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I’m Moving Forward and Facing the Uncertainty of Aging
It takes a lot of courage to grow old.
I’ve come to appreciate this after conversations with hundreds of older adults over the past eight years for nearly 200 “Navigating Aging” columns.
Time and again, people have described what it’s like to let go of certainties they once lived with and adjust to new circumstances.
These older adults’ lives are filled with change. They don’t know what the future holds except that the end is nearer than it’s ever been.
And yet, they find ways to adapt. To move forward. To find meaning in their lives. And I find myself resolving to follow this path as I ready myself for retirement.
Patricia Estess, 85, of the Brooklyn borough of New York City spoke eloquently about the unpredictability of later life when I reached out to her as I reported a series of columns on older adults who live alone, sometimes known as “solo agers.”
Estess had taken a course on solo aging. “You realize that other people are in the same boat as you are,” she said when I asked what she had learned. “We’re all dealing with uncertainty.”
Consider the questions that older adults — whether living with others or by themselves — deal with year in and out: Will my bones break? Will my thinking skills and memory endure? Will I be able to make it up the stairs of my home, where I’m trying to age in place?
Will beloved friends and family members remain an ongoing source of support? If not, who will be around to provide help when it’s needed?
Will I have enough money to support a long and healthy life, if that’s in the cards? Will community and government resources be available, if needed?
It takes courage to face these uncertainties and advance into the unknown with a measure of equanimity.
“It’s a question of attitude,” Estess told me. “I have honed an attitude of: ‘I am getting older. Things will happen. I will do what I can to plan in advance. I will be more careful. But I will deal with things as they come up.’”
For many people, becoming old alters their sense of identity. They feel like strangers to themselves. Their bodies and minds aren’t working as they used to. They don’t feel the sense of control they once felt.
That requires a different type of courage — the courage to embrace and accept their older selves.
Marna Clarke, a photographer, spent more than a dozen years documenting her changing body and her life with her partner as they grew older. Along the way, she learned to view aging with new eyes.
“Now, I think there’s a beauty that comes out of people when they accept who they are,” she told me in 2022, when she was 70, just before her 93-year-old husband died.
Arthur Kleinman, a Harvard professor who’s now 83, gained a deeper sense of soulfulness after caring for his beloved wife, who had dementia and eventually died, leaving him grief-stricken.
“We endure, we learn how to endure, how to keep going. We’re marked, we’re injured, we’re wounded. We’re changed, in my case for the better,” he told me when I interviewed him in 2019. He was referring to a newfound sense of vulnerability and empathy he gained as a caregiver.
Herbert Brown, 68, who lives in one of Chicago’s poorest neighborhoods, was philosophical when I met him at his apartment building’s annual barbecue in June.
“I was a very wild person in my youth. I’m surprised I’ve lived this long,” he said. “I never planned on being a senior. I thought I’d die before that happened.”
Truthfully, no one is ever prepared to grow old, including me. (I’m turning 70 in February.)
Chalk it up to denial or the limits of imagination. As May Sarton, a writer who thought deeply about aging, put it so well: Old age is “a foreign country with an unknown language.” I, along with all my similarly aged friends, are surprised we’ve arrived at this destination.
For me, 2025 is a turning point. I’m retiring after four decades as a journalist. Most of that time, I’ve written about our nation’s enormously complex health care system. For the past eight years, I’ve focused on the unprecedented growth of the older population — the most significant demographic trend of our time — and its many implications.
In some ways, I’m ready for the challenges that lie ahead. In many ways, I’m not.
The biggest unknown is what will happen to my vision. I have moderate macular degeneration in both eyes. Last year, I lost central vision in my right eye. How long will my left eye pick up the slack? What will happen when that eye deteriorates?
Like many people, I’m hoping scientific advances outpace the progression of my condition. But I’m not counting on it. Realistically, I have to plan for a future in which I might become partially blind.
It’ll take courage to deal with that.
Then, there’s the matter of my four-story Denver house, where I’ve lived for 33 years. Climbing the stairs has helped keep me in shape. But that won’t be possible if my vision becomes worse.
So my husband and I are taking a leap into the unknown. We’re renovating the house, installing an elevator, and inviting our son, daughter-in-law, and grandson to move in with us. Going intergenerational. Giving up privacy. In exchange, we hope our home will be full of mutual assistance and love.
There are no guarantees this will work. But we’re giving it a shot.
Without all the conversations I’ve had over all these years, I might not have been up for it. But I’ve come to see that “no guarantees” isn’t a reason to dig in my heels and resist change.
Thank you to everyone who has taken time to share your experiences and insights about aging. Thank you for your openness, honesty, and courage. These conversations will become even more important in the years ahead, as baby boomers like me make their way through their 70s, 80s, and beyond. May the conversations continue.
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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Midwives Blame California Rules for Hampering Birth Centers Amid Maternity Care Crisis
Jessie Mazar squeezed the grab handle in her husband’s pickup and groaned as contractions struck her during the 90-minute drive from her home in rural northeastern California to the closest hospital with a maternity unit.
She could have reached Plumas District Hospital, in Quincy, in just seven minutes. But it no longer delivers babies.
Local officials have a plan for a birth center in Quincy, where midwives could deliver babies with backup from on-call doctors and a standby perinatal unit at the hospital, but state health officials have yet to approve it.
That left Mazar to brave the long, winding road — one sometimes blocked by snow, floods, or forest fires — to have her baby. Women across California are facing similar ordeals as hospitals increasingly close money-losing maternity units, especially in rural areas.
Midwife-operated birth centers offer an alternative for women with low-risk pregnancies and can play a crucial role in filling the gap left by hospitals’ retreat from obstetrics, maternal health advocates say.
Declining birth rates, staffing shortages, and financial pressures have led 56 California hospitals — about 1 in 6 — to shutter maternity units over the past dozen years.
But midwives say California’s regulatory regime around birth centers is unnecessarily preventing new centers from opening and leading some existing facilities to close. Obtaining a license can take as long as four years.
“All they’ve essentially done is made it more dangerous to have a baby,” said Sacramento midwife Bethany Sasaki. “People have to drive two hours now because a birth center can’t open, so it’s more dangerous. People are going to be having babies in cars on the side of the road.”
Last month, state Assembly member Mia Bonta introduced legislation to streamline the regulatory process and fix what she calls “a broken system” for licensing birth centers.
“We know that alternative birth centers lead to often better outcomes, lower-risk births, more opportunity for children to be born healthy, and also to lower maternal mortality and morbidity,” she said.
The proposed bill would remove various bureaucratic requirements, though many details have yet to be finalized. Bonta introduced the bill in its current form as a jumping-off point for discussions about how to expedite licensing.
“It’s a starting place,” said Sandra Poole, health policy advocate for the Western Center on Law & Poverty, a co-sponsor of the legislation.
For now, birth centers struggle with a gantlet of rules, only some clearly connected to patient safety. Over the past decade, the number of licensed birth centers in California dropped from 12 to five, according to Bonta.
Plumas County officials are trying to address one key issue: how far a birth center can be from a hospital with a round-the-clock obstetrics unit. State regulations say it can be no more than a 30-minute drive, a distance set when many more hospitals had maternity units.
The first-of-its-kind “Plumas model” aims to take advantage of flexibility provisions in the law to address the obstacle in a way that could potentially be replicated elsewhere in the state.
But the hospital’s application for a birth center and a perinatal unit has been “languishing” with the California Department of Public Health, which is “looking for cover from the legislature,” said Robert Moore, chief medical officer of Partnership HealthPlan of California, a Medi-Cal managed-care plan serving most of Northern California. Asked about the application, a CDPH spokesperson said only that it was under review.
The goal should be for all women to be within an hour’s drive of a hospital with an obstetrics unit, Moore said. Data shows the complication rate goes up after an hour and even higher after two hours, he said, while the benefit is less compelling between 30 and 60 minutes.
Numerous other regulations have made it difficult for birth centers to keep their doors open.
Since August, birth centers in Sacramento and Monterey have had to stop operating because their heating ducts failed to meet licensing requirements. The facilities fall under the same state Department of Health Care Access and Information regulations as primary care clinics, though birth centers see healthy families, not sick ones, and don’t need hospital-grade ventilation, said midwife Caroline Cusenza.
She had spent $50,000 remodeling the Monterey Birth & Wellness Center to include state-required items, such as nursing and hand-washing stations and a housekeeping closet. In the end, a requirement for galvanized steel heating vents, which would have required opening the ceiling at an unaffordable cost, prompted her heart-wrenching decision to close.
“We’re turning women away in tears,” said Sasaki, who owned Midtown Birth Center in Sacramento. She bought the building for $760,000 and spent $250,000 remodeling it in a way she believed met all licensing requirements. But regulators would not license it unless the heating system was redone. Sasaki estimated it would have cost an additional $50,000 to bring it into compliance — too much to keep operating.
She blamed her closure on “regulatory dysfunction.”
Legislation signed by Gov. Gavin Newsom last year could ease onerous building codes such as those governing Sasaki’s and Cusenza’s heating systems, said Poole, the health policy advocate.
The state has taken two to four years to issue birth center licenses, according to a brief by the Osher Center for Integrative Health at the University of California-San Francisco. The state Department of Public Health “works tirelessly to ensure health facilities are able to be properly licensed and follow all applicable requirements within our authority before and during their operation,” spokesperson Mark Smith said.
Bonta, an Oakland Democrat who chairs the Assembly’s health committee, said she would consider increasing the allowable drive time between a birth center and a hospital maternity unit as part of her new legislation.
The state last updated birth center regulations more than a decade ago, before hospitals’ mass exodus from obstetrics. “The hurdle is the time and distance standards without compromising safety,” Poole said. “But where there’s nothing right now, we would say a birth center is certainly a better alternative to not having any maternal care.”
Moore noted that midwife-led births in homes and birth centers are the mainstay of obstetric care in Europe, where the infant mortality rate is considerably lower than in the U.S. More than 98% of American babies are born in hospitals.
Babies delivered by midwives are more likely to be born vaginally, less likely to require intensive care, and more likely to breastfeed, the California Maternal Quality Care Collaborative has found. Midwife-led births also lead to fewer infant emergency room visits, hospitalizations, and neonatal deaths. And they cost far less: Birth centers generally charge one-quarter or less of the average cost of about $36,000 for a vaginal birth in a California hospital.
If they catered only to private-pay clients, Cusenza and Sasaki could have continued operating without licenses. They must be licensed, however, to receive payments from Medi-Cal and some private insurance companies, which they needed to remain in business. Medi-Cal, the state’s Medicaid health insurance program, which covers low-income residents, paid for about 40% of the state’s births in 2022.
Bonta has heard reports from midwives that the key to getting licensed is hunting down the right state health department advocate. “I don’t believe that we should be building resources based on the model of ‘Where’s Waldo?’ in finding a champion inside CDPH,” she said.
Lori Link, director of midwifery at Plumas District Hospital, believes the Plumas model can turn what’s become a maternity desert into an oasis. Jessie Mazar, whose son was born in September without complications at a Truckee hospital, would welcome the opportunity to deliver her planned second child in Quincy.
“That would be convenient,” she said. “We’re not holding our breath.”
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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Voters Backed Abortion Rights But State Judges Have Final Say
In November, Montana voters safeguarded the right to abortion in the state’s constitution. They also elected a new chief justice to the Montana Supreme Court who was endorsed by anti-abortion advocates.
That seeming contradiction is slated to come to a head this year. People on polar sides of the abortion debate are preparing to fight over how far the protection for abortion extends, and the final say will likely come from the seven-person state Supreme Court. With the arrival of new Chief Justice Cory Swanson, who ran as a judicial conservative for the nonpartisan seat and was sworn in Jan. 6, the court now leans more conservative than before the election.
A similar dynamic is at play elsewhere. Abortion rights supporters prevailed on ballot measures in seven of the 10 states where abortion was up for a vote in November. But even with new voter-approved constitutional protections, courts will have to untangle a web of existing state laws on abortion and square them with any new ones legislators approve. The new makeup of supreme courts in several states indicates that the results of the legal fights to come aren’t clear-cut.
Activists have been working to reshape high courts, which in recent years have become the final arbiters of a patchwork of laws regulating abortions. That’s because the 2022 U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned federal abortion protections, leaving rulemaking to the states.
Since then, the politics of state supreme court elections have been “supercharged” as fights around abortion shifted to states’ top courts, according to Douglas Keith, a senior counsel at the nonpartisan Brennan Center for Justice.
“Because we’re human, you can’t scrub these races of any political connotations at all,” said former Montana Supreme Court Justice Jim Nelson. “But it’s getting worse.”
The wave of abortion litigation in state courts has spawned some of the most expensive state supreme court races in history, including more than $42 million spent on the nonpartisan 2023 Supreme Court race in Wisconsin, where abortion access was among the issues facing the court. Janet Protasiewicz won the seat, flipping the balance of the court to a liberal majority.
In many states, judicial elections are nonpartisan but political parties and ideological groups still lobby for candidates. In 2024, abortion surfaced as a top issue in these races.
In Michigan, spending by non-candidate groups alone topped $7.6 million for the two open seats on the state Supreme Court. The Michigan races are officially labeled as nonpartisan, although candidates are nominated by political parties.
An ad for the two candidates backed by Democrats cautioned that “the Michigan state Supreme Court can still take abortion rights away” even after voters added abortion protections to the state constitution in 2022. The ad continued, “Kyra Harris Bolden and Kimberly Thomas are the only Supreme Court candidates who will protect access to abortion.” Both won their races.
Abortion opponent Kelsey Pritchard, director of state public affairs for Susan B. Anthony Pro-Life America, decried the influence of abortion politics on state court elections. “Pro-abortion activists know they cannot win through the legislatures, so they have turned to state courts to override state laws,” Pritchard said.
Some abortion opponents now support changes to the way state supreme courts are selected.
In Missouri, where voters passed a constitutional amendment in November to protect abortion access, the new leader of the state Senate, Cindy O’Laughlin, a Republican, has proposed switching to nonpartisan elections from the state’s current model, in which the governor appoints a judge from a list of three finalists selected by a nonpartisan commission. Although Republicans have held the governor’s mansion since 2017, she pointed to the Missouri Supreme Court’s 4-3 ruling in September that allowed the abortion amendment to remain on the ballot and said courts “have undermined legislative efforts to protect life.”
In a case widely expected to reach the Missouri Supreme Court, the state’s Planned Parenthood clinics are trying to use the passage of the new amendment to strike down Missouri’s abortion restrictions, including a near-total ban. O’Laughlin said her proposal, which would need approval from the legislature and voters, was unlikely to influence that current litigation but would affect future cases.
“A judiciary accountable to the people would provide a fairer venue for addressing legal challenges to pro-life laws,” she said.
Nonpartisan judicial elections can buck broader electoral trends. In Michigan, for example, voters elected both Supreme Court candidates nominated by Democrats last year even as Donald Trump won the state and Republicans regained control of the state House.
In Kentucky’s nonpartisan race, Judge Pamela Goodwine, who was endorsed by Democratic Gov. Andy Beshear, outperformed her opponent even in counties that went for Trump, who won the state. She’ll be serving on the bench as a woman’s challenge to the state’s two abortion bans makes its way through state courts.
Partisan judicial elections, however, tend to track with other partisan election results, according to Keith of the Brennan Center. So some state legislatures have sought to turn nonpartisan state supreme court elections into fully partisan affairs.
In Ohio, Republicans have won every state Supreme Court seat since lawmakers passed a bill in 2021 requiring party affiliation to appear on the ballot for those races. That includes three seats up for grabs in November that solidified the Republican majority on the court from 4-3 to 6-1.
“These justices who got elected in 2024 have been pretty open about being anti-abortion,” said Jessie Hill, an attorney with the American Civil Liberties Union of Ohio, who has been litigating a challenge to Ohio’s abortion restrictions since voters added protections to the state constitution in 2023.
Until the recent ballot measure vote in Montana, the only obstacle blocking Republican-passed abortion restrictions from taking effect had been a 25-year-old decision that determined Montana’s right to privacy extends to abortion.
Nelson, the former justice who was the lead author of the decision, said the court has since gradually leaned more conservative. He noted the state’s other incoming justice, Katherine Bidegaray, was backed by abortion rights advocates.
“The dynamic of the court is going to change,” Nelson said after the election. “But the chief justice has one vote, just like everybody else.”
Swanson, Montana’s new chief justice, had said throughout his campaign that he’ll make decisions case by case. He also rebuked his opponent, Jerry Lynch, for saying he’d respect the court’s ruling that protected abortion. Swanson called such statements a signal to liberal groups.
At least eight cases are pending in Montana courts challenging state laws to restrict abortion access. Martha Fuller, president and CEO of Planned Parenthood Advocates of Montana, said that the new constitutional language, which takes effect in July, could further strengthen those cases but that the court’s election outcome leaves room for uncertainty.
The state’s two outgoing justices had past ties to the Democratic Party. Fuller said they also consistently supported abortion as a right to privacy. “One of those folks is replaced by somebody who we don’t know will uphold that,” she said. “There will be this period where we’re trying to see where the different justices fall on these issues.”
Those cases likely won’t end the abortion debate in Montana.
As of the legislative session’s start in early January, Republican lawmakers, who have for years called the state Supreme Court liberal, had already proposed eight bills regarding abortion and dozens of others aimed at reshaping judicial power. Among them is a bill to make judicial elections partisan.
Montana Sen. Daniel Emrich, a Republican who requested a bill titled “Prohibit dismembering of person and provide definition of human,” said it’s too early to know which restrictions anti-abortion lawmakers will push hardest.
Ultimately, he said, any new proposed restrictions and the implications of the constitutional amendment will likely land in front of the state Supreme Court.
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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Beyond Hard Hats: Mental Struggles Become the Deadliest Construction Industry Danger
If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”
BIRMINGHAM, Ala. — Frank Wampol had a dark realization when he came across some alarming data a few years ago: Over 5,000 male construction workers die from suicide annually — five times the number who die from work-related injuries, according to several studies. That’s considerably more than the suicide rate for men in the general population.
“To say this is a crisis would be an understatement,” said Wampol, vice president of safety and health at BL Harbert International, a construction company based in Birmingham with over 10,000 employees.
Since then, the company has added mental health first-aid training for on-site supervisors and distributed information about suicide prevention to laborers in the field. The efforts are part of a larger push led by the industry and supported by unions, research institutions, and federal agencies to address construction workers’ mental health.
But initiatives to combat this mental health crisis are tougher to implement than protocols for hard hats, safety vests, and protective goggles. And some of the potential solutions, such as paid sick leave, have drawn pushback from the industry as it eyes costs.
Safety experts have long been concerned about the physical hazards of construction work. The “Fatal Four” hazards are falls, electrocutions, being struck by an object like a brick or a crane boom, and getting caught between two objects, according to the Occupational Safety and Health Administration.
Only in recent years have the psychosocial hazards of construction work moved onto the public radar. Studies paint a grim picture, said Douglas Trout, an occupational medicine physician and deputy director of the Office of Construction Safety and Health at the National Institute for Occupational Safety and Health.
In addition to high suicide rates, drug use is rampant, especially opioids such as heroin and fentanyl. A recent study from the Centers for Disease Control and Prevention found that construction ranks highest in overdose deaths by occupation.
“Rates of suicides and overdose deaths are some of the worst outcomes related to mental health conditions,” Trout said. “And unfortunately, these are the more measurable ones.”
Less measurable but also prevalent among construction workers are anxiety and depression, which often remain undiagnosed. Almost half of construction workers have experienced symptoms of both, a rate higher than that of the general U.S. population, according to a preliminary 2024 study by the Center for Construction Research and Training, an arm of North America’s Building Trades Unions. But fewer than 5% of construction workers reported seeing a mental health professional, compared with 22% of all U.S. adults, according federal statistics.
The combination of high-hazard environments and organizational factors puts construction workers at particular risk for mental health issues, Trout said. Construction is a high-stress occupation involving long hours, extended separation from family and friends, and low job security due to the industry’s cyclical nature.
Even though health insurance and workers’ compensation are offered by some contractors, paid sick leave for laborers, craft workers, and mechanics is not standard. While 18 states and Washington, D.C., have approved laws requiring paid sick leave and federal contractors have to offer it, the mandates don’t apply to many construction workers. And industry advocates are pushing back against such legal requirements, claiming they don’t fit the transient and seasonal nature of construction work.
If workers get injured, they often “try to tough it out and get back to the job as quickly as possible,” said Nazia Shah, director of safety and health services at the Associated General Contractors of America, the country’s largest construction trade association.
To manage pain from injuries, workers often resort to prescription opioids. Some then develop a dependency and turn to street drugs. “It’s a vicious cycle,” Shah said.
If a worker is fatigued, distracted by pain or personal issues, or impaired by some type of substance, the results can be catastrophic, said Wampol, a 20-year industry veteran who went into construction after retiring from a career as a firefighter and paramedic.
The biggest step, Shah said, is “breaking the stigma and normalizing conversations around mental health.”
The hurdles are particularly high in this male-dominated field, where harassment and bullying are common and speaking up about emotional hardships is often considered a sign of weakness, Shah said.
Several organizations, including the Associated Builders and Contractors, have created short “toolbox talks” to review the signs and symptoms of mental health issues, the risks of self-medicating with drugs and alcohol, and the resources available through health insurance and employee assistance programs.
Some, such as the AGC’s Missouri Chapter, hand out hard-hat stickers, cards, and “hope coins” — small tokens that symbolize support. They all serve as conversation starters and include information on the 988 Suicide & Crisis Lifeline in English and Spanish.
Many contractors hold regular stand-downs, with supervisors halting work at a construction site to provide on-the-spot training related to a specific mental health issue. Others, such as BL Harbert, offer health education fairs and team with local health clinics for lunch-and-learn events.
But Stanley Wheat, an on-site safety manager at BL Harbert, said that even the best policies, procedures, and training materials won’t stick without making an effort on the ground. “A PowerPoint presentation alone won’t cut it. You’ve got to know your people, and you’ve got to engage them.”
Wheat, a military veteran who has worked in construction for over two decades, said it’s important to make rounds several times a day at a job site — getting to know the workers and observing changes in their behaviors.
“You start noticing the guy who’s isolating himself, sitting alone at lunch, not talking with anybody,” he said.
Wheat can relate. His uncle died by suicide, but his family would never talk about it. During his time in the military, Wheat said, he went to rehab for drug and alcohol addiction. He dropped out of college to work in construction.
“I’ve been there,” he said. “I skinned my knuckles. I pulled my back. I worked injured.”
Wheat tries to strike up conversations with workers who he thinks are having a rough time. He listens, sometimes shares his personal story, and suggests resources for help.
Peer-to-peer support is among the more promising concepts in the effort to curb the mental health crisis in construction. Workers often don’t want to talk with management or outsiders, Trout said, “but they usually trust each other.”
One successful model is Mates, a program for mental health and suicide prevention that originated in Australia in 2008. The idea is to train on-site personnel — workers, foremen, superintendents — to spot and support co-workers in crisis, offer a confidential space to talk, and guide them to help if needed. The volunteers, called “connectors,” are typically identified by green hard hat stickers. Efforts are underway to bring a formalized Mates program to the U.S., Trout said.
Other, often small and local initiatives are being implemented, too. Some contractors have hired full-time wellness coordinators or bring mental health care providers to construction sites so employees can start appointments immediately. A few companies have put dedicated trailers on their job sites that serve as quiet rooms, with lounge chairs, board games, and video consoles, so workers can take a moment to decompress.
Many contractors also have added naloxone — an emergency medication used to reverse opioid overdoses, often known by the brand Narcan — to on-site medical kits.
Going forward, as President-elect Donald Trump takes office next week, the industry faces major uncertainties, including possible ripple effects from tariffs, mass deportations, tax cuts, and deregulation.
No matter what comes, Wampol said, the construction industry needs to understand that the investment in mental wellness and suicide prevention programs creates “a healthier, more productive workforce” — and, ultimately, a better bottom line.
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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Cinco cambios críticos que puede sufrir Medicaid bajo Trump
Durante la presidencia de Joe Biden, la inscripción en Medicaid alcanzó un nivel récord y la tasa de personas sin seguro médico llegó a su nivel histórico más bajo.
Pero se espera que el regreso de Donald Trump a la Casa Blanca, junto con un Senado y una Cámara de Representantes controlados por republicanos, cambie esta situación.
Los republicanos en Washington afirman que planean utilizar recortes de financiamiento y cambios regulatorios para reducir drásticamente Medicaid, el programa de salud federal gerenciado por los estados que cuesta casi $900.000 millones al año y que, junto con el Programa de Seguro Médico Infantil (CHIP), ofrece atención a unos 79 millones de estadounidenses, en su mayoría de bajos ingresos o con discapacidades.
Las propuestas incluyen revertir la expansión de Medicaid impulsada por la Ley de Cuidado de Salud a Bajo Precio (ACA), que en los últimos 11 años sumó cerca de 20 millones de adultos de bajos ingresos al programa.
Trump ha dicho que quiere recortar drásticamente el gasto del gobierno, lo que podría ser necesario para que los republicanos extiendan los recortes de impuestos de 2017 que vencen a finales de este año.
Trump no habló demasiado sobre Medicaid durante su campaña de 2024. Su primera administración aprobó requisitos de trabajo en varios estados, aunque solo Arkansas los implementó antes de que un juez federal determinara que violaban los principios de ACA. También intentó otorgar financiamiento en bloque a los estados.
El presidente del Comité de Presupuesto de la Cámara, Jodey Arrington (republicano de Texas), dijo a KFF Health News que Medicaid y otros programas federales de beneficencia necesitan cambios importantes para ayudar a reducir la deuda federal. “Sin esos cambios, veremos con pesar cómo este país sufre un colapso fiscal”.
El representante Chip Roy (republicano de Texas), miembro del Comité de Presupuesto, indicó que el Congreso necesita explorar recortes al gasto federal en Medicaid.
“Es necesaria una reforma integral en el sector de salud, que podría incluir deshacer gran parte del daño causado por ACA y Obamacare”, dijo Roy. “Francamente, podríamos terminar proporcionando un mejor servicio si lo hacemos de la manera correcta”.
Defensores de las personas de bajos ingresos temen que los recortes que buscan los republicanos dejen a más estadounidenses sin seguro, dificultándoles el acceso a la atención médica.
“Medicaid es un objetivo obvio para recortes enormes”, dijo Joan Alker, directora ejecutiva del Centro para Niños y Familias de la Universidad Georgetown. “Probablemente se avecina una lucha existencial sobre el futuro de Medicaid”.
El programa, que cumplirá 60 años en julio, está llegando al final de una gran crisis, después que las protecciones de cobertura implementadas durante la pandemia de covid-19 expiraran en 2023, y todos los inscriptos tuvieran que demostrar que seguían siendo elegibles.
Más de 25 millones de personas perdieron su cobertura durante los 18 meses posteriores al inicio del proceso de “desafiliación”, aunque no ha aumentado notablemente el número de personas sin seguro, según los datos más recientes del censo.
Pero este número podría ser insignificante comparado con lo que ocurra en los próximos cuatro años, dijo Matt Salo, ex director ejecutivo y fundador de la Asociación Nacional de Directores de Medicaid. “Lo que vamos a ver es un cambio dramático aún mayor en quiénes estarán cubiertos por Medicaid y cómo operará el programa”, aseguró.
Sin embargo, Salo señaló que cualquier esfuerzo por reducir el programa enfrentará resistencia.
“Muchas entidades poderosas —gobiernos estatales, organizaciones de atención administrada, proveedores de atención de largo plazo y todos aquellos interesados en que Medicaid funcione de manera eficiente— estarán altamente motivadas para resistirse a recortes que consideren draconianos, ya que podrían afectar sus modelos de negocio”, afirmó.
Algunas de las estrategias del partido republicano para reducir el tamaño de Medicaid son:
- Cambio a financiamiento en bloque. Actualmente, el gobierno federal iguala un porcentaje del gasto estatal anual en Medicaid, sin un límite específico. Los republicanos quieren cambiar a pagos fijos anuales, lo que impactaría en la cantidad de dinero federal que algunos estados reciben. Desde Ronald Reagan, los presidentes republicanos han intentado sin éxito imponer una suma fija de financiación para Medicaid.
- Recortes a la financiación de ACA para Medicaid. ACA financió la cobertura para estadounidenses con ingresos de hasta el 138% del nivel federal de pobreza ($20.783 de ingresos anuales para un individuo en 2024). Los republicanos podrían intentar reducir ese financiamiento al mismo porcentaje que el gobierno federal paga por el resto de los inscritos en el programa, que promedia un 60%. “Debemos tener en cuenta que estamos subsidiando a la población sana y apta para trabajar que se beneficia de la expansión de Medicaid a un ritmo mayor que el que subsidiamos a los más pobres y enfermos, que era la intención original del programa”, dijo Arrington. “Eso no está bien”.
- Reducción de fondos federales. Desde su inicio, la tasa de contribución federal varía según la riqueza relativa de la población del estado. Los estados más pobres reciben una tasa más alta y ningún estado recibe menos del 50% en contrapartida. Los republicanos podrían buscar reducir la tasa base del 50% a menos del 40%.
- Agregar requisitos de trabajo. Aunque los tribunales federales han dictaminado que no se puede condicionar la cobertura a trabajar o a estar buscando trabajo, el Partido Republicano podría intentarlo nuevamente. “Si podemos lograr que los adultos sanos tengan requisitos de trabajo estrictos, eso puede suponer un enorme ahorro de costos”, dijo el representante Tom McClintock (republicano de California) a KFF Health News. Como la mayoría de los inscriptos en Medicaid ya trabajan, van a la escuela o son cuidadores, los críticos dicen que un requisito de ese tipo simplemente agregaría burocracia a la obtención de cobertura, con poco impacto en el empleo.
- Imponer barreras a la inscripción. Unos 10 estados ofrecen a algunas poblaciones lo que se denomina elegibilidad continua, mediante la cual las personas permanecen inscriptas durante años sin tener que renovar su cobertura. Se ha demostrado que esa política evita que los beneficiarios abandonen el programa durante períodos cortos por dificultades o problemas con el papeleo, lo que puede generar facturas médicas inesperadas y deuda. La administración Trump podría intentar derogar las exenciones que permiten a los estados otorgar elegibilidad continua, lo que obligaría a las personas en esos estados a tener que volver a solicitar cobertura cada año.
Si los planes de los republicanos para reducir Medicaid se concretan, expertos dicen que las personas de bajos ingresos que se vean obligadas a comprar seguros privados enfrentarán dificultades para pagar las primas y copagos comunes en estos planes comerciales, que no suelen existir en Medicaid.
El Paragon Health Institute, un centro de estudios conservador dirigido por Brian Blasé, ex asesor de Trump, ha publicado informes que dicen que los miles de millones de dólares adicionales que los estados recibieron para ampliar Medicaid bajo ACA han sido una bendición para las aseguradoras privadas que administran el programa y para las personas relativamente más ricas que, según la organización, no deberían estar inscriptas.
Josh Archambault, miembro senior del conservador Cicero Institute, dijo que espera que la administración Trump haga responsables a los estados por pagar miles de millones de más a los proveedores, y por inscribir en Medicaid a personas que no son elegibles.
Archambault agregó que el Partido Republicano buscará reducir Medicaid a sus poblaciones “tradicionales”: niños, embarazadas y personas con discapacidades.
“Necesitamos reequilibrar el programa que la mayoría de la gente piensa que tiene un bajo rendimiento”, apuntó. La mayoría de los estadounidenses, incluidas grandes mayorías tanto de republicanos como de demócratas, ven el programa de manera favorable, según encuestas.
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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