On the campaign trail, both former President Donald Trump and Vice President Kamala Harris are eager to portray themselves as guardians of Medicare. Each presidential candidate accuses the other of backing spending cuts and other policies that would damage the health insurance program for older Americans.

But the election’s outcome could alter the very nature of the nearly 60-year-old federal program. More than half of Medicare beneficiaries are already enrolled in plans, called Medicare Advantage, run by commercial insurers, and if Trump wins, that proportion is expected to grow — perhaps dramatically.

Trump and many congressional Republicans have already taken steps to aggressively promote Medicare Advantage. And Project 2025, a political wish list produced by the conservative Heritage Foundation for the next presidency, calls for making insurer-run plans the default enrollment option for Medicare.

Such a change would effectively privatize the program, because people tend to stick with the plans they’re initially enrolled in, health analysts say. Trump has repeatedly tried to distance himself from Project 2025, though the document’s authors include numerous people who worked in his first administration.

Conservatives say Medicare beneficiaries are better off in the popular Advantage plans, which offer more benefits than the traditional, government-run program. Critics say increasing insurers’ control of the program would trap consumers in health plans that are costlier to taxpayers and that can restrict their care, including by imposing onerous prior authorization requirements for some procedures.

“Traditional Medicare will wither on the vine,” said Robert Berenson, a former official in the Jimmy Carter and Bill Clinton administrations who’s now a senior fellow at the Urban Institute, a left-leaning research group.

While the fate of Medicare has gotten scant attention so far in the campaign, the different visions under Trump versus Harris indicate the high stakes.

A candidate’s position on protecting Medicare and Social Security is the most important health care issue, or among the most important, in determining 63% of Americans’ vote in the presidential election, according to a September poll by Gallup and West Health, a family of nonprofit and nonpartisan organizations focused on health care and aging.

Medicare, which covers about 66 million people, is funded largely by payroll taxes. At age 65, most Americans are automatically enrolled in Medicare coverage for hospitalization and doctor visits, known as Part A and Part B, though others must sign up. Consumers must also sign up for other aspects of Medicare, specifically drug coverage (Part D) and supplemental plans from insurers that pay for costs that aren’t covered by traditional Medicare, such as extended stays in skilled nursing facilities and cost sharing.

People on Medicare pay premiums plus as much as 20% of the cost of their care.

Medicare Advantage plans typically combine coverage for hospital and outpatient care and prescriptions, while eliminating the 20% coinsurance requirement and capping customers’ annual out-of-pocket costs. Many of the plans don’t charge an extra monthly premium, though some carry a deductible — an amount patients must pay each year before coverage kicks in.

Sometimes the plans throw in extras like coverage for eye exams and glasses or gym memberships.

However, they control costs by limiting patients to networks of approved doctors and hospitals, with whom the plans negotiate payment rates. Some hospitals and doctors refuse to do business with some or all Medicare Advantage plans, making those networks narrow or limited. Traditional Medicare, in comparison, is accepted by nearly every hospital and doctor.

Medicare’s popularity is one reason both candidates are pledging to enhance it. Last month, Harris released a plan that would add benefits including care for hearing and vision, and long-term in-home health care. The costs would be covered by savings from expanding Medicare’s negotiations with drugmakers, reducing fraud, and increasing discounts drugmakers pay for certain brand-name drugs in the program, according to Harris’ campaign.

Trump’s campaign said he would prioritize home care benefits and support unpaid family caregivers through tax credits and reduced red tape.

The Trump campaign also noted enhancements to Medicare Advantage plans during his tenure as president, such as increasing access to telehealth and expanding supplemental benefits for seniors with chronic diseases.

But far less attention has been paid to whether to give even more control of Medicare to private insurers. Joe Albanese, a senior policy analyst at Paragon Health Institute, a right-leaning research group, said “a Trump administration and GOP Congress would be more friendly” to the idea.

The concept of letting private insurers run Medicare isn’t new. Former House Speaker Newt Gingrich, a Republican, asserted in 1995 that traditional Medicare would fade away if its beneficiaries could pick between the original program and private plans.

The shift to Medicare Advantage was accelerated by legislation in 2003 that created Medicare’s drug benefit and gave private health plans a far greater role in the program.

Lawmakers thought private insurers could better contain costs. Instead, the plans have cost more. In 2023, Medicare Advantage plans cost the government and taxpayers about 6% — or $27 million — more than original Medicare, though some research shows they provide better care.

The Trump administration promoted Medicare Advantage in emails during the program’s open enrollment period each year, but support for the privately run plans has become bipartisan as they have grown.

“It helps inject needed competition into a government-run program and has proven to be more popular with those who switch,” said Roger Severino, lead architect of Project 2025’s section on the Department of Health and Human Services. He served as director of HHS’ civil rights office during the Trump administration.

But enrollees who want to switch back to traditional Medicare may not be able to. If they try to buy supplemental coverage for the 20% of costs Medicare doesn’t cover, they may find they have to pay an unaffordable premium. Unless they enroll in the plans close to the time they first become eligible for Medicare, usually at age 65, insurers selling those supplemental plans can deny coverage or charge higher premiums because of preexisting conditions.

“More members of Congress are hearing from constituents who are horrified and realize they are trapped in these plans,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a liberal public policy organization.

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HHS announced new baseline health and safety requirements for hospitals to make pregnancy, childbirth, and postpartum care safer

In the final days of the campaign, stark disagreements between Vice President Kamala Harris and former President Donald Trump over the future of American health care are on display — in particular, in sober warnings about abortion access, the specter of future cuts to the Affordable Care Act, and bold pronouncements about empowering activists eager to change course and clean house.

Trump and his campaign have been vague about plans on health care policies, though current and former Trump aides have published blueprints that go well beyond reversing programs in force under the Biden administration, to overhauling public health agencies and enabling Trump to quickly fire officials who disagree.

Harris, on the other hand, has staked out positions primarily preserving and protecting existing health care access — on abortion, transgender health care, insurance coverage, and more.

Here are some of the most consequential changes in health policies that could hinge on who wins the White House.

ACA Premiums

The election is likely to affect the cost of health insurance for millions who buy coverage on the Affordable Care Act marketplaces.

That’s because extra, pandemic-era subsidies that lower the cost of premiums will expire at the end of 2025 — unless Congress and the next president act.

Harris has pledged to make the enhanced subsidies permanent, while Trump has made no such commitment.

Letting them expire “would reduce fraud and waste,” said Brian Blase, a former Trump adviser who is president of the Paragon Health Institute, a conservative policy research firm.

About 19.7 million people with ACA coverage benefit from a subsidy — 92% of all enrollees. The expanded subsidies, started in 2021, helped increase ACA enrollment to a record high and reduce the uninsured rate to a record low.

They have also cut premium payments by an estimated 44%. Many pay no premiums at all.

Without congressional action, almost all ACA enrollees will experience steep increases in premium payments in 2026, according to KFF. The Urban Institute estimates 4 million people could wind up uninsured.

Letting the subsidies lapse could cause blowback for Republicans in 2026, said Jonathan Oberlander, a health policy expert at the University of North Carolina’s School of Medicine: “Is it worth the pain politically?”

— Phil Galewitz

Abortion

When he was president, Trump promised — and delivered — Supreme Court justices who would vote to overturn the constitutional right to an abortion. In the event of a second term, he has promised to leave abortion policy to the states — though he would have significant leeway to reduce access nationwide.

Harris has promised to restore the protections of Roe v. Wade, though doing so would require Congress’ help. At the very least, a Harris presidency would mostly preserve existing protections and prevent new federal restrictions.

Trump’s first actions would likely mirror those of many Republican presidents since the 1980s: defunding Planned Parenthood and the United Nations’ family planning agency, and, more recently, allowing employers with religious or moral objections to contraception to decline coverage through job-sponsored health plans.

But Trump could go considerably further, effectively banning abortion even in states where it is legal. For instance, the FDA could reduce availability of the abortion pill mifepristone or cancel its approval. This has been the subject of numerous lawsuits, including one before the Supreme Court that was recently revived.

Trump could also order the Justice Department to enforce the Comstock Act, an 1873 law that bans mailing “every article or thing designed, adapted, or intended for producing abortion, or for any indecent or immoral use.” That could apply not just to abortion pills, but also to supplies for abortion procedures.

— Julie Rovner

Drug Prices

Both campaigns say they are committed to lowering drug prices. Trump has offered few specifics, though the America First Policy Institute, a think tank led by close Trump allies, has put forward policies that are considerably less aggressive than Harris’ proposals.

Harris has said she would expand drug pricing negotiations and out-of-pocket drug spending caps enabled by the Inflation Reduction Act. She has also called for more transparency requirements for pharmacy benefit managers, or PBMs, the powerful drug-industry middlemen.

America First’s plan would cut costs by lowering reimbursements to doctors for some expensive infused drugs, using trade policy to force other developed countries to increase what they pay for drugs, and making more prescription medications available over the counter.

The plan makes no mention of bipartisan legislation under consideration in both chambers of Congress that seeks to achieve lower drug prices through new transparency requirements for PBMs.

— Arthur Allen

Trans People’s Health

The presidential election could determine whether transgender Americans hold on to broad protections ensuring access to gender-affirming medical care. Trump has said he would seek to ban hormone replacement therapy, gender reassignment surgery, and other treatments for minors — and make the services more difficult for adults to receive.

In the closing days of the campaign, Trump and his political action committees have leaned into divisive ads attacking Harris for past comments supporting access to care for transgender people who are incarcerated.

Backed by Republicans eager to stoke culture-war social issues, Trump has pledged to repeal Biden policies affecting transgender health care, including rules prohibiting federally funded providers and insurers from discriminating based on gender identity.

As some states passed legislation that opposed transgender rights, the Biden administration expanded coverage for gender-affirming care and increased research funding for the National Institutes of Health.

In a video on his campaign site, Trump vowed to order federal agencies to “cease all programs that promote the concept of sex and gender transition at any age” and bar government programs such as Medicare and Medicaid from paying for gender-affirming care.

Trump also said he would strip federal funding from hospitals that provide such care, create a right to sue doctors who perform gender-affirming procedures on children, and investigate whether the pharmaceutical industry and hospitals have “deliberately covered up horrific long-term side effects” of transition treatments.

Harris has been largely silent on the Trump campaign’s rhetoric targeting trans people. But she has said she would “follow the law” in providing transgender Americans the same right as others to access medically necessary care.

— Daniel Chang

Medicaid

Though the word “Medicaid” was barely uttered on the campaign trail this year, the election will determine future benefits for its 80 million primarily low-income and disabled enrollees.

“The stakes are very high,” said UNC’s Oberlander.

While Harris has described Medicaid as a key program to improve health, Trump has framed it as a broken welfare program in need of cuts.

Nearly half of Medicaid enrollees are children, and the program pays for about 40% of births nationwide.

The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level, or $20,783 this year. All but 10 states, which are GOP-led, have opted to expand their program.

The Biden administration has largely focused on efforts to protect and expand Medicaid to reduce the number of uninsured people.

The Trump administration, and GOP proposals since then, sought to reduce Medicaid spending by stiffening eligibility standards, such as adding work requirements, and by changing federal financing to a block grant, which would put more burden on states.

— Phil Galewitz

Shaking Up Biomedical Agencies

Trump said at an Oct. 27 rally in New York City that he would give anti-vaccine activist Robert F. Kennedy Jr. free rein to “go wild” on health and food policy in a second term.

Even a Republican-controlled Senate would be unlikely to confirm Kennedy for any top government position. Regardless of whether he had a specific role, RFK Jr.’s influence could be powerful, said Georges Benjamin, executive director of the American Public Health Association.

Kennedy said Trump promised to give him “control” of public health, including naming leaders of the NIH, FDA, and the Centers for Disease Control and Prevention. He has advocated for a doctor who made a name for herself as a right-wing health guru, Casey Means, to head the FDA. This week, in a discussion on CNN during which he put forward the debunked theory that vaccines cause autism, Trump transition team co-chair Howard Lutnick said Kennedy wanted data on vaccines “so he can say these things are unsafe,” at which point “the companies will yank the vaccines right off … the market.”

Numerous Trump allies have urged disempowering public health agencies — stripping the CDC of much of its research and promotional authority while streamlining NIH and adding congressional oversight over its grant-making.

Project 2025, the Heritage Foundation blueprint disavowed by Trump but whose authors include many former Trump officials, says the drug industry and other corporations have “captured” regulatory agencies: “We must shut and lock the revolving door” between agencies like the NIH, CDC, and FDA, and the industries they regulate, it states.

Kennedy recently posted on the social platform X that “FDA’s war on public health” — by which he meant restrictions on disproven therapies and cure-alls like raw milk and ivermectin — “was about to end.”

He warned FDA employees who are “part of the corrupt system” that they should “1. Preserve your records, and 2. Pack your bags.”

— Arthur Allen

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Celebrating HOPE month

HHS released a statement marking the beginning of Marketplace open enrollment and new data on business owners, self-employed adults obtaining health insurance

President Biden and Vice President Harris’s efforts to strengthen access to health care are linked to historic gains in rural Americans’ health insurance coverage.

ST. LOUIS — Voters in Missouri, Nebraska, and Alaska will soon decide whether workers in those states should be entitled to paid sick leave.

If approved, the ballot measures would allow many workers to accrue paid time off, a benefit supporters say means workers — especially those with low-paying jobs — would no longer have to fear losing wages or possibly the jobs themselves for getting sick. Proponents say such policies benefit the broader public, too, allowing workers to stay home when sick or to care for ill family members to stem the spread of infectious diseases.

But opponents say the measures force new burdens on employers, who should be the ones deciding which benefits are best.

The coronavirus pandemic highlighted gaps in such benefits. At the height of the health crisis, the federal government provided temporary relief for sick workers, but those federal protections ended in 2021.

Fifteen states and the District of Columbia now have laws requiring at least some employers to provide paid sick time, according to the Center for American Progress, a left-leaning think tank based in Washington, D.C. They are largely Democratic-controlled places.

The three sick leave ballot measures up for vote are in Republican-led states. Ballot measures, which are allowed in 24 states, let voters amend state constitutions or enact laws by voting directly on an issue, allowing them to bypass state legislatures. For example, voters ushered in Medicaid expansion in Missouri and Nebraska in 2020 and 2018, respectively, after their legislatures wouldn’t pass it.

Still, as Election Day quickly approaches, the three sick leave ballot initiatives have flown under the radar, unlike higher-profile ballot measures — say, on abortion, which is on the ballot in 10 states, including Missouri and Nebraska.

Campaigns supporting the sick leave initiatives in Alaska, Missouri, and Nebraska raked in less than $9 million combined in cash contributions, according to a KFF Health News analysis of state campaign filings as of Oct. 28.

That’s significantly less than Missouri’s ballot measures on abortion and sports betting, which have amassed more than $55 million combined in cash contributions, according to state records. TV ads flood the airwaves on those two measures and yard signs on abortion saturate the region.

Most of the money for the sick leave measures has come from backers outside those three states, the filings show, with the Sixteen Thirty Fund, a D.C.-based advocacy group, being the top contributor to each of the three campaigns. “No one should have to choose between their health and a paycheck,” the group said in a statement.

The group, which funds progressive causes nationwide, does not disclose its donors, but in recent years nonprofits tied to George Soros and Swiss billionaire Hansjörg Wyss have reportedly given to it.

It appears no groups have organized formal campaign committees opposing the sick leave measures.

For Alana Ashmore, 18, paid sick leave would be welcome. The St. Louis woman works two jobs: one as a restaurant server and another at a gym. When she’s too sick to work, she said, she immediately worries about being able to afford her $800 monthly rent and starts thinking: “I better find a way to get money.” She said she plans to vote for the measure.

More than 930,000 Missourians lack paid sick time, like Ashmore, and the measure is expected to benefit 728,000 private-sector workers in the state, according to the Missouri Budget Project, a nonprofit focused on analyzing public policy. Some state or local government workers would not be eligible.

If the measures pass, many workers in these three states could accrue paid time off as they work, earning about a week of paid leave per year. In Missouri and Nebraska, workers for large organizations could earn one hour of paid sick time for every 30 hours worked. To earn one day of paid sick time, they would need to work 40 hours a week for six weeks. In Alaska, eligible workers could accrue a maximum of 56 hours of paid time each year.

In Missouri and Alaska, the measures also seek to raise the minimum wage.

In all three states, the measures have received broad support, including from major unions. Jodi Lepaopao, the campaign manager for Paid Sick Leave for Nebraskans, said her campaign has received support from at least 200 businesses, though not from the meatpacking plants whose workers she said stand to gain the most, as they often lack paid sick leave.

During the pandemic, meatpacking plants were heavily hit by covid-19. Nearly 1 in 5 meatpacking plant workers were infected from March to July 2020, “a profound burden of cases unparalleled in any other worker population,” researchers found.

“This is going to be a big win for them, if we can win,” Lepaopao said.

St. Louis-based Generate Health, a nonprofit that supports healthy outcomes for Black moms and their babies, has backed the paid leave proposition in Missouri for both its employees and its clients.

“To have a healthy baby, you have to have a healthy family and, ultimately, a healthy community,” said Lora Gulley, director of advocacy for Generate Health.

But not every employer has thrown support behind the push for paid sick leave.

Missouri’s Chamber of Commerce and Industry opposes the proposition because it would place mandates on employers that it has said would “increase the cost of doing business and increase liability for our state’s employers.”

The National Federation of Independent Business has also opposed paid sick leave requirements, and specifically has come out against the Alaska measure as a threat to small businesses.

Separately, ballot measures can boost voter turnout, said Adam Snipes, director of strategic partnerships at the Ballot Initiative Strategy Center, which works to pass progressive ballot measures around the country. Voters are often galvanized to head to the polls by the issues, causing ripple effects across all races.

“While they might be skeptical of politicians, they are highly participatory when it comes to ballot measures,” Snipes said.

KFF Health News Midwest correspondent Bram Sable-Smith contributed to this article.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Nada, nada, nada”, dijo.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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Becky Carroll was missing a few teeth, and others were stained or crooked. Ashamed, she smiled with lips pressed closed. Her dentist offered to fix most of her teeth with root canals and crowns, Carroll said, but she was wary of traveling a long road of dental work.

Then Carroll saw a TV commercial for another path: ClearChoice Dental Implant Centers. The company advertises that it can give patients “a new smile in as little as one day” by surgically replacing teeth instead of fixing them.

So Carroll saved and borrowed for the surgery, she said. In an interview and a lawsuit, Carroll said that at a ClearChoice clinic in New Jersey in 2021, she agreed to pay $31,000 to replace all her natural upper teeth with pearly-white prosthetic ones. What came next, Carroll said, was “like a horror movie.”

Carroll alleged that her anesthesia wore off during implant surgery, so she became conscious as her teeth were removed and titanium screws were twisted into her jawbone. Afterward, Carroll’s prosthetic teeth were so misaligned that she was largely unable to chew for more than two years until she could afford corrective surgery at another clinic, according to a sworn deposition from her lawsuit.

ClearChoice has denied Carroll’s claims of malpractice and negligence in court filings and did not respond to requests for comment on the ongoing case.

“I thought implants would be easier, and all at once, so you didn’t have to keep going back to the dentist,” Carroll, 52, said in an interview. “But I should have asked more questions … like, Can they save these teeth?”

Dental implants have been used for more than half a century to surgically replace missing or damaged teeth with artificial duplicates, often with picture-perfect results. While implant dentistry was once the domain of a small group of highly trained dentists and specialists, tens of thousands of dental providers now offer the surgery and place millions of implants each year in the U.S.

Amid this booming industry, some implant experts worry that many dentists are losing sight of dentistry’s fundamental goal of preserving natural teeth and have become too willing to remove teeth to make room for expensive implants, according to a months-long investigation by KFF Health News and CBS News. In interviews, 10 experts said they had each given second opinions to multiple patients who had been recommended for mouths full of implants that the experts ultimately determined were not necessary. Separately, lawsuits filed across the country have alleged that implant patients like Carroll have experienced painful complications that have required corrective surgery, while other lawsuits alleged dentists at some implant clinics have persuaded, pressured, or forced patients to remove teeth unnecessarily.

The experts warn that implants, for a single tooth or an entire mouth, expose patients to costs and surgery complications, plus a new risk of future dental problems with fewer treatment options because their natural teeth are forever gone.

“There are many cases where teeth, they’re perfectly fine, and they’re being removed unnecessarily,” said William Giannobile, dean of the Harvard School of Dental Medicine. “I really hate to say it, but many of them are doing it because these procedures, from a monetary standpoint, they’re much more beneficial to the practitioner.”

Giannobile and nine other experts say they are combating a false public perception that implants are more durable and longer-lasting than natural teeth, which some believe stems in part from advertising on TV and social media. Implants require upkeep, and although they can’t get cavities, studies have shown that patients can be susceptible to infections in the gums and bone around their implants.

“Just because somebody can afford implants doesn’t necessarily mean that they’re a good candidate,” said George Mandelaris, a Chicago-area periodontist and member of the American Academy of Periodontology Board of Trustees. “When an implant has infection, or when an implant has bone loss, an implant dies a much quicker death than do teeth.”

In its simplest form, implant surgery involves extracting a single tooth and replacing it with a metal post that is screwed into the jaw and then affixed with a prosthetic tooth commonly made of porcelain, also known as a crown. Patients can also use “full-arch” or “All-on-4” implants to replace all their upper or lower teeth — or all their teeth.

For this story, KFF Health News and CBS News sought interviews with large dental chains whose clinics offer implant surgery — ClearChoice, Aspen Dental, Affordable Care, and Dental Care Alliance — each of which declined to be interviewed or did not respond to multiple requests for comment. The Association of Dental Support Organizations, which represents these companies and others like them, also declined an interview request.

ClearChoice, which specializes in full-arch implants, did not answer more than two dozen questions submitted in writing. In an emailed statement, the company said full-arch implants “have become a well-accepted standard of care for patients with severe tooth loss and teeth with poor prognosis.”

“The use of full-arch restorations reflects the evolution of modern dentistry, offering patients a solution that restores their ability to eat, speak, and live comfortably — far beyond what traditional dentures can provide,” the company said.

Carroll said she regrets not letting her dentist try to fix her teeth and rushing to ClearChoice for implants.

“Because it was a nightmare,” she said.

‘They Are Not Teeth’

Dental implant surgery can be a godsend for patients with unsalvageable teeth. Several experts said implants can be so transformative that their invention should have contended for a Nobel Prize. And yet, these experts still worry that implants are overused, because it is generally better for patients to have their natural teeth.

Paul Rosen, a Pennsylvania periodontist who said he has worked with implants for more than three decades, said many patients believe a “fallacy” that implants are “bulletproof.”

“You can’t just have an implant placed and go off riding into the sunset,” Rosen said. “In many instances, they need more care than teeth because they are not teeth.”

Generally, a single implant costs a few thousand dollars while full-arch implants cost tens of thousands. Neither procedure is well covered by dental insurance, so many clinics partner with credit companies that offer loans for implant surgeries. At ClearChoice, for example, loans can be as large as $65,000 paid off over 10 years, according to the company’s website.

Despite the price, implants are more popular than ever. Sales increased by more than 6% on average each year since 2010, culminating in more than 3.7 million implants sold in the U.S. in 2022, according to a 2023 report produced by iData Research, a health care market research firm.

Some worry implant dentistry has gone too far. In 10 interviews, dentists and dental specialists with expertise in implants said they had witnessed the overuse of implants firsthand. Each expert said they’d examined multiple patients in recent years who were recommended for full-arch implants by other dentists despite their teeth being treatable with conventional dentistry.

Giannobile, the Harvard dean, said he had given second opinions to “dozens” of patients who were recommended for implants they did not need.

“I see many of these patients now that are coming in and saying, ‘I’ve been seen, and they are telling me to get my entire dentition — all of my teeth — extracted.’ And then I’ll take a look at them and say that we can preserve most of your teeth,” Giannobile said.

Tim Kosinski, who is a representative of the Academy of General Dentistry and said he has placed more than 19,000 implants, said he examines as many as five patients a month who have been recommended for full-arch implants that he deems unnecessary.

“There is a push in the profession to remove teeth that could be saved,” Kosinski said. “But the public isn’t aware.”

Luiz Gonzaga, a periodontist and prosthodontist at the University of Florida, said he, too, had turned away patients who wanted most or all their teeth extracted. Gonzaga said some had received implant recommendations that he considered “an atrocity.”

“You don’t go to the hospital and tell them ‘I broke my finger a couple of times. This is bothering me. Can you please cut my finger off?’ No one will do that,” Gonzaga said. “Why would I extract your tooth because you need a root canal?”

Jaime Lozada, director of an elite dental implant residency program at Loma Linda University, said he’d not only witnessed an increase in dentists extracting “perfectly healthy teeth” but also treated a rash of patients with mouths full of ill-fitting implants that had to be surgically replaced.

Lozada said in August that he’d treated seven such patients in just three months.

“When individuals just make a decision of extracting teeth to make it simple and make money quick, so to speak, that’s where I have a problem,” Lozada said. “And it happens quite often.”

When full-arch implants fail, patients sometimes don’t have enough jawbone left to anchor another set. These patients have little choice but to get implants that reach into cheekbones, said Sohail Saghezchi, an oral and maxillofacial surgeon at the University of California-San Francisco.

“It’s kind of like a last resort,” Saghezchi said. “If those fail, you don’t have anywhere else to go.”

‘It Was Horrendous Dentistry’

Most of the experts interviewed for this article said their rising alarm corresponded with big changes in the availability of dental implants. Implants are now offered by more than 70,000 dental providers nationwide, two-thirds of whom are general dentists, according to the iData Research report.

Dentists are not required to learn how to place implants in dental school, nor are they required to complete implant training before performing the surgery in nearly all states. This year, Oregon started requiring dentists to complete 56 hours of hands-on training before placing any implants. Stephen Prisby, executive director of the Oregon Board of Dentistry, said the requirement — the first and only of its kind in the U.S. — was a response to dozens of investigations in the state into botched surgeries and other implant failures, split evenly between general dentists and specialists.

“I was frankly stunned at how bad some of these dentists were practicing,” Prisby said. “It was horrendous dentistry.”

Many dental clinics that offer implants have consolidated into chains owned by private equity firms that have bought out much of implant dentistry. In health care, private equity investment is sometimes criticized for overtreatment and prioritizing short-term profit over patients.

Private equity firms have spent about $5 billion in recent years to buy large dental chains that offer implants at hundreds of clinics owned by individual dentists and dental specialists. ClearChoice was bought for an estimated $1.1 billion in 2020 by Aspen Dental, which is owned by three private equity firms, according to PitchBook, a research firm focused on the private equity industry. Private equity firms also bought Affordable Care, whose largest clinic brand is Affordable Dentures & Implants, for an estimated $2.7 billion in 2021, according to PitchBook. And the private equity wing of the Abu Dhabi government bought Dental Care Alliance, which offers implants at many of its affiliated clinics, for an estimated $1 billion in 2022, according to PitchBook.

ClearChoice and Aspen Dental each said in email statements that the companies’ private equity owners “do not have influence or control over treatment recommendations.” Both companies said dentists or dental specialists make all clinical decisions.

Private equity deals involving dental practices increased ninefold from 2011 to 2021, according to an American Dental Association study published in August. The study also said investors showed an interest in oral surgery, possibly because of the “high prices” of implants.

“Some argue this is a negative thing,” said Marko Vujicic, vice president of the association’s Health Policy Institute, who co-authored the study. “On the other hand, some would argue that involvement of private equity and outside capital brings economies of scale, it brings efficiency.”

Edwin Zinman, a San Francisco dental malpractice attorney and former periodontist who has filed hundreds of dental lawsuits over four decades, said he believed many of the worst fears about private equity owners had already come true in implant dentistry.

“They’ve sold a lot of [implants], and some of it unnecessarily, and too often done negligently, without having the dentists who are doing it have the necessary training and experience,” Zinman said. “It’s for five simple letters: M-O-N-E-Y.”

Hundreds of Implant Clinics With No Specialists

For this article, journalists from KFF Health News and CBS News analyzed the webpages for more than 1,000 clinics in the nation’s largest private equity-owned dental chains, all of which offer some implants. The analysis found that more than 70% of those clinics listed only general dentists on their websites and did not appear to employ the specialists — oral surgeons, periodontists, or prosthodontists — who traditionally have more training with implants.

Affordable Dentures & Implants listed specialists at fewer than 5% of its more than 400 clinics, according to the analysis. The rest were staffed by general dentists, most of whom did not list credentialing from implant training organizations, according to the analysis.

ClearChoice, on the other hand, employs at least one oral surgeon or prosthodontist at each of its more than 100 centers, according to the analysis. But its new parent company, Aspen Dental, which offers implants in many of its more than 1,100 clinics, does not list any specialists at many of those locations.

Not everyone is worried about private equity in implant dentistry. In interviews arranged by the American Academy of Implant Dentistry, which trains dentists to use implants, two other implant experts did not express concerns about private equity firms.

Brian Jackson, a former academy president and implant specialist in New York, said he believed dentists are too ethical and patients are too smart to be pressured by private equity owners “who will never see a patient.”

Jumoke Adedoyin, a chief clinical officer for Affordable Care, who has placed implants at an Affordable Dentures & Implants clinic in the Atlanta suburbs for 15 years, said she had never felt pressure from above to sell implants.

“I’ve actually felt more pressure sometimes from patients who have gone around and been told they need to take their teeth out,” she said. “They come in and, honestly, taking a look at them, maybe they don’t need to take all their teeth out.”

Still, lawsuits filed across the country have alleged that dentists at implant clinics have extracted patients’ teeth unnecessarily.

For example, in Texas, a patient alleged in a 2020 lawsuit that an Affordable Care dentist removed “every single tooth from her mouth when such was not necessary,” then stuffed her mouth with gauze and left her waiting in the lobby as he and his staff left for lunch. In Maryland, a patient alleged in a 2021 lawsuit that ClearChoice “convinced” her to extract “eight healthy upper teeth,” by “greatly downplay[ing] the risks.” In Florida, a patient alleged in a 2023 lawsuit that ClearChoice provided her with no other treatment options before extracting all her teeth, “which was totally unnecessary.”

ClearChoice and Affordable Care denied wrongdoing in their respective lawsuits, then privately settled out of court with each patient. ClearChoice and Affordable Care did not respond to requests for comment submitted to the companies or attorneys. Lawyers for all three plaintiffs declined to comment on these lawsuits or did not respond to requests for comment.

Fred Goldberg, a Maryland dental malpractice attorney who said he has represented at least six clients who sued ClearChoice, said each of his clients agreed to get implants after meeting with a salesperson — not a dentist.

“Every client I’ve had who has gone to ClearChoice has started off meeting a salesperson and actually signing up to get their financing through ClearChoice before they ever meet with a dentist,” Goldberg said. “You meet with a salesperson who sells you on what they like to present as the best choice, which is almost always that they’re going to take out all your natural teeth.”

Becky Carroll, the ClearChoice patient from New Jersey, told a similar story.

Carroll said in her lawsuit that she met first with a ClearChoice salesperson referred to as a “patient education consultant.” In an interview, Carroll said the salesperson encouraged her to borrow money from family members for the surgery and it was not until after she agreed to a loan and passed a credit check that a ClearChoice dentist peered into her mouth.

“It seems way backwards,” Carroll said. “They just want to know you’re approved before you get to talk to a dentist.”

CBS News producer Nicole Keller contributed to this report.

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

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

With the 2024 election campaign in its final days, House Speaker Mike Johnson this week floated “massive” health care reform if former President Donald Trump wins — changes that are also dependent, of course, on whether Republicans control Congress next year.

Meanwhile, new reporting uncovers more maternal deaths under state abortion bans, plus at least one case in which a woman was jailed after a miscarriage. Plus, other investigations are shining a light on a reality of American health care, regardless of who wins on Tuesday: the consequences of health industry profiteering.

This week’s panelists are Emmarie Huetteman of KFF Health News, Lauren Weber of The Washington Post, Shefali Luthra of The 19th, and Jessie Hellmann of CQ Roll Call.

Panelists Jessie Hellmann CQ Roll Call @jessiehellmann Read Jessie's stories. Shefali Luthra The 19th @shefalil Read Shefali's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• Trump has called for reopening the fight over the Affordable Care Act, and given enough votes in Congress, Johnson suggested this week that he’s ready to back the former president’s play. To be sure, the expiration next year of enhanced ACA premium subsidies will put the health law back on the agenda — though given the law’s popularity, changes may be a hard sell even to some Republicans.
• Trump also unveiled his own proposal to address the long-term care crisis: a tax credit for family caregivers. His plan follows Vice President Kamala Harris’ proposal weeks ago to create a new Medicare benefit that pays for home health care.
• New reporting is out this week on women suffering miscarriages being denied reproductive health care — or even being charged with manslaughter and incarcerated. While many abortion opponents say they have no intention of harming or punishing women, the consequences of overturning Roe v. Wade are coming into clearer focus.

Also this week, KFF Health News’ Julie Rovner interviews Irving Washington, a senior vice president at KFF and the executive director of its Health Misinformation and Trust Initiative.

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

Emmarie Huetteman: KFF Health News’ “‘Dreamers’ Can Enroll in ACA Plans This Year — But a Court Challenge Could Get in the Way,” by Julie Appleby.

Lauren Weber: The New York Times’ “What Drugmakers Did Not Tell Volunteers in Alzheimer’s Trials,” by Walt Bogdanich and Carson Kessler.

Shefali Luthra: NBC News’ “They’re Middle Class and Insured. Childbirth Still Left Them With Crippling Debt,” by Aria Bendix.

Jessie Hellmann: ProPublica’s “‘Not Medically Necessary’: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care,” by T. Christian Miller, ProPublica; Patrick Rucker, The Capitol Forum; and David Armstrong, ProPublica.

Also mentioned on this week’s podcast:

• KFF Health News’ “Ghosts, Ghouls, and Ghastly Drug Prices in Winning Halloween Haikus.”
• ProPublica’s “A Woman Died After Being Told It Would Be a ‘Crime’ To Intervene in Her Miscarriage at a Texas Hospital,” by Cassandra Jaramillo and Kavitha Surana.
• The Washington Post’s “She Said She Had a Miscarriage — Then Got Arrested Under an Abortion Law,” by Caroline Kitchener.
• The 19th’s “Anti-Abortion Centers Are Stepping Into Electoral Politics,” by Shefali Luthra.
• The New York Times’ “How Taxpayers Are Helping Health Insurers Make Even Bigger Profits,” by Chris Hamby.
• KFF’s Health Misinformation and Trust Initiative, a program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem.

Credits Francis Ying Audio producer Stephanie Stapleton 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.

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HHS Office for Civil Rights announces $90,000 settlement with Bryan County Ambulance Authority for potential HIPAA Security Rule violation involving ransomware.

HHS Awards $3.7B to LIHEAP

HHS Office for Civil Rights Settles Ransomware Cybersecurity Investigation for $500,000 with Plastic Surgery Associates of South Dakota

Statement from Secretary Xavier Becerra on IV Solution Production Resuming in North Carolina following Hurricane Helene

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

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

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

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

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

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

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

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

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

And there could be more back-and-forth.

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

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

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

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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When Cynthia Ruiz turns on her kitchen faucet, she hears a slight squeak before cloudy fluid bursts out of the spout. The water in her Central Valley town of East Orosi is clean enough most of the time to wash dishes, flush toilets, and take showers, but it’s not safe to swallow. Drinking water is trucked in twice a month.

“There are times where the water is so bad you can’t even wash dishes,” said Ruiz, who is advised not to drink the tap water, which is laden with nitrates — runoff from orange and nectarine fields surrounding the town of roughly 400. “We need help to fix our water problem.”

Tucked in a $10 billion climate bond on the November ballot is an earmark to improve drinking water quality for communities such as East Orosi. Proposition 4 would allocate $610 million for clean, safe, and reliable drinking water and require at least 40% be spent on projects that benefit vulnerable populations or disadvantaged communities. But it’s a fraction of what the state says is needed.

While most Californians have access to safe water, roughly 750,000 people as of late October are served by 383 failing water systems, many clustered in remote and sparsely populated areas. A June assessment by the California State Water Resources Control Board pegged the cost of repairing failing and at-risk public water systems at about $11.5 billion.

“We have communities in California that are served drinking water that has been out of compliance with regulatory standards for potent toxins like arsenic for years,” said Lara Cushing, an associate professor in UCLA’s Department of Environmental Health Sciences.

And climate change is eroding people’s access to clean water, she said. “There is kind of a perfect storm, if you will, of compounding hazards.”

Supporters say Proposition 4, to enact the Safe Drinking Water, Wildfire Prevention, Drought Preparedness, and Clean Air Bond Act of 2024, would jump-start upgrades by authorizing grants and loans for local governments to repair water systems contaminated with lead, arsenic, nitrates, or other chemicals tied to cancer, liver and kidney problems, and other serious health issues.

Water priorities vary by region, and the bond would give communities flexibility to address their needs, said MJ Kushner, a policy advocate at the Community Water Center, a statewide nonprofit. “It isn’t a one-size-fits-all solution,” Kushner said.

A taxpayer group opposing the bond says the state will go further into debt on piecemeal projects. It says the state is increasingly addressing its climate-related programs with bonds, which it calls the most expensive way for government to pay for things, rather than within the state budget.

Lawmakers in July added Proposition 4 to the ballot after Democratic Gov. Gavin Newsom, facing a $47 billion deficit, cut $6.6 billion in climate spending from the state budget, according to Department of Finance spokesperson H.D. Palmer. The reductions followed $3.1 billion in climate cuts Newsom and lawmakers enacted in 2023.

Susan Shelley, a spokesperson for the Howard Jarvis Taxpayers Association, said the state has already borrowed billions and that now isn’t the time to add more debt given the deficit.

“If the legislature chose to cut these from the budget, they should not go on the credit card,” Shelley said. “It’s irresponsible.”

According to the nonpartisan Legislative Analyst’s Office, the state has routinely allocated state funds for climate-related programs, with about 15% coming from bonds. The office estimates it would cost taxpayers $400 million a year for the next 40 years to repay the bond — a total of $16 billion.

Since 2000, California voters have approved eight water bonds totaling $27 billion, for projects involving flood management, habitat restoration, drought preparation, and drinking water improvement, according to the Public Policy Institute of California.

Scientists say climate change has led to more severe weather, including devastating floods and droughts; the spread of infectious diseases such as West Nile virus; and earlier deaths from respiratory illnesses. Public health experts add that as climate change worsens, its impact on people’s health will grow more severe and could cost the state more in the long run.

“If we quantify the damages associated with the do-nothing policy, you’ll see that typically, at the end of the day, the bill plus the interest costs are going to be less than the cost if we do nothing,” said Kurt Schwabe, an environmental economics and policy professor at the University of California-Riverside.

If approved, Ruiz hopes Proposition 4 can help East Orosi, a predominantly Latino and low-income community. Though she receives 25 gallons of drinking water twice a month, she sometimes runs out. The last time the 47-year-old drank tap water at home was when she was in high school.

“I don’t think any community anywhere in California should have to wait this long to get clean water,” Ruiz said.

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

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

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Conservative groups are working to undermine support for Montana’s Medicaid expansion in hopes the state will abandon the program. The rollback would be the first in the decade since the Affordable Care Act began allowing states to cover more people with low incomes.

Montana’s expansion, which insures roughly 78,800 people, is set to expire next year unless the legislature and governor opt to renew it. Opponents see a rare opportunity to eliminate Medicaid expansion in one of the 40 states that have approved it.

The Foundation for Government Accountability and Paragon Health Institute, think tanks funded by conservative groups, told Montana lawmakers in September that the program’s enrollment and costs are bloated and that the overloaded system harms access to care for the most vulnerable.

Manatt, a consulting firm that has studied Montana’s Medicaid program for years, then presented legislators with the opposite take, stating that more people have access to critical treatment because of Medicaid expansion. Those who support the program say the conservative groups’ arguments are flawed.

State Rep. Bob Keenan, a Republican who chairs the Health and Human Services Interim Budget Committee, which heard the dueling arguments, said the decision to kill or continue Medicaid expansion “comes down to who believes what.”

The expansion program extends Medicaid coverage to adults with incomes up to 138% of the federal poverty level, or nearly $21,000 a year for a single person. Before, the program was largely reserved for children, people with disabilities, and pregnant women. The federal government covers 90% of the expansion cost while states pick up the rest.

National Medicaid researchers have said Montana is the only state considering shelving its expansion in 2025. Others could follow.

New Hampshire legislators in 2023 extended the state’s expansion for seven years and this year blocked legislation to make it permanent. Utah has provisions to scale back or end its Medicaid expansion program if federal contributions drop.

FGA and Paragon have long argued against Medicaid expansion. Tax records show their funders include some large organizations pushing conservative agendas. That includes the 85 Fund, which is backed by Leonard Leo, a conservative activist best known for his efforts to fill the courts with conservative judges.

The president of Paragon Health Institute is Brian Blase, who served as a special assistant to former President Donald Trump and is a visiting fellow at FGA, which quotes him as praising the organization for its “conservative policy wins” across states. He was also announced in 2019 as a visiting fellow at the Heritage Foundation, which was behind the Project 2025 presidential blueprint, which proposes restricting Medicaid eligibility and benefits.

Paragon spokesperson Anthony Wojtkowiak said its work isn’t directed by any political party or donor. He said Paragon is a nonpartisan nonprofit and responds to policymakers interested in learning more about its analyses.

“In the instance of Montana, Paragon does not have a role in the debate around Medicaid expansion, other than the testimony,” he said.

FGA declined an interview request. As early as last year, the organization began calling on Montana lawmakers to reject reauthorizing the program. It also released a video this year of Montana Republican Rep. Jane Gillette saying the state should allow its expansion to expire.

Gillette requested the FGA and Paragon presentations to state lawmakers, according to Keenan. He said Democratic lawmakers responded by requesting the Manatt presentation.

Manatt’s research was contracted by the Montana Healthcare Foundation, whose mission is to improve the health of Montanans. Its latest report also received support from the state’s hospital association.

The Montana Healthcare Foundation is a funder of KFF Health News, an independent national newsroom that is part of the health information nonprofit KFF.

Bryce Ward, a Montana health economist who studies Medicaid expansion, said some of the antiexpansion arguments don’t add up.

For example, Hayden Dublois, FGA’s data and analytics director, told Montana lawmakers that in 2022 72% of able-bodied adults on Montana’s Medicaid program weren’t working. If that data refers to adults without disabilities, that would come to 97,000 jobless Medicaid enrollees, Ward said. He said that’s just shy of the state’s total population who reported no income at the time, most of whom didn’t qualify for Medicaid.

“It’s simply not plausible,” Ward said.

A Manatt report, citing federal survey data, showed 66% of Montana adults on Medicaid have jobs and an additional 11% attend school.

FGA didn’t respond to a request for its data, which Dublois said in the committee hearing came through a state records request.

Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, also declined to comment. As of late October, a KFF Health News records request for the data the state provided FGA was pending.

In his presentation before Montana lawmakers, Blase said the most vulnerable people on Medicaid are worse off due to expansion as resources pool toward new enrollees.

“Some people got more medical care; some people got less medical care,” Blase said.

Reports released by the state show its standard monthly reimbursement per Medicaid enrollee remained relatively flat for seniors and adults who are blind or have disabilities.

Drew Gonshorowski, a researcher with Paragon, cited data from a federal Medicaid commission that shows that, overall, states spend more on adults who qualified through the expansion programs than they do on others on Medicaid. That data also shows states spend more on seniors and people with disabilities than on the broader adult population insured by Medicaid, which is also true in Montana.

Nationally, states with expansions spend more money on people enrolled in Medicaid across eligibility groups compared with nonexpansion states, according to a KFF report.

Zoe Barnard, a senior adviser for Manatt who worked for Montana’s health department for nearly 10 years, said not only has the state’s uninsured rate dropped by 30% since it expanded Medicaid, but also some specialty services have grown as more people access care.

FGA has long lobbied nonexpansion states, including Texas, Kansas, and Mississippi, to leave Medicaid expansion alone. In February, an FGA representative testified in support of an Idaho bill that included an expansion repeal trigger if the state couldn’t meet a set of rules, including instituting work requirements and capping enrollment. The bill failed.

Paragon produced an analysis titled “Resisting the Wave of Medicaid Expansion,” and Blase testified to Texas lawmakers this year on the value of continuing to keep expansion out of the Lone Star State.

On the federal level, Paragon recently proposed a Medicaid overhaul plan to phase out the federal 90% matching rate for expansion enrollees, among other changes to cut spending. The left-leaning Center on Budget and Policy Priorities has countered that such ideas would leave more people without care.

In Montana, Republicans are defending a supermajority they didn’t have when a bipartisan group passed the expansion in 2015 and renewed it in 2019. Also unlike before, there’s now a Republican in the governor’s office. Gov. Greg Gianforte is up for reelection and has said the safety net is important but shouldn’t get too big.

Keenan, the Republican lawmaker, predicted the expansion debate won’t be clear-cut when legislators convene in January.

“Medicaid expansion is not a yes or no. It’s going to be a negotiated decision,” he said.

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The city of Beverly Hills has agreed to train its employees on abortion clinic protections after local officials interfered with the opening of an abortion clinic in “blatant” violation of state law, according to a proposed settlement to be unveiled Thursday by California Attorney General Rob Bonta.

Bonta’s office said the city’s then-mayor, city attorney, and city manager pressured DuPont Clinic’s landlord last spring to cancel the lease and that city officials also delayed permits to the clinic. They went so far as to warn the building owner that it could be liable for bomb threats and shootings at the medical office building in the wealthy city’s business district.

The Washington, D.C.-based reproductive health provider is one of a handful of clinics nationwide that advertise abortions past 28 weeks of gestation. It had secured a lease and begun preparations to open a second U.S. location in Beverly Hills.

Concerned about potential anti-abortion protests and negative media coverage, city officials “engaged in a pressure campaign under the guise of public safety,” according to Bonta’s complaint. The actions “blatantly violated” state law, Bonta said in the complaint. It’s the state’s first action under the voter-passed initiative known as Proposition 1, which enshrined abortion rights in the state constitution.

“It’s a stark reminder that there are efforts right here in California to undermine reproductive freedom,” Bonta said in an interview with KFF Health News ahead of the announcement. “These are city officials who took an oath to uphold the state constitution and state law, and they did the opposite.”

In signing the agreement, the city did not admit fault or liability. In a statement, Mayor Lester Friedman said the city disagreed with the allegations in the attorney general’s complaint.

“Beverly Hills is already home to medical facilities that offer complete reproductive health services,” Friedman said in a statement. “The city reaffirms and pledges that it did not and will not discriminate against any reproductive healthcare provider and strongly supports a woman’s right to choose.”

As part of the agreement which has been approved by the Beverly Hills City Council and must be approved by the Los Angeles County Superior Court, city officials will be required to train employees about state and federal protections for abortion clinics, create a protocol for handling complaints of potential violations, and appoint a “reproductive justice compliance officer” to manage the training program and materials.

California prohibits abortions past the point of fetal viability, around 24 weeks, except in cases in which the life or health of the woman is at risk. Proposition 1 strengthened reproductive freedom protections in the state constitution.

Approved by an overwhelming majority of statewide voters in 2022, the law says that the state, and by extension local governments, “shall not deny or interfere with an individual’s reproductive freedom in their most intimate decisions, which includes their fundamental right to choose to have an abortion and their fundamental right to choose or refuse contraceptives.”

Bonta said the measure, which at the time was widely regarded as a largely symbolic measure in deeply progressive California, provided a strong legal basis for the state’s case against the city of Beverly Hills and led directly to the settlement agreement.

“There are protections, both constitutional and statutory, that protect reproductive freedom in California,” Bonta said. “Cities need to honor and follow those rights and protections and when they’re not, we will get involved.”

DuPont Clinic had announced plans in October 2022 to expand to the Los Angeles area, according to Bonta’s office. The following month, flyers opposing the clinic’s opening appeared in and around the building.

Beverly Hills police officials later drafted a plan to send a letter to other tenants of the building warning them of the potential security risks, something Bonta said they’d never done with previous properties targeted by protesters.

The city attorney instructed city officials to not issue permits to DuPont until he’d spoken with the clinic about “whether the proposed use is allowed or not.” He later suggested DuPont provide a letter “confirming its intention to comply with California law” as it relates to abortions later in pregnancy.

“They acted differently and inserted themselves in delayed permits and launching a pressure campaign based on the fact that reproductive freedom is at stake,” Bonta said. “They targeted DuPont because of the fact that it provided fully legal reproductive health care.”

During a City Council meeting in April 2023, City Manager Nancy Hunt-Coffey sent an email to council members alerting them of the controversy over the new clinic, just before several activists spoke in opposition. The clinic could, she warned, “be the focus of protests, rallies and unfortunately other more violent actions on occasion.”

“How did this get through?” council member Sharona Nazarian immediately wrote back.

Hunt-Coffey replied: “Well, it’s a private business renting space in a private building.  We don’t have anything in our code that prevents it…”

What followed was a series of attempts by then-mayor Julian Gold, Hunt-Coffey, and the Beverly Hills police chief to stymie the clinic’s opening, Bonta said. Gold and the police chief met with building owner Douglas Emmett Inc., warning that the clinic could become a “lightning rod” for the city and that the landlord would be “responsible” and “liable” if anything were to happen. Gold also raised the possibility of bomb threats and active shooters, and the safety of other tenants in the building.

The clinic never opened.

Bonta said his office is prepared to go after local governments that shirk their responsibility to uphold state laws that protect abortion rights. He also suggested he would support amending state law to levy financial penalties on those who violate it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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