogo del Instituto de Métricas y Evaluación de la Salud de la Universidad Washington y autor del artículo. La educación también ofrece más oportunidades de empleo a tiempo completo con beneficios de salud. “El dinero te permite tomar medidas para cuidarte”, dijo Mokdad.

El grupo con los ingresos más altos en la mayoría de los años del análisis estuvo compuesto de manera predominante por personas blancas, seguido por el grupo principalmente asiático. Este último, sin embargo, mantuvo, por lejos, las tasas más altas de graduación universitaria. Aproximadamente la mitad terminó la universidad, en comparación con menos de un tercio en otras poblaciones.

El estudio sugiere que la educación explica en parte las diferencias entre las personas blancas que viven en condados de bajos ingresos, donde el ingreso individual promedio fue inferior a $32.363. Desde el año 2000, las personas blancas de los condados de bajos ingresos de los estados del sureste (definidos como los de Appalachia y el valle inferior del Mississippi) tuvieron una esperanza de vida mucho más baja que la de los estados del medio oeste superior, como Montana, Nebraska y Iowa. (Los autores proporcionan detalles sobre cómo se definieron y delimitaron los grupos en su informe).

El consumo de opioides y las tasas de VIH no explicaron la disparidad entre estos grupos blancos de bajos ingresos, dijo Bollyky. Pero desde 2010, más del 90% de las personas blancas del grupo del norte se graduaron de la escuela secundaria, en comparación con alrededor del 80% en el sureste de Estados Unidos.

Comparado con otros, el efecto de la educación no se mantuvo en los grupos latinos. Los latinos tuvieron tasas más bajas de graduación de la escuela secundaria que los blancos, pero vivieron más tiempo en promedio. Esta tendencia de larga data cambió recientemente entre los latinos del suroeste debido a covid. Las personas hispanas o latinas y negras tenían casi el doble de probabilidades de morir a causa de la enfermedad.

En promedio, los negros han experimentado durante mucho tiempo peor salud que otras razas y etnias en Estados Unidos, excepto los nativos americanos. Pero este análisis revela una mejora constante en la esperanza de vida de los negros desde el año 2000 hasta aproximadamente 2012. Durante este período, la brecha entre la esperanza de vida de los negros y los blancos se redujo.

Esto es así para los tres grupos de negros en el análisis: aquellos que viven en condados de bajos ingresos en estados del sudeste como Mississippi, Louisiana y Alabama; aquellos en condados altamente segregados y metropolitanos, como Queens, Nueva York y Wayne, Michigan, donde muchos vecindarios son casi completamente negros o completamente blancos; y los negros en todas partes.

Mejores medicamentos para tratar la hipertensión y el VIH ayudan a explicar estas mejoras que han experimentado muchos estadounidenses entre 2000 y 2010. Y las personas negras, en particular, han visto un marcado aumento de la graduación de secundaria, y avances en la educación universitaria en ese período.

Sin embargo, para las poblaciones negras el progreso se estancó en 2016. Las disparidades en materia de riqueza aumentaron. En 2021, los estadounidenses asiáticos y muchos blancos tenían los ingresos más altos del estudio, y vivían en condados con ingresos per cápita de alrededor de $50.000. Los tres grupos de negros del análisis se mantuvieron por debajo de los $30.000.

La brecha de riqueza entre los negros y los blancos tiene raíces históricas que se remontan a la época de la esclavitud, las leyes de Jim Crow y las políticas que impedían a los negros ser dueños de propiedades en vecindarios con mejores servicios de escuelas públicas, entre otros. En el caso de los nativos americanos, la brecha histórica de riqueza se puede rastrear hasta la casi aniquilación de la población y el desplazamiento masivo en los siglos XIX y XX.

La desigualdad ha seguido aumentando por varias razones, como la creciente brecha salarial entre los líderes corporativos predominantemente blancos y los trabajadores con salarios bajos, que son, de manera desproporcionada, personas de color. Artículos de KFF Health News muestran que la decisión de algunos estados de no expandir Medicaid ha puesto en peligro la salud de cientos de miles de personas que viven en la pobreza.

Investigadores han estudiado los posibles beneficios para la salud de los pagos de reparación para abordar las injusticias históricas que llevaron a las brechas raciales de riqueza. Un nuevo estudio estima que estos pagos podrían reducir la muerte prematura entre los estadounidenses negros en un 29%.

Menos controversiales son las intervenciones adaptadas a las comunidades. Por ejemplo, la obesidad a menudo comienza en la infancia, por lo que los responsables de las políticas podrían invertir en programas después de la escuela que brinden a los niños un lugar para socializar, estar activos y comer alimentos saludables, dijo Harris. Estos programas tendrían que ser gratuitos para los niños cuyos padres no pueden pagarlos, y ofrecer transporte.

Pero si no se introducen cambios en las políticas que aumenten los salarios bajos, reduzcan los costos médicos, pongan a disposición viviendas seguras y una educación pública sólida, y garanticen el acceso a la atención de salud reproductiva, incluido el aborto, Harris dijo que la expectativa de vida general del país puede empeorar.

“Si el gobierno federal está realmente interesado en la salud de Estados Unidos”, agregó, “podría calificar a los estados en función de sus indicadores de salud y darles incentivos para que mejoren”.

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Under President Joe Biden, enrollment in Medicaid hit a record high and the uninsured rate reached a record low.

Donald Trump’s return to the White House — along with a GOP-controlled Senate and House of Representatives — is expected to change that.

Republicans in Washington say they plan to use funding cuts and regulatory changes to dramatically shrink Medicaid, the nearly $900-billion-a-year government health insurance program that, along with the related Children’s Health Insurance Program, serves about 79 million mostly low-income or disabled Americans.

The proposals include rolling back the Affordable Care Act’s expansion of Medicaid, which over the last 11 years added about 20 million low-income adults to its rolls. Trump has said he wants to drastically cut government spending, which may be necessary for Republicans to extend 2017 tax cuts that expire at the end of this year.

Trump made little mention of Medicaid during the 2024 campaign. The first Trump administration approved work requirements in several states, though only Arkansas implemented theirs before a federal judge said it violated the law. The first Trump administration also sought to block grant funding to states.

House Budget Committee Chair Jodey Arrington (R-Texas) told KFF Health News that Medicaid and other federal entitlement programs need major changes to help cut the federal debt. “Without them, we will watch this country sadly enter into fiscal collapse.”

Rep. Chip Roy (R-Texas), a member of the Budget Committee, said Congress needs to explore cutting federal spending on Medicaid.

“You need wholesale reform on the health care front, which can include undoing a lot of the damage being done by the ACA and Obamacare,” Roy said. “Frankly, we could end up providing better service if we do it the right way.”

Advocates for poor people fear GOP funding cuts will leave more Americans without insurance, making it harder for them to get care.

“Medicaid is an obvious target for huge cuts,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “An existential fight about Medicaid’s future likely lies ahead.”

Medicaid, which turns 60 in July, is nearing the end of a disruptive period, after covid pandemic-era coverage protections expired in 2023 and all enrollees had to prove they still qualified. More than 25 million people lost coverage over the 18 months after the “unwinding” began, though it has not notably increased the number of people without insurance, according to the latest census data.

The unwinding’s disruptions could pale in comparison to what happens in the next four years, said Matt Salo, former executive director and founder of the National Association of Medicaid Directors. “What we are going to see is an even bigger seismic shift in who Medicaid covers and how it operates,” he said.

But Salo said any efforts to shrink the program will face pushback.

“A lot of powerful entities — state governments, managed-care organizations, long-term care providers, and everyone under the sun who wants to do well by doing good — wants to see Medicaid work efficiently and be adequately funded,” he said. “And they will be highly motivated to push back on something they see as draconian cuts, because it could affect their business model.”

The GOP is looking at several tactics to reduce the size of Medicaid:

• Shifting to block grants. Switching to annual block grants could lower federal funding for states to operate the program while giving states more discretion over how to spend the money. Currently, the government matches a certain percentage of state spending each year with no cap. Republican presidents since Ronald Reagan have sought to block-grant Medicaid with no success. Arrington said he favors ending the open-ended federal funding to states and replacing it with a set annual amount based on how many people each state has in the program.
• Cutting ACA Medicaid funding. The ACA provided financing to cover, through Medicaid, Americans with incomes up to 138% of the federal poverty level, or $20,783 for an individual last year. The federal government pays 90% of the cost for adults covered through the law’s Medicaid expansion, which 40 states and Washington, D.C., have adopted. The GOP may try to lower that funding to the same match rate the feds pay states for everyone else in the program, which averages about 60%. “We should absolutely note that we are subsidizing the healthy, able-bodied Medicaid expansion population at a higher rate than we do the poorest and sickest among us, which was the original intent of the program,” Arrington said. “That’s not right.”
• Lowering federal matching funds. Since Medicaid began, the federal match rate has been based on the relative wealth of a state’s population, with poorer states receiving a higher rate and no state receiving less than a 50% match. Ten states get the base rate — all but two are Democratic-run states, including New York and California. The GOP may seek to cut the base rate to 40% or less.
• Adding work requirements. During the first Trump term, federal courts ruled that Medicaid law doesn’t allow coverage to be conditioned on enrollees’ working or seeking jobs. But the GOP may try again. “If we can get strict work requirements on able-bodied adults, that can be a huge cost savings by itself,” Rep. Tom McClintock (R-Calif.) told KFF Health News. Because most Medicaid enrollees already work, go to school, or serve as caregivers, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
• Placing enrollment hurdles. About 10 states offer some populations what’s called continuous eligibility, whereby people stay enrolled for years without having to renew their coverage. That policy’s been shown to prevent enrollees from falling out of the program for short periods because of hardships or paperwork problems, which can lead to surprise medical bills and debt. The Trump administration could seek to repeal waivers that allow states to grant multiyear continuous eligibility, which would require people in those states to reapply for coverage annually.

If the GOP’s plans to shrink Medicaid are realized, Democrats and health experts say, low-income people forced to buy private insurance would face challenges paying monthly premiums and the large copayments and deductibles common to commercial plans that typically don’t exist in Medicaid.

The Paragon Health Institute, a leading conservative think tank run by former Trump adviser Brian Blase, has issued reports saying the billions in extra money states took to expand Medicaid under the ACA has been a boon to private insurers that manage the program and relatively wealthier people it says shouldn’t be enrolled.

Josh Archambault, a senior fellow with the conservative Cicero Institute, said he hopes the Trump administration holds states accountable for overpaying providers and enrolling people in Medicaid who are not eligible. Conservatives have cited CMS reports saying states improperly pay Medicaid providers billions of dollars a year, though the federal government notes that is mostly due to lack of documentation.

He said the GOP will look to scale back Medicaid to its “traditional” populations of children, pregnant women, and people with disabilities. “We need to rebalance the program that most people think is underperforming,” he said. Most Americans, including large majorities of both Republicans and Democrats, view the program favorably, according to polls.

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

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The Host Julie Rovner KFF Health News @jrovner 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.

The new, GOP-led, 119th Congress and President-elect Donald Trump have big legislative plans for the year — which mostly don’t include health policy. But health is likely to play an important supporting role in efforts to renew tax cuts, revise immigration policies, and alter trade — if only to help pay for some Republican initiatives.

Meanwhile, the outgoing Biden administration is racing to finish its health policy to-do list, including finalizing a policy that bars credit bureaus from including medical debt on individuals’ credit reports.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists Shefali Luthra The 19th @shefalil Read Shefali's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• The 119th Congress is now in session. Health care doesn’t make the list of priorities as lawmakers lay the table for the incoming Trump administration — though Republicans have floated Medicaid work requirements to cut federal spending.
• A lot of health legislation hit the cutting-room floor in December, including a bipartisan proposal targeting pharmacy benefit managers — which would have saved the federal government and patients billions of dollars. And speaking of bipartisan efforts, a congressional report from the Senate Budget Committee adds to evidence that private equity involvement in care is associated with worse outcomes for patients — notably, lawmakers’ constituents.
• As the nation bids a final farewell to former President Jimmy Carter, his global health work, in particular, is being celebrated — especially his efforts to eradicate such devastating diseases as Guinea worm disease and river blindness.
• Meanwhile, the Biden administration finalized the rule barring medical debt from appearing on credit reports. The surgeon general cautions that alcohol should come with warning labels noting cancer risk. And the new Senate Republican leader is raising abortion-related legislation to require lifesaving care for all babies born alive — yet those protections already exist.

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

Julie Rovner: The Wall Street Journal’s “UnitedHealth’s Army of Doctors Helped It Collect Billions More From Medicare,” by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty.

Alice Miranda Ollstein: The New York Times’ “Ozempic, Lego Bricks and Hearing Aids: What Trump’s Greenland Plan Could Hit,” by Ana Swanson and Jenny Gross.

Shefali Luthra: Vox.com’s “Gigantic SUVs Are a Public Health Threat. Why Don’t We Treat Them Like One?” by David Zipper.

Lauren Weber: The Washington Post’s “Laws Restrict U.S. Shipping of Vape Products. Many Companies Do It Anyway,” by David Ovalle and Rachel Roubein.

Also mentioned in this week’s podcast:

The Senate Budget Committee’s “Profits Over Patients: The Harmful Effects of Private Equity on the U.S. Health Care System.”

Credits Taylor Cook Audio producer Lonnie Ro Audio producer Emmarie Huetteman Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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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HELENA, Mont. — A last-minute change to a 2019 bill put an end date on Montana’s Medicaid expansion program, setting the stage for what is anticipated to be the most significant health care debate of the 2025 Montana Legislature.

In recent interviews, legislative leaders predicted a vigorous debate over keeping the Medicaid expansion program, which pays the medical bills of more than 75,000 low-income Montanans at an annual cost of about $1 billion to the federal and state governments. They also expect the topic to seep into other health policy decisions, such as the approval of new spending on Montana’s behavioral health system and regulation of hospital tax-exempt status.

“It all kind of links together,” said state Sen. Dennis Lenz, a Billings Republican and chair of the Senate Public Health, Welfare, and Safety Committee.

Legislators from both parties also expect lawmakers from the GOP majority to continue to pursue abortion restrictions, despite a November statewide vote making abortion a right under the Montana Constitution.

The Medicaid expansion debate, however, looms largest among the health care topics.

“This is definitely the elephant in the room, so to speak,” said Senate Minority Leader Pat Flowers, a Belgrade Democrat.

Montana expanded Medicaid, initially for four years, in 2015, through a coalition of minority Democrats, some moderate Republicans, and a Democratic governor. A similar coalition renewed the program in 2019, but at the last moment, Senate Republicans tacked on an end date of June 30, 2025. That put the matter in the lap of this year’s legislature.

Republicans still hold strong majorities in the state House and Senate, whose leaders voiced concerns about the expansion program.

This time around, the governor — Greg Gianforte — is a Republican. Last year, the Gianforte administration completed a postpandemic eligibility reassessment that cut the number of expansion enrollees from a high of 125,000 people in April and May 2023 to approximately 76,600 people as of October, the most recent data available.

Gianforte has included funding for Medicaid expansion in his proposed budget, which must be approved by the legislature to take effect. His office said he wants “strong work requirements for able-bodied adults without dependents” to take part in the program. Spokesperson Kaitlin Price said the governor “has been clear that the safety net of Medicaid should be there for those who truly need it, but that it will collapse if all are allowed to climb on it.”

GOP legislative leaders clearly are skeptical of the program, saying it won’t continue without some “sideboards,” or additional requirements of enrollees and providers.

Whether any expansion bill passes “will depend on the people pushing it,” said Senate President Matt Regier, a Kalispell Republican who opposes expansion. “If there is no give-and-take, it could be an interesting vote.”

Flowers said he knows getting Medicaid expansion through the Senate will be tough. Republicans hold a 32-18 majority, and the GOP caucus leans conservative.

“There are a lot of my colleagues on the Republican side that are ideologically opposed, and I think you’re going to see that in their consistent voting against reauthorizing,” Flowers said.

Medicaid, funded by both the state and federal governments, provides health coverage for certain groups of low-income people. Expansion extended Medicaid coverage to nondisabled adults ages 19 to 64 with incomes up to 138% of the federal poverty level — about $20,800 a year for an individual in 2024.

The 2010 federal Affordable Care Act opened Medicaid to this new group of adults, starting in 2014. But a 2012 U.S. Supreme Court ruling said states could choose whether to adopt the change, and 40 have done so.

Republican state Rep. Ed Buttrey said he would sponsor a bill to reauthorize Medicaid expansion without an expiration date, but many GOP lawmakers remain unconvinced that expansion is needed, viewing it as a costly, unnecessary welfare program.

“I understand there are some pros to Medicaid expansion, but, as a conservative, I do have issues with — I guess I can’t get around it — socialized medicine,” said House Speaker Brandon Ler (R-Savage).

In September, representatives from a pair of conservative-funded think tanks made a case for ending Medicaid expansion, saying its enrollment and costs are bloated. The consulting firm Manatt, on the other hand, said more people have access to critical treatment because of Medicaid expansion.

At the least, it appears many Republicans want to require participants to work, pay premiums, or meet other conditions, if the program is to continue.

Premiums and work requirements are in Montana’s law right now. The Biden administration, though, nixed both, so they haven’t been in effect. Montana Republicans expect the incoming Trump administration to be more open to such provisions.

Democrats say Medicaid expansion has succeeded on many fronts: covering thousands of low-income workers, helping keep rural health care providers and hospitals afloat, and bringing hundreds of millions of federal dollars into Montana’s economy. The state pays 10% of the program’s costs, which totaled about $962.4 million in fiscal year 2024. The federal government picked up $870 million of that tab.

“With all that, it’s just stunning to me that there could be opposition,” Flowers said. “There is just no reason for us, collectively as a state, not to support this.”

Democrats will have their own expansion bill, brought by Rep. Mary Caferro of Helena. She said the bill would remove the work requirements and premiums, shine more light on the contracting activities of the state health department, and reopen some public assistance offices that have been closed. It also would make expansion permanent.

“We’re 10 years into this program,” said Rep. SJ Howell of Missoula, the Democratic vice chair of the House Human Services Committee, which debates health policy legislation. “I think that continuing a cycle of uncertainty for patients and providers doesn’t make sense.”

Legislators also see the expansion debate tying into other health care discussions.

Regier and Lenz said Montana’s nonprofit hospitals — strong supporters of expansion — have benefited greatly from the program and may need to give something back in return. One possibility: more government oversight of the “community benefits” that hospitals must provide to receive tax-exempt status.

They also noted that Montanans pay a fee for hospital stays to support the Medicaid program and that a fee on hospital outpatient revenue helps pay the costs of Medicaid expansion. Those fees and the resulting money raised for hospitals may merit review, they said.

Meanwhile, backers said Medicaid expansion underpins one of the governor’s major policy priorities, to improve the state’s behavioral health system. Gianforte has proposed spending up to $100 million over the next two years on 10 recommendations made by an advisory commission that reviewed the system for the past 18 months.

If Medicaid expansion ends, many adults would lose access to the mental health and addiction treatment system that Gianforte wants to improve, advocates said, while treatment providers would lose a significant source of revenue.

Money for the behavioral health changes would come, in part, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte’s proposals during the budgeting process. Howell said Democrats want to look at whether the changes would use enough of the $300 million fund quickly enough and on the most pressing needs.

Meanwhile, Republicans said they’ll likely introduce bills on abortion — even though Montanans approved Constitutional Initiative 128 by a 58-42 margin in November. CI-128 said the right to an abortion cannot be “denied or burdened” except by a “compelling government interest achieved by the least restrictive means.”

“It’s not going to slow us down in our pro-life positions,” Ler said of CI-128.

At a minimum, GOP leaders said, some of CI-128’s terms should be defined.

“With a very poorly written ballot initiative like that, we need to say, ‘What does that abortion industry look like under CI-128 and what’s our role as a state?’” Regier said.

But state Sen. Cora Neumann, a Bozeman Democrat on the Senate Public Health, Welfare, and Safety Committee, said the CI-128 vote provided a strong mandate for the right of privacy.

Enacting restrictions would lead to “that slippery slope of what’s next, if we allow legislators to rule on what’s happening in the doctor’s office,” she said. “What kind of can of worms could be opened to other invasions of privacy?”

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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