Batalla para proteger a los pacientes de deudas médicas se traslada a los estados

Con la administración Trump cortando las medidas federales para proteger a los estadounidenses de facturas médicas impagables, defensores de pacientes y consumidores centran ahora sus esfuerzos en las legislaturas estatales para contener el problema de la deuda médica en el país.

A pesar de algunos avances este año, especialmente en estados con mayoría demócrata, los recientes reveses en las legislaturas más conservadoras dejan claro lo difícil que es proteger a los pacientes.

Este año fracasaron proyectos de ley para proteger a los consumidores de deudas médicas en Indiana, Montana, Nevada, Dakota del Sur y Wyoming, debido a la oposición de la industria. Y defensores advierten que los estados deben actuar, ya que se espera que millones de personas pierdan su seguro médico debido a la ley fiscal y de gasto del presidente Donald Trump.

“Este ya era un tema clave incluso antes del cambio de administración en Washington”, dijo Kate Ende, directora de políticas de la organización Consumers for Affordable Health Care, con sede en Maine. “La retirada a nivel federal hizo aún más urgente movilizarse”.

Este año, Maine se unió a una creciente lista de estados que han prohibido que la deuda médica aparezca en los reportes de crédito de sus residentes, una protección que puede facilitar el acceso a una vivienda, un auto o incluso un empleo. La medida fue aprobada por unanimidad y con apoyo bipartidista.

Se estima que 100 millones de personas en Estados Unidos tienen algún tipo de deuda relacionada con la atención médica.

El gobierno federal estaba a punto de prohibir que la deuda médica apareciera en los reportes de crédito, gracias a una normativa emitida en los últimos días del mandato del ex presidente Joe Biden. Esa medida habría beneficiado a unas 15 millones de personas en todo el país.

Pero la administración Trump no defendió la normativa ante las demandas legales de agencias de cobro y burós de crédito, que argumentaban que la Oficina para la Protección Financiera del Consumidor (CFPB, en inglés) se había excedido en su autoridad.

Un juez federal de Texas, designado por Trump, falló que la normativa debía anularse.

Ahora, solo los pacientes que viven en estados que han aprobado sus propias normas sobre reportes de crédito podrán beneficiarse de esta protección. Más de una docena de estados tienen estas restricciones, entre ellos California, Colorado, Connecticut, Minnesota, Nueva York y Vermont, que al igual que Maine, adoptaron una prohibición este año.

En los últimos años, más estados han aprobado otras protecciones contra la deuda médica, como límites a la tasa de interés que se puede cobrar y restricciones al uso del embargo de salarios o la incautación de bienes para cobrar facturas médicas impagas.

En muchos casos, estas medidas han recibido apoyo bipartidista, lo que refleja la popularidad de las protecciones al consumidor. En Virginia, el gobernador republicano firmó una ley este año que limita el embargo de salarios y establece un tope a los intereses.

Y varios legisladores republicanos en California se unieron a los demócratas para respaldar una medida que facilita el acceso a ayuda financiera de los hospitales para quienes enfrentan facturas elevadas.

“Este es el tipo de asunto de sentido común que afecta al bolsillo de las personas y que atrae tanto a republicanos como a demócratas”, señaló Eva Stahl, vicepresidenta de Undue Medical Debt, una organización sin fines de lucro que compra y perdona deudas médicas, y que ha trabajado para que se amplíen protecciones para pacientes.

Pero en varias legislaturas estatales, el impulso por nuevas protecciones se topó con barreras.

Proyectos de ley para prohibir que las deudas médicas aparecieran en los reportes de crédito fracasaron en Wyoming y Dakota del Sur, a pesar del apoyo de algunos legisladores republicanos. Y las medidas para limitar los cobros agresivos contra residentes con deuda médica fueron rechazadas en Indiana, Montana y Nevada.

En algunos estados, las propuestas enfrentaron una fuerte oposición de agencias de cobro, burós de crédito y bancos, que argumentaron ante los legisladores que sin información sobre deudas médicas podrían terminar otorgando a los consumidores préstamos de alto riesgo.

La representante estatal Lana Greenfield (republicana de Dakota del Sur), repitió las objeciones de la industria al pedir a sus colegas que votaran en contra de la prohibición. “Los bancos pequeños de comunidades pequeñas no podrían obtener información sobre una factura médica muy, muy grande. Y entonces, podrían otorgar un préstamo de buena fe a alguien sin saber realmente cuál era su crédito”, dijo Greenfield en el pleno de la Cámara.

Durante el gobierno de Biden, los investigadores de la CFPB encontraron que, a diferencia de otros tipos de deuda, la médica no era un buen indicador de la solvencia crediticia.

Pero el representante estatal Brian Mulder (republicano de Dakota del Sur), presidente del comité de salud que redactó la legislación, destacó el poder del sector bancario en el estado, donde regulaciones favorables lo han convertido en un imán para las instituciones financieras.

En Montana, una propuesta para proteger parte de los bienes de los deudores frente al embargo avanzó fácilmente en el comité. Sus defensores esperaban que fuera especialmente útil para pacientes nativos americanos, quienes enfrentan de forma desproporcionada la carga de la deuda médica.

Pero cuando el proyecto de ley llegó al pleno de la Cámara, los opositores “aparecieron en masa” y hablaron personalmente con los legisladores republicanos una hora antes de la votación, contó Ed Stafman, legislador demócrata y autor de la propuesta.

“Juntaron el número de votos suficientes para derrotar el proyecto por poco”, dijo.

Tanto defensores de los pacientes como legisladores que respaldaron estas medidas dijeron que son optimistas respecto a superar la oposición de la industria en el futuro.

Y hay señales de que algunas propuestas para ampliar las protecciones a los pacientes podrían avanzar en otros estados conservadores, como Ohio y Texas.

En Texas, una propuesta que obligaría a los hospitales sin fines de lucro a ampliar la ayuda financiera para quienes enfrentan facturas altas ha recibido el respaldo de organizaciones conservadoras influyentes.

“Estas cosas a veces toman tiempo”, dijo Lucy Culp, quien lidera el cabildeo estatal de Blood Cancer United (anteriormente conocida como Leukemia & Lymphoma Society). Esta organización ha impulsado leyes estatales de protección contra la deuda médica en años recientes, incluso en Montana y Dakota del Sur.

Lo más preocupante, dijo Culp, es la ola de pacientes sin seguro que se espera debido a los recortes en la cobertura médica derivados de la nueva ley fiscal aprobada por los republicanos. Esto agravará aún más el problema de la deuda médica en el país.

“Los estados no están preparados para eso”, advirtió Culp.

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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Readers Speak Up for Patients Who Can’t, and for Kids With Disabilities

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

A reporter at Just the News shared our article about a man whose organs were nearly harvested while he was still alive:

Disinformed consent is standard operating procedure in the organ donation industry. And much of medicine. "The sisters said hospital staffers told them the movements were involuntary."https://t.co/tDSp4oCNgL

— Greg Piper (@gregpiper) September 13, 2025

— Greg Piper, Washington, D.C.

Too Close a Call With Organ Donation

When I was a third-year med student doing a rotation on the trauma surgery team, we had a patient in the surgical intensive care unit who had arrived 12 hours earlier with bullet holes in his abdomen. We worked to stabilize him all night; the next day, he was still alive. 

The team determined, however, that although his body was alive, he was likely brain-dead and a candidate for organ donations (“A Surgical Team Was About To Harvest This Man’s Organs — Until His Doctor Intervened,” Sept. 12). 

As we prepared for him to become a donor, I noticed he had a bit of movement. Of course, I was the unknowing third-year med student, so my comments were essentially deemed a nuisance, at best, to the team. (I was, by the way, already a globally recognized researcher in a field distant from trauma surgery.)

Nevertheless, after checking on the patient, I told one of the surgeons, “I think he was trying to communicate with us.”

I was told it was just spinal reflex and I didn’t know what I was looking at.

I couldn’t shake the feeling. I was deeply concerned that I knew what I saw, and it seemed like communication. After our rounds, I went back up to the patient’s bedside, stood over him, and simply said, “Are you able to hear me?”

With a tube in his trachea, stopping any air from entering or exiting (required to make sounds with the vocal cords), he attempted to communicate something in response. The poor guy had an endotracheal tube and was on a ventilator, but because he was given a diagnosis of being brain-dead, he was not being provided with appropriate pain meds and was in and out of consciousness — as best as I could tell. 

I asked him again if he could hear me, and again he tried to communicate with the tube in his throat. It was clear he was absolutely not brain-dead.

I ran and got the team. They evaluated him again — after having already spoken in front of both him and his family about harvesting his organs. This time, the surgeon made a more thorough evaluation. It turned out that he was awake and aware. As they looked him over, they realized he didn’t have bullet holes only in his abdomen; he had a bullet hole through the back of his skull, the bullet still lodged in his brain. During the exam, someone had lifted his head to discover a small, round pool of blood underneath. The bullet in his head went entirely unnoticed in the chaos of trying to stabilize his much more severe hemorrhages.

A CT scan showed the bullet clearly, lodged in the middle of his brain. The neurosurgery team did a procedure to reduce the swelling and pressure in his skull, and he sprang back to life.

The young man, surely a victim of gang violence in South Atlanta, began to interact almost normally with his family over the coming days. For his family, it was almost a rebirth of their child. He had heard the entire conversation about harvesting his organs but could do essentially nothing. It turned out his brain death was documented when he was still under anesthesia, masking his conscience and alertness that would eventually return.

Unfortunately, after an elated two or three days, the man ultimately succumbed to his brain injury.

Still, I will never, ever forget how terrible that experience must have been for him, and, honestly, I don’t know what would have happened if some “naive” third-year med student hadn’t pushed to get the considerably busier surgery team to fully recognize what was happening with their patient.

I deeply appreciate your writing, and I hope it is raising significant awareness.

And I say this as someone with an immediate family member on multiple transplant lists: While I want desperately for lists to move faster, it should never happen at the expense of providing the complete and full dignity that every life deserves. 

— Michael J. Mina, Boston

A radiologist in Denver also posted his thoughts about the article on the social platform X:

This is very rare in the world of transplant surgery. But it should be "never", rather than "rare".https://t.co/yJ3BZkLXND

— Paul Hsieh (@PaulHsieh) September 14, 2025

— Paul Hsieh, Denver

Speaking for Kids With Disabilities

I read the article “Parents Fear Losing Disability Protections as Trump Slashes Civil Rights Office” (Sept. 15) with a renewed sense of purpose. Efforts to dismantle the U.S. Department of Education may be imprudent at best, with little or no consideration for the potential that lies within all of us. I know, because I became a recipient of its special education services after flipping over on my three-wheel motorcycle and landing on my head with the bike over me. I was barely 18 years old and not wearing a helmet. I was in a coma for a week and remained in an acute care hospital for a month. I sustained a severe traumatic brain injury — or, to be more precise, a severe cerebral contusion.

I wish the architects of this federal dismantling could know that I received rehabilitation therapy for over a year and received services through a special education program for more than six years before I graduated with a four-year bachelor’s degree from San Diego State University. I continued on to graduate school and earned two master’s degrees from the University of Southern California.

I established a 30-year career — starting as a lobbyist for the National Association of Social Workers in Washington, D.C., before returning to my home state to finish my career as a research scientist for the California Department of Public Health’s Maternal and Child Health Division. I worked there for 16 years before my retirement in 2020.

We — as children with disabilities — have much to offer to society that cannot be foreseen when we are young. I am the product of dedicated care by my therapists and teachers. This is what I believe the current president and elected officials across the country need to understand. We can be productive citizens when given the chance to thrive.

— Brason Lee, Sacramento, California

A Democratic member of Congress weighs in on X:

Disabled kids are facing great challenges in their schools, and the dismantling of the Department of Education will only worsen these struggles. It is vital we support our students of all backgrounds.https://t.co/pN1cAnRXOd

— Grace Meng (@Grace4NY) September 17, 2025

— Grace Meng, Queens borough of New York City

A Hole in ‘Big Loopholes’?

The article “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab” (Sept. 25) by Michelle Andrews had one glaring omission: The hospitals are supported by government funding for charity care, but private practice providers — such as the specialists in emergency medicine, anesthesiology, and radiology who were mentioned — are not. Do you expect those providers to work for free? I think, to be fair to doctors, there should have been a mention of that in the article.

— Roger Broome, Galena, Ohio

A science writer in New York shared her thoughts on X about our coverage of Trump administration policies:

These clinics were already stretched thin before the new guidance. That seems unlikely to change given the major staffing cuts at HRSA, which directs funding to community clinics and other HHS programs. H/t @sjtribble and @HMLLarweh at @KFFHealthNews https://t.co/ngit8sP9X8

— lauren schneider (@laur_insider) August 8, 2025

— Lauren Schneider, New York City

When HRSA Hurts, Nursing Suffers

The Health Resources and Services Administration, or HRSA, is vitally important to building and maintaining the strength of the pipeline of new nurses and other clinicians entering our health care workforce. With a growing health care shortage across the country, it’s incredibly important that HRSA be maintained and strengthened to meet the growing and more complicated health care challenges of tomorrow (“Deep Staff Cuts at a Little-Known Federal Agency Pose Trouble for Droves of Local Health Programs,” Aug. 1).

One of HRSA’s most important responsibilities is managing Nursing Workforce Development Programs under Title VIII of the Public Health Service Act. These grants help fund everything from education to practice, recruitment, and retention, particularly in rural and underserved communities. As both a nurse and nurse educator myself, I’ve seen how, for decades, Title VIII programs have strengthened the pipeline by covering scholarships and education to support registered nurses, advanced practice nurses, and nurse educators.

As the U.S. population rapidly ages and develops increasingly complex health care needs, we must ensure we have a robust workforce equipped to provide high-quality care in every community. Unfortunately, the Bureau of Labor Statistics projects an average shortfall of roughly 190,000 registered nurses each year from 2024 to 2034. Complicating this issue, faculty shortages, limited clinical sites, and capacity constraints forced nursing schools to turn away over 80,000 qualified applications last year alone.

Our country must do more to graduate enough students to close these gaps. Maintaining funding and staffing for HRSA is essential to sustain a robust health care workforce and ensure patients’ access to care nationwide.

Policymakers must protect and fully appropriate HRSA in the 2026 budget and beyond. There are countless passionate, smart, and dedicated learners out there ready to step into the roles of nurse and nurse educator. We must protect HRSA to open pathways for them to get there.

— Patty Knecht, chief nursing officer of Ascend Learning/ATI Nursing Education, Downingtown, Pennsylvania

A health economist and health policy expert at the Altarum Institute expresses his opinion succinctly on social media:

Make America Ill Againhttps://t.co/DPFJtfB0fl

— Paul Hughes-Cromwick (Pooge) (@cromwick) August 1, 2025

— Paul Hughes-Cromwick, Ann Arbor, Michigan

Keeping PACE With Vulnerable Seniors

Elder homelessness is one of the clearest symptoms of our broken senior care system, as highlighted in the recent article “Health Care Groups Aim To Counter Growing ‘National Scandal’ of Elder Homelessness” (Aug. 18). Today, too many seniors are walking a tightrope, threatened to be tipped off balance when financial or medical issues arise.

This risk of homelessness is especially prevalent in rural communities, where older adults often have lower incomes, higher poverty rates, and greater prevalence of chronic illness. And while homelessness nationwide rose by less than 1% from 2020 to 2022, rural areas saw nearly a 6% increase — clear evidence that rural community members are being left behind by our current system.

Thankfully, the Program of All-Inclusive Care for the Elderly, or PACE, is uniquely equipped to address these challenges. Often, rural PACE programs like ours encounter participants struggling to get through the winter without heat, living in homes with leaky roofs, or lacking safe wheelchair access. In these scenarios, we can authorize heating installation, arrange urgent repairs, or build ramps that make it possible for our participants to remain safely at home.

These are just a few of the many examples that demonstrate how far PACE providers can, and do, go to ensure our participants can stay in their homes. And, by addressing these issues early, the program is saving Medicaid dollars.

To reduce housing instability among older adults, policymakers at both the state and federal levels should expand eligibility and ensure that PACE providers have the flexibility to act quickly when warning signs appear. By investing in PACE, we can reduce homelessness and build a stronger model for community-based care in America.

— Craig Worland, interim CEO and COO of One Senior Care, Erie, Pennsylvania

Saw mention of an idea on Facebook a couple of days ago and then read your PACE article about senior housing and felt compelled to share. Please pass along to your PACE colleagues and anyone else who can help make this possible. The idea was/is to convert the many closed malls, shopping centers, and big-box stores across the U.S. into affordable housing. Rather than leave them as empty eyesores, decaying and becoming havens for vermin and worse, rather than trying to find and fund land purchases and building from scratch, just think how many thousands of people could be housed! Some spaces could be reserved for essential services — groceries, drugstores, coffee shops, restaurants, salon/barber shops, laundry/dry cleaners, etc. Recreate nature with a walking path complete with live trees and plants, and paint the ceiling like the Wienermobile, where “the sky is always blue!” The possibilities are endless. Go for it! Thanks for the opportunity to share. I’ll be out here advocating and watching for this to blossom!

— Brenda Peters, Charlotte, North Carolina

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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Health Care’s Employment Growth Clouded by Immigration Crackdown, Medicaid Cuts

The health care sector is a bright spot in the economy this year, driving nearly half of the nation’s employment gains, but economists and experts say immigration crackdowns and looming Medicaid cuts pose a threat to future job growth.

Employers added 487,000 jobs from January to August, according to the latest nonfarm payroll data from the Bureau of Labor Statistics. The health care sector accounted for 48% of that lackluster growth, expanding by about 232,000 jobs, even though the sector employs only about 11% of workers.

“On the labor side, health care growth is driving the economy,” said Stanford economics professor Neale Mahoney.

Economists say President Donald Trump’s immigration crackdown and cuts to public insurance programs threaten to dampen that growth. They could add unease about the economy and cause headwinds for the GOP in next year’s midterm elections. The health care sector is unusually dependent on foreign-born workers, while a new law trimming federal spending on the $900-billion-a-year Medicaid program is projected, based on a preliminary version of the bill, to trigger the loss of 1.2 million jobs nationwide, according to the Commonwealth Fund.

In recent years, health care job growth has been most pronounced in the home health sector, rising by nearly 300,000 jobs to 1.82 million workers from August 2019 to August 2025, as millions of older residents hire workers to visit and take care of them, Mahoney said. Job growth has also been strong at hospitals and doctors’ offices. Nursing homes and residential care homes posted weaker numbers from 2019 to 2025 amid an increase in the number of people using caregiving at home.

Some research indicates that health care job growth is not always good for the economy. For instance, a growing number of administrators in health care may raise health care costs without providing much benefit to patients. Yet, health care jobs are considered stable and often recession-proof, and the health care industry is now the top employer in most states. Even with job growth in the sector, many places remain desperate for health care workers to meet rising demand.

But several economists said recent federal policy changes on immigration and Medicaid might drag down job growth.

If immigration crackdowns by the Trump administration continue, it could get tough for health care organizations to find enough people to hire. “Health care as an industry is pretty reliant on immigrant labor,” said Allison Shrivastava, an economist with the Indeed Hiring Lab. “It has a large share of non-native labor force, so it's going to be impacted more.”

About 18% of Americans employed in health care were born abroad, according to 2023 Census Bureau data. And about 5% of health care workers were not citizens, including about 60,000 doctors and surgeons, 117,000 registered nurses, and 155,000 home health or personal care aides, census data shows.

Many of those workers are here legally; the Census Bureau does not track how many noncitizens are living in the U.S. with authorization. But even those with legal status, including permanent residents, may be vulnerable to deportation. The federal government deported about 200,000 people from February through August, a significant increase from prior months, according to data obtained by The Guardian.

At the same time, some health care workers may choose not to study in or move to America if they perceive it as hostile to immigrants. The number of immigrant visas issued by the United States from March to May fell by about 23,000, or 14%, from the same period last year, State Department data shows. In addition, reported unauthorized border crossing attempts have plummeted.

Shrivastava said Indeed’s job posting data shows continued strong demand for doctors among employers willing to help with the visa sponsorship process. But it’s not clear if people will take them up on the offers.

Meanwhile, Congress this summer passed what Republicans called the “One Big Beautiful Bill Act,” which was quickly signed by Trump. That bill makes about $910 billion in cuts to federal Medicaid spending over 10 years, according to a KFF analysis of data from the Congressional Budget Office.

Medicaid reductions are projected to cause millions to be without health insurance in the coming years. Hospitals, nursing homes, and community health centers will have to absorb more of the cost of treating uninsured people by reducing services and employees, or else close altogether.

The cuts could have a significant impact on the job market. California alone could see up to 217,000 fewer jobs, of which two-thirds would be in the health care sector, according to an analysis by the University of California-Berkeley Labor Center conducted before the bill was finalized and signed.

“It doesn't mean necessarily that 200,000 people are going to lose their job,” said Miranda Dietz, interim director of the Health Care Program at the Labor Center. “Some people will lose their job, and in some cases, the job growth won't be as fast as anticipated.”

Complicating the picture is Trump’s recent firing of the official who headed the Labor Department’s statistical branch, leading to concerns that jobs data will not be free from political influence.

It’s not clear when — or if — immigration actions and Medicaid cuts will affect hiring in the health care sector, but there are signs of potential softening. Federal data showed a significant decline in job openings in the health care and social assistance sector in July. Indeed’s job posting data also shows a decline in some health care fields, but Laura Ullrich, director of economic research in North America at the Indeed Hiring Lab, noted that, overall, postings remain above prepandemic levels.

For now, job growth is expected to remain high, particularly among nurse practitioners, physician assistants, and home health aides, according to BLS projections.

Many health care jobs require years of higher education but result in high pay, with family physicians typically making more than $240,000 a year and registered nurses typically taking in about $94,000 a year.

Joshua Lejano, president of the Sacramento State chapter of the California Nursing Students’ Association, said he is “cautiously optimistic” that he will quickly land a job as a registered nurse when he graduates in December. He said he is completing nursing clinical rotations that give him real-world experience that will condition him for long shifts.

Lejano said hospitals in his area are expanding capacity while some veteran nurses are leaving the profession due to burnout from the covid pandemic, creating openings. “Right now, I think the big thing is just staying on top of all the application cycles,” he said.

Health care jobs that don’t require as much training tend to pay much less. Median annual earnings for the U.S.’ roughly 4.4 million home health and personal care aides were about $35,000 last year, roughly equivalent to pay for waiters and waitresses, federal data shows.

The growth in health care jobs has been especially beneficial for women, Ullrich said. Nearly 80% of health care and social assistance workers are female, according to a recent Indeed study. The research found that female workers accounted for more than a million new health care jobs in the last two years.

The sector is resilient, Shrivastava said, because Americans generally do not view health care as a luxury good: They pay for it in good times and bad. Health insurance costs are on track for their biggest jump in at least five years. Also, health care spending often centers on old and very old people, a group growing dramatically as baby boomers age. The number of Americans 65 or older rose from 34 million in 1995 to 61 million in 2024.

“So many of these health care jobs are to support the growing population of older Americans,” Ullrich said. “So that's not surprising that we're seeing growth there. But I think what is surprising is how lopsided it is.”

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

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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Where Jobs Are Scarce, Over 1 Million People Could Dodge Trump’s Medicaid Work Rules

Millions of Medicaid enrollees may have a way out of the new federal work requirement — if they live in a county with high unemployment.

By January 2027, President Donald Trump’s far-reaching domestic policy law will require many adult, nondisabled Medicaid enrollees in 42 states and Washington, D.C., to work or volunteer 80 hours a month or go to school.

But under the law, Medicaid enrollees in counties where unemployment is at least 8% or 1.5 times the national unemployment rate could be shielded from the work requirement, if their state applies for an exemption.

A new analysis by KFF shows that exemption in the GOP’s work requirement could offer a reprieve to potentially millions of Americans caught in a tough spot — needing to work to secure health insurance but having trouble finding a job.

The Congressional Budget Office projected the work requirement would apply to 18.5 million Medicaid enrollees, causing about 5.3 million to lose their government health coverage by 2034. CBO spokesperson Caitlin Emma confirmed to KFF Health News that analysts factored the unemployment rate exemption into their projections. Only states that expanded Medicaid under the 2010 Affordable Care Act or a special waiver must enact a work requirement, under the federal law.

But how many people could be exempt depends on how the Trump administration interprets the law, in addition to whether their states’ officials apply.

For example, if Trump officials exempt people in counties where the unemployment rate has been above the law’s thresholds for any month over a 12-month period, about 4.6 million Medicaid enrollees in 386 counties could qualify for an exemption today based on the latest unemployment data, according to KFF, a health information nonprofit that includes KFF Health News.

That amounts to just under a quarter of all Medicaid enrollees subject to the work requirement.

Under that one-month threshold, “the impact could be fairly significant,” said Jennifer Tolbert, a co-author of the analysis and the deputy director of KFF’s Program on Medicaid and the Uninsured.

But, she said, the Trump administration is more likely to adopt a stricter threshold based on average unemployment over a 12-month period. That would align with work requirements under the federal Supplemental Nutrition Assistance Program, the food assistance commonly known as food stamps.

Only about 1.4 million Medicaid enrollees living in 158 counties could be exempted under that standard, or about 7% of the total subject to work requirements, KFF found. That’s about 7% of enrollees who live in expansion states who would otherwise need to meet the new requirement.

Based on the 12-month criteria, about 90% of Medicaid enrollees who could be exempted based on high unemployment reside in five states, according to KFF: California, New York, Michigan, Kentucky, and Ohio. California alone accounts for over half of those who could be exempted.

The unemployment rate exemption is one of several carve-outs from the Medicaid work requirement in the GOP’s law. The law also exempts parents with children under 14, people who are disabled or frail, and those who are pregnant, incarcerated, or in a substance use disorder program, among others. The high unemployment provision is different than most because it exempts people living in entire counties.

Two top Republicans key to the bill’s passage — House Speaker Mike Johnson and Sen. Mike Crapo, chair of the Senate Finance Committee — did not respond to requests for comment.

To qualify for the Medicaid exemption, states would have to apply to the federal government on behalf of individuals in eligible counties. And if a county earned an exemption, the government would determine how long it applies.

Even if the federal government grants exemptions broadly, health advocates fear some Republican-led states could balk at applying for exemptions in order to keep enrollment down, as they say has been the case with SNAP exemptions. As of 2023, 18 states did not have an exemption under the SNAP program, even though some of their residents might be eligible.

“It’s not a guarantee that people can rely on,” said Emily Beauregard, executive director of Kentucky Voices for Health, an advocacy group that intends to push for the broadest possible exemptions to help people maintain their coverage. Eastern Kentucky has several counties with perennially high unemployment.

In advocating for Trump’s bill, many Republicans in Washington argued that most people who gained Medicaid benefits under the Affordable Care Act should be working to get off of government assistance.

But as Georgia’s and Arkansas’ experiences have shown, Medicaid work requirements can be costly for states to run and frustrating for enrollees to navigate. About 18,000 people in Arkansas, or nearly a quarter of the state’s adults who gained Medicaid coverage through the ACA expansion, lost coverage when the state had a work requirement in 2018 and 2019. A court ended the state’s work requirement program.

Critics point out that most Medicaid enrollees already work or have a disability or caregiving responsibilities, and they argue the reporting requirements merely serve as a bureaucratic hurdle to obtaining and keeping coverage. Under the GOP law, enrollees’ work status needs to be verified at least twice a year.

Most of the coverage losses due to work requirements occur among people who work or should qualify for an exemption but nevertheless lose coverage due to red tape, research shows.

Not every state must implement a work requirement under Trump’s law, only those that chose to expand Medicaid coverage to more low-income people through the ACA or a federal waiver. The ACA has provided hundreds of billions in federal dollars to help states cover everyone making up to 138% of the federal poverty level — $21,597 for an individual in 2025.

Forty states and Washington, D.C., took up the expansion. Georgia and Wisconsin partly expanded their Medicaid eligibility by getting a federal waiver, adding them to the list of states subject to the work requirement. These two states were not included in the KFF analysis because of a lack of county-level enrollment data.

Jennifer Wagner, director of Medicaid eligibility and enrollment at the left-leaning Center on Budget and Policy Priorities, said she is pleased the law makes some exceptions for places where jobs are scarce. It could limit how many people lose coverage because of the work requirement, she said.

Wagner said SNAP’s unemployment rate exemption has helped millions of people avoid losing their food assistance, but its impact also depends on whether a state seeks the waiver.

She is concerned the Trump administration may make it difficult for counties to get exempted under the Medicaid law.

“I’m glad it’s in there as it will certainly help people, but it’s still a terrible bill,” she said. “This will not really blunt the harm of the bill.”

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‘Historic’ White House Announcement on Autism and Tylenol Causes Confusion

On Monday, President Donald Trump stood beside the “Make America Healthy Again” team for a “historic” announcement on autism. Back in April, Health and Human Services Secretary Robert F. Kennedy Jr. had promised to reveal what was causing “the autism epidemic” by September. 

At the start of this month, people close to the MAHA movement suggested that Kennedy’s upcoming autism announcement would link Tylenol use during pregnancy with the condition. Researchers worried it would veer into vaccines. Both Kennedy and Trump have spread misinformation about an association between vaccines and autism in the past, despite many rigorous studies refuting any link. 

Ann Bauer at the University of Massachusetts-Lowell, an epidemiologist who co-wrote a recent analysis about Tylenol and autism, told me, “I was sick to my stomach,” worrying that Kennedy would distort her team’s conclusions. She also feared scientists would reject her team’s measured concerns about Tylenol in a backlash against politicized or misleading remarks. 

Bauer and her colleagues had reviewed 46 studies on Tylenol, autism, and attention-deficit/hyperactivity disorder. Many found no link, while some suggested Tylenol might occasionally exacerbate other potential causes of autism, such as genetics. 

Since Tylenol is the only safe painkiller for use during pregnancy and fevers during pregnancy can be agonizing as well as dangerous, the team suggested judicious use of the medicine until the science was settled. 

That’s not what Trump advised. “Don’t take Tylenol,” he said. “Don’t give Tylenol to the baby. When the baby’s born, they throw it at you. Here, throw, give him a couple of Tylenol. They give him a shot. They give him a vaccine. And every time they give him a vaccine, they’re throwing Tylenol. And some of these babies, they, you know, they, they’re long born, and all of a sudden, they’re gone.” 

In emailed statements, HHS and White House spokespeople said Trump is using “gold-standard science” to address rising autism rates. 

Helen Tager-Flusberg, director of the Center for Autism Research Excellence at Boston University, called Trump’s comments dangerous. Centers for Disease Control and Prevention scientists told me they were never asked to brief Kennedy or the White House on autism, or to review the recommendations. Had researchers been asked, they would have explained that no single drug, chemical, or other environmental factor is strongly linked to the developmental disorder. 

Quick fixes — the kind promised by Kennedy — won’t make a dent, Tager-Flusberg said. “We know genetics is the most significant risk factor,” she said, “but you can’t blame Big Pharma for genetics, and you can’t build a political movement on genetics research and ride to victory.” 

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Off-Label Drug Helps One Boy With Autism Speak, Parents Say. But Experts Want More Data.

Caroline Connor’s concerns about her son’s development began around his 1st birthday, when she noticed he wasn’t talking or using any words. Their pediatrician didn’t seem worried, but the speech delay persisted. At 2½, Mason was diagnosed with autism.

The Connors went on a mission, searching for anything that would help.

“We just started researching on our own. And that’s when my husband Joe came across Dr. Frye in a research study he was doing,” Caroline said.

Richard Frye, a pediatric neurologist, is one of many doctors searching for treatments that can help kids with autism. He’s studying leucovorin, an inexpensive, generic drug derived from folic acid, also known as folate or vitamin B9. Leucovorin is currently prescribed to ease the side effects of cancer chemotherapy. Pregnant women are prescribed multivitamins with folic acid to prevent neural tube defects. The neural tube develops into the brain and spinal cord.

Leucovorin isn’t a cure for autism, but “it could really have a substantial impact on a very good percentage of children with autism,” Frye said.

This week, the FDA began the process of approving leucovorin as a treatment for autism, despite a lack of any large, phase 3 clinical trials.

“We do have some good preliminary evidence that leucovorin helps,” Frye said. “But normally, the FDA would want to see at least a couple of large phase 3, placebo-controlled, randomized clinical trials. Right now, we only have phase 2B studies, and more research is needed to answer key questions, like how to dose it correctly, when to start, and which children will benefit most.”

The theory behind the drug’s use for autism postulates that some children have a blockage in the transport of folic acid into the brain that potentially contributes to some of the neurological problems associated with the disorder. Leucovorin bypasses that blockage and can help some autistic kids improve their ability to speak. Three randomized controlled trials of leucovorin to treat autism have shown positive effects on speech.

Frye cited five blinded controlled studies to date, all positive, although at different doses and in different populations. Still, he said, “the evidence isn’t yet where it would normally be for a drug.”

Frye said he was “disappointed” that his group had not received funding from the National Institutes of Health’s new Autism Data Science Initiative and that he was not consulted on the design of upcoming leucovorin trials. “It’s strange, because I’ve been leading this work for decades,” he noted.

The Science of Cerebral Folate Deficiency

Cerebral folate deficiency, or a deficiency of folate in the brain, was first described by physician-researcher Vincent Ramaekers. Ramaekers found that some kids with neurodevelopmental disorders had normal levels of folic acid in the blood, but low levels in their spinal fluid. He then teamed up with researcher Edward Quadros, who had been studying how an autoimmune disorder might lead to a blockage of folic acid transport into the brain. Ramaekers and Quadros found that autoantibodies against the folate receptor alpha (FR⍺), which transports folic acid from the blood into the brain and the placenta, might cause abnormal fetal brain development and some autism spectrum disorders.

One study found that over 75% of children with autism spectrum disorder had FR⍺ autoantibodies, compared with 10%-15% of healthy kids. There is evidence of a familial or genetic predisposition for developing FR⍺ autoantibodies. While environmental and immune system dysregulation may also play a role, there’s no evidence to suggest that vaccines cause the development of FR⍺ autoantibodies.

The brain has a backup system to the FR⍺ known as the reduced folate carrier, or RFC. The RFC isn’t as efficient a transporter as the FR⍺, but it can transport leucovorin, also known as folinic acid, into the brain. Enzymes in the brain convert leucovorin into the active form of folate.

Treatment with leucovorin increases brain levels of folate in kids with cerebral folate deficiency, or CFD. In one study led by Frye, one-third of such kids experienced improvement in their speech and other behavior when treated with leucovorin. Two randomized trials conducted in France and India showed similar results. A folate receptor autoantibody test (FRAT) is available to help identify which children may most likely respond to leucovorin treatment.

Frye’s team has also identified new potential biomarkers, such as the soluble folate receptor protein, that could predict which children require higher doses.

Frye noted that there are many nuances to treating CFD with leucovorin, including the addition of adjunctive treatments to optimize mitochondrial function.

The side effects associated with leucovorin are mild. Some children experience hyperactivity during the first few weeks of treatment, but that typically subsides within a month or two. A similar pattern is seen with other B vitamins.

Mason’s ‘Little Bottle of Hope’

Mason Connor’s first words came just three days after he started taking leucovorin at age 3, his parents say.

Doctors can currently prescribe the drug only for autism off-label, which means repurposing a drug approved for one condition to treat another.

“We’ve done the science, and the next step is that we want to get more funding so we can actually get it FDA-approved,” Frye said.

He welcomed the FDA’s recent interest but cautioned that it “may have been a little premature,” given the gaps in knowledge and the need for physician education on how to prescribe leucovorin correctly in autism.

There’s one big problem. “Leucovorin’s an old drug, and you can get it for a very low price. So nobody is going to make a lot of money on it. So there’s no reason for them to invest,” Frye said.

Compounding the challenge: supply and quality vary. “Leucovorin is a generic, and different manufacturers use different additives,” Frye explained. “Some formulations children with autism don’t tolerate well.”

Frye used to recommend that patients use the generic form of leucovorin manufactured by West-Ward Pharmaceuticals, a U.S. subsidiary of Hikma, but, he said, “it ran out early this year. Right now, the only reliable source is through a high-quality compounding pharmacy that knows how to make it for kids with autism.” Frye is in the process of establishing a for-profit company to manufacture the right form of leucovorin for kids with autism.

An estimated 20%-30% of all prescriptions in the U.S. are off-label, according to the nonprofit Every Cure. This is often done as there are more than 14,000 known human diseases with no FDA-approved drugs to treat them. Drugs like leucovorin are frequently used off-label because doctors believe that the benefits outweigh the risks. However, there is often limited awareness about these treatments, so they may go unused.

David Fajgenbaum, Every Cure’s co-founder and president, said he’s “literally alive today from a repurposed drug” after he was diagnosed with a rare cancer-like disease that almost killed him. His research into his disease led to a drug meant for another condition.

“It’s heartbreaking to think about drugs being on the pharmacy shelf while someone suffers from a disease,” Fajgenbaum said.

Every Cure uses AI to scour available medical data on diseases and treatments to uncover potential matches. Every Cure brought to light the work of Frye, Ramaekers, Quadros, and others on leucovorin in the treatment of autism.

“I think our system is just flawed and there’s this major gap where drug companies are great at developing new drugs for new diseases, and we as a system are really lousy at looking for new diseases for old drugs. That’s why we started Every Cure — to unlock these hidden cures,” Fajgenbaum said.

Mason is now 5, and the plan is for him to start mainstream kindergarten this fall — helped toward a new path by an old medicine.

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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KFF Health News' 'What the Health?': Public Health Further Politicized Under the Threat of More Firings

The Host

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

In a highly unusual White House news conference this week, President Donald Trump — without evidence — boldly blamed the painkiller Tylenol and a string of childhood vaccines for causing a recent rise in autism. That came just days after the newly reconstituted Advisory Committee on Immunization Practices, now populated with vaccine skeptics and opponents, voted to change long-standing recommendations.

Podcast host Julie Rovner interviews Demetre Daskalakis, who until last month was the head of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases, about the reaction to these unprecedented actions.

Meanwhile, as the government approaches a likely shutdown, with Congress at a standoff over funding for the new fiscal year that starts Oct. 1, the Trump administration is ordering federal agencies not to just furlough workers but to fire them if their jobs do not align with the president’s priorities.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, and Sandhya Raman of CQ Roll Call.

Panelists

Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Sandhya Raman CQ Roll Call @SandhyaWrites @SandhyaWrites.bsky.social Read Sandhya's stories.

Among the takeaways from this week’s episode:

• The federal Office of Management and Budget on Wednesday night sent a memo to government agencies asking for contingency plans in the event of a government shutdown starting Oct. 1. Such a memo isn’t unusual when it comes to pre-shutdown planning. This time around, it took an unprecedented turn in informing agency personnel that they should prepare for mass firings of employees whose programs lack alternative funding sources or who are working on a program whose mission doesn’t directly align with Trump’s priorities. Though federal RIFs, or reductions in force, and government shutdowns have each happened before, the combined RIF/shutdown threat is a first.

• It seems we are headed for a shutdown. Before adjourning until after the fiscal year ends Sept. 30, the House approved a stopgap funding measure. But, because House members do not plan to return to Washington until Oct. 6, that leaves the Senate in a jam. If senators change anything in the bill, it would require another House vote, which, because of the House schedule, might not happen before the month ends.

• There’s also interparty strife. Republicans say they want a clean bill to provide short-term funding, while Democrats have other ideas. Their prevailing attitude is that they went along with this approach in March and got burned. This week, Trump also canceled a meeting with Democratic leaders. The bottom line is that both sides are jockeying for a position that would allow them to cast shutdown blame across the aisle. Some call it a game of three-dimensional chess, while others call it a game of chicken. Either way, there will be consequences.

• Confusion and chaos have emerged as buzzwords to describe two recent events: last week’s meeting of the CDC’s Advisory Committee on Immunization Practices and this week’s White House press conference about autism. Both were marked by mixed messages. At the White House event, for instance, Trump warned pregnant women not to take Tylenol. But the FDA information that shortly followed downplayed the Tylenol risk.

• The Trump administration’s new $100,000 fee for H-1B visas could have an impact on health care. Such visas are often used by graduating medical students and other health professionals who come to the U.S. for training, then stay to practice. That $100,000 fee is steep and generated an almost immediate backlash from hospitals and health systems, especially those in rural areas — a reaction that caught administration officials off guard. Administration officials have suggested that health professionals would qualify for an exemption from this fee. What is not yet clear is what hoops the sponsoring hospitals would have to jump through to qualify for it.

• Trump has given 17 drug companies a Sept. 29 deadline by which they will have to commit to adopting his “most favored nation” pricing policy. It’s intended to increase the cost drugmakers charge in other countries while lowering prices in the U.S. Talks between the administration and the drugmakers are ongoing. So far, indications are that Trump might end up with half a loaf. Some large drugmakers have announced they will raise the prices of specific medications in other countries but have not agreed to reduce prices in the U.S.

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

Julie Rovner: NBC News’ “RFK Jr. Has the Federal Vaccine Court in His Sights. Attacking It Could Threaten Vaccine Production in the U.S.,” by Liz Szabo.

Anna Edney: The Washington Post’s “Do State Abortion Laws Affect Women’s Recruiting? That’s Up to Athletes,” by Kevin B. Blackistone.

Sandhya Raman: ProPublica’s “Psychiatric Hospitals Turn Away Patients Who Need Urgent Care. The Facilities Face Few Consequences,” by Eli Cahan.

Also mentioned in this week’s podcast:

• Axios’ “Drugmakers Meet Trump Only Halfway on Pricing Plan,” by Peter Sullivan.
• Bloomberg Law’s “White House Says Doctors May Win Reprieve From H-1B Visa Fee,” by Rachel Cohrs Zhang, John Tozzi, and Jessica Nix.

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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As Trump Punts on Medical Debt, Battle Over Patient Protections Moves to States

With the Trump administration scaling back federal efforts to protect Americans from medical bills they can’t pay, advocates for patients and consumers have shifted their work to contain the nation’s medical debt problem to state Capitols.

Despite progress in some mostly blue states this year, however, recent setbacks in more conservative legislatures underscore the persistent challenges in strengthening patient protections.

Bills to shield patients from medical debt failed this year in Indiana, Montana, Nevada, South Dakota, and Wyoming in the face of industry opposition. And advocates warn that states need to step up as millions of Americans are expected to lose insurance coverage because of President Donald Trump’s tax and spending law.

“This is an issue that had been top of mind even before the change of administrations in Washington,” said Kate Ende, policy director of Maine-based Consumers for Affordable Health Care. “The pullback at the federal level made it that much more important that we do something.”

This year, Maine joined a growing list of states that have barred medical debt from residents’ credit reports, a key protection that can make it easier for consumers to get a home, a car, or sometimes a job. The measure passed unanimously with bipartisan support.

An estimated 100 million adults in the U.S. have some form of health care debt.

The federal government was poised to bar medical debt from credit reports under regulations issued in the waning days of former President Joe Biden’s administration. That would have helped an estimated 15 million people nationwide.

But the Trump administration did not defend the regulations from lawsuits brought by debt collectors and the credit bureaus, who argued that the Consumer Financial Protection Bureau exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

Now, only patients in states that have enacted their own credit reporting rules will benefit from such protections. More than a dozen have such limits, including California, Colorado, Connecticut, Minnesota, New York, and Vermont, which, like Maine, enacted a ban this year.

Still more states have passed other medical debt protections in recent years, including caps on how much interest can be charged on such debt and limits on the use of wage garnishments and property liens to collect unpaid medical bills.

In many cases, the medical debt rules won bipartisan support, reflecting the overwhelming popularity of these consumer protections. In Virginia, the state’s conservative Republican governor this year signed a measure restricting wage garnishment and capping interest rates.

And several GOP lawmakers in California joined Democrats in support of a measure to make it easier for patients to access financial assistance from hospitals for big bills.

“This is the kind of commonsense, pocketbook issue that appeals to Republicans and Democrats,” said Eva Stahl, a vice president at Undue Medical Debt, a nonprofit that buys up and retires patients’ debts and has pushed for expanded patient protections.

But in several statehouses, the drive for more safeguards hit walls.

Bills to ban medical debts from appearing on credit reports failed in Wyoming and South Dakota, despite support from some GOP lawmakers. And measures to limit aggressive collections against residents with medical debt were derailed in Indiana, Montana, and Nevada.

In some states, the measures faced stiff opposition from debt collectors, the credit reporting industry, and banks, who told legislators that without information about medical debts, they might end up offering consumers risky loans.

In Maine, the Consumer Data Industry Association, which represents credit bureaus, told lawmakers that regulating medical debt should be left to the federal government. “Only national, uniform standards can achieve the dual goals of protecting consumers and maintaining accurate credit reports,” warned Zachary Taylor, the group’s government relations director.

In South Dakota, state Rep. Lana Greenfield, a Republican, echoed industry objections in urging her colleagues to vote against a credit reporting ban. “Small-town banks could not receive information on a mega, mega medical bill. And so, they would in good faith perhaps loan money to somebody without knowing what their credit was,” Greenfield said on the House floor.

Under the Biden administration, CFPB researchers found that medical debt, unlike other debt, was not a good predictor of creditworthiness.

But South Dakota state Rep. Brian Mulder, a Republican who chairs the health committee and authored the legislation, noted the power of the banking industry in South Dakota, where favorable regulations have made the state a magnet for financial institutions.

In Montana, legislation to shield a portion of debtors’ assets from garnishment easily passed a committee. Supporters hoped the measure would be particularly helpful to Native American patients, who are disproportionately burdened by medical debt.

But when the bill reached the House floor, opponents “showed up en masse,” talking one-on-one with Republican lawmakers an hour before the vote, said Rep. Ed Stafman, a Democrat who authored the bill. “They lassoed just enough votes to narrowly defeat the bill,” he said.

Advocates for patients and legislators who backed some of these measures said they’re optimistic they’ll be able to overcome industry opposition in the future.

And there are signs that legislation to expand patient protections may make headway in other conservative states, including Ohio and Texas. A proposal in Texas to force nonprofit hospitals to expand aid to patients facing large bills picked up support from leading conservative organizations.

“These things can sometimes take time,” said Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society. The patients’ group has been pushing for state medical debt protections in recent years, including in Montana and South Dakota.

More concerning, Culp said, is the wave of uninsured patients expected as millions of Americans lose health coverage due to cutbacks in the recently passed GOP tax law. That will almost certainly make the nation’s medical debt problem more dire.

“States are not ready for that,” Culp said.

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

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Amid Confusion Over US Vaccine Recommendations, States Try To ‘Restore Trust’

When the CDC’s Advisory Committee on Immunization Practices met last week, confusion filled the room.

Members admitted they didn’t know what they were voting on, first rejecting a combined measles-mumps-rubella-chickenpox vaccine for young toddlers, then voting to keep it funded minutes later. The next day, they reversed themselves on the funding.

Now Jim O’Neill, the deputy health and human services secretary and the Centers for Disease Control and Prevention’s acting director (a lawyer, not a doctor), must sign off. The panel’s recommendations matter, because insurers and federal programs rely on them, but they are not binding. States can follow the recommendations, or not.

In the West, California, Oregon, Washington, and Hawaii have joined forces in the West Coast Health Alliance. Their first move was to issue joint recommendations on covid, flu, and RSV vaccines, going further than ACIP.

“Public health should never be a patchwork of politics,” said Sejal Hathi, Oregon’s state health director.

California’s health director, Erica Pan, described the goal as “demonstrating unity around science and values” while reducing public confusion.

The bloc is also exploring coordinated lab testing, data sharing, and even group purchasing. “Our intent is to restore trust in science and safeguard people’s freedom to protect themselves and their families without endless barriers,” Hathi said.

In the Northeast, New York and its neighbors created the Northeast Public Health Collaborative. Democratic Gov. Kathy Hochul called it a rebuke to Washington, D.C.’s retreat from science.

“Every resident will have access to the COVID vaccine, no exceptions,” she said in a statement.

The group has already gone beyond vaccines. After the CDC disbanded its infection-control advisory body, the Northeast states created their own return-to-work rules. Work groups now span vaccines, labs, emergency preparedness, and surveillance.

“Infectious diseases don’t respect borders,” said Connecticut’s health commissioner, Manisha Juthani. “We had to move in the same direction to protect our residents.”

The two blocs are in regular contact. “We communicate every day,” Hathi said.

“We can’t just sit by while federal agencies are hollowed out,” said acting New York City health commissioner Michelle Morse. “Public health is local, and we have to act like it.”

State leaders describe their coalitions as filling a vacuum left by Washington, D.C.

“You would think emerging from a pandemic, we would be embracing public health, but the federal government was heading in the opposite direction,” said James McDonald, New York state health commissioner.

Massachusetts commissioner Robbie Goldstein added: “The federal government has historically been the entity that held us all together. In January of this year, that tradition seemed to be going away.”

Boston University law professor Matt Motta summarized the dilemma: “States are taking matters into their own hands, sometimes to expand access to vaccines, sometimes to roll it back. That’s technically how the system works, but it risks inefficiency and confusion.”

Public health law has long tilted toward the states.

“If there was a public health issue, we’d say it’s for the states,” said Wendy Parmet of the Northeastern University School of Law.

States have mandated vaccines since the 1800s. Federal agencies can approve vaccines and fund programs, but they cannot force mandates except in very specific circumstances (e.g., federal employees).

UC Law-San Francisco’s Dorit Reiss agreed with Parmet: “Public health authority resides primarily with the states. Recommendations are recommendations.”

ACIP’s votes matter for coverage rules and insurance mandates, but states are free to diverge.

That divergence is already widening. Florida, led by Surgeon General Joseph Ladapo, is moving to eliminate childhood vaccine requirements altogether — a first-in-the-nation step. Georgetown Law’s Larry Gostin warned this could reopen century-old battles dating to Jacobson v. Massachusetts (1905), when the Supreme Court upheld state vaccine mandates for public safety.

Health leaders warn that competing systems risk causing confusion and costing lives. “Federal silence creates a vacuum, and states either step up together or splinter apart,” Hathi said.

Pan added that “without federal credibility, we’re left improvising.”

McDonald cautioned that partisan divides could grow sharper.

And Morse said that “blue and red states could each go their own way, leaving the public even more divided.”

Gostin put it bluntly: “That risks confusion, inefficiency, and ultimately lives.”

This state-by-state tug-of-war is not new. In the 1800s, local boards of health fought cholera with sewers and sanitation when federal authority was absent. In the 1950s, states organized mass polio clinics, with uneven uptake until federal funding smoothed disparities.

During the covid pandemic, Trump White House response coordinator Deborah Birx saw firsthand the limits of federal power. She visited 44 states, urging governors to adopt masks, closures, and vaccines.

“I was trying to get them to tailor responses to their populations, not just follow generic federal guidance,” she later recalled.

Supreme Court Justice Louis Brandeis once said that states are “laboratories of democracy,” where leaders could test out new ideas without putting the whole country at risk. But diseases don’t follow state lines. A virus that starts in Tallahassee could spread to Times Square by the next morning.

Today, states have become laboratories of public health. Each state is experimenting — some expanding protections, others cutting them back. And those choices could, for better or worse, affect us all.

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

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El aumento de personas sin seguro médico pondrá en aprietos a los sistemas de salud locales

RIO GRANDE CITY, Texas. — Jake Margo Jr. estaba en la sala de triaje del Starr County Memorial Hospital explicando por qué una persona con fiebre persistente, que podía tratarse con medicamentos de venta libre, no necesitaba ser admitida en la sala de emergencias.

“Vamos a atender primero a los pacientes más graves”, dijo Margo, que es médica de familia.

De todas formas, esa tarde de junio no quedaba espacio disponible. Un pequeño monitor en la pared mostraba los signos vitales de los pacientes que ya llenaban la sala de emergencias. Y afuera, bajo el calor del sur de Texas, una ambulancia esperaba a que se liberara una cama para el paciente que había traído.

“Aquí viene todo el mundo”, dijo Margo. “Pero cuando estás abrumado y sobrepasado, hay un límite a lo que puedes hacer”.

El condado de Starr, una comunidad rural y mayoritariamente hispana en la frontera sur de Estados Unidos, fue noticia en 2024 al votar, por primera vez en más de un siglo, por un candidato republicano en una elección presidencial.

La inmigración y la economía fueron los temas que impulsaron el cambio político en esta comunidad, donde aproximadamente un tercio de la población vive bajo la línea de la pobreza.

Ahora, las medidas que adoptaron recientemente la administración Trump y el Congreso controlado por el Partido Republicano han despertado una nueva preocupación: la creciente dificultad para que médicos, hospitales y otros proveedores de salud puedan seguir atendiendo a personas sin seguro médico.

Este es un temor que va más allá del condado de Starr, una localidad que tiene una de las tasas más altas de población sin seguro del país. Comunidades de todo Estados Unidos que tienen números similares de personas sin seguro podrían verse en serios problemas a medida que más residentes pierden su cobertura médica.

Se calcula que, en 10 años, 14 millones de personas se quedarán sin seguro médico en Estados Unidos como consecuencia de la ley fiscal y de presupuesto del presidente Donald Trump, a la que los republicanos llaman One Big Beautiful Bill Act.

A esto se agrega la eliminación de los subsidios extraordinarios que redujeron el costo de los planes a partir de la Ley de Cuidado de Salud a Bajo Precio (ACA).

La nueva ley también limita programas que otorgan miles de millones de dólares a los hospitales y clínicas que atienden a personas sin seguro, lo que complica aún más su supervivencia.

“No se puede dejar sin cobertura a tanta gente sin que, en muchas comunidades, el sistema de salud colapse”, afirmó Sara Rosenbaum, presidenta y fundadora del Department of Health Policy and Management de la George Washington University’s Milken Institute School of Public Health.

“El futuro es el sur de Texas”, pronosticó.

KFF Health News está examinando el impacto de los cambios en la política nacional de salud en las personas sin seguro y sus comunidades.

Aunque la administración Trump respondió a KFF Health News que está haciendo “una inversión histórica en la atención médica rural”, quienes tratan a pacientes de bajos ingresos, así como investigadores y defensores de los consumidores, aseguran que las recientes decisiones políticas harán más difícil que las personas permanezcan saludables.

Algunos médicos, hospitales y clínicas que conforman la red de seguridad sanitaria han advertido que podrían perder tanto dinero que se verían obligados a cerrar.

“Porque la factura del paciente no se va a pagar”, dijo Joseph Alpert, editor en jefe de The American Journal of Medicine y profesor de Medicina en la Universidad de Arizona. “Los pacientes sin seguro saturan el sistema de salud”, añadió.

El condado de Starr es un ejemplo de esta situación.

Los médicos de atención primaria del condado reciben algo menos de 3.900 personas cada uno, casi tres veces el promedio nacional.

Margo, la médica de familia, explicó que como hay tantas personas sin seguro y son tan pocos los lugares donde los atienden, cuando se sienten mal muchas van directamente a la sala de emergencias.

Además, muchos de esos pacientes han descuidado su salud y por eso llegan más enfermos y necesitan tratamientos más costosos. La ley federal exige que las salas de emergencia de los hospitales que participan en Medicare atiendan o transfieran a los pacientes, sin tomar en cuenta si pueden pagar o no.

Esto obliga a Margo y a su equipo a practicar lo que describió como “medicina de desastre”.

“Llegan con dolor en el pecho o no pueden respirar. Se desmayan. Nunca han visto a un médico”, dijo. “Están literalmente muriendo”.

Sistemas de salud en “modo de supervivencia”

Cuando alguien no tiene seguro o depende de Medicaid, suele recurrir a una red de seguridad sanitaria: médicos, hospitales, clínicas y centros comunitarios que ofrecen servicios gratuitos o reciben reembolsos muy bajos si se los compara con los seguros comerciales.

Estas instituciones muchas veces funcionan con un financiamiento muy precario y dependen de innumerables ayudas federales. Los recortes impulsados por la administración Trump, con el argumento de eliminar el “desperdicio, fraude y abuso”, generaron dudas respecto de si estos proveedores podrán soportar todavía mayor presión financiera.

La nueva ley de Trump financia las prioridades del gobierno. Entre ellas están la ampliación de los recortes fiscales que benefician principalmente a los estadounidenses de mayores ingresos y el refuerzo de los controles a los inmigrantes.

Esos costos se cubren en parte con una reducción de casi $1.000 millones en el gasto federal en salud para Medicaid durante la próxima década. Y, también, con cambios en los mercados de seguros establecidos por ACA, como la exigencia de trámites adicionales y la reducción de los plazos para inscribirse.

Muchos republicanos argumentan que Medicaid ha crecido demasiado y se ha desviado de su misión original de cubrir a personas de bajos recursos y con discapacidades. El Partido Republicano ha tratado de revertir ACA desde que se aprobó.

Kush Desai, vocero de la Casa Blanca, dijo que las proyecciones sobre cuántas personas podrían perder el seguro médico de la no partidista Congressional Budget Office son “exageradas”. No ofreció una cifra que la administración considere más precisa.

Los que apoyan la One Big Beautiful Bill aseguran que quienes necesitan cobertura médica pueden obtenerla si cumplen con los nuevos requisitos, como trabajar para recibir Medicaid.

Michael Cannon, director de estudios de políticas de salud del Cato Institute, un centro de pensamiento libertario, sostuvo que incluso con esta ley el gasto en Medicaid seguirá creciendo, aunque más lentamente.

“Los proveedores ineficientes deberían cerrar”, dijo Cannon. “La ley no provocará un colapso”, aseguró.

Una encuesta reciente de la AMGA, una asociación que representa a los sistemas de salud de todo el país y antes era conocida como American Medical Group Association, reveló que casi la mitad de los centros de salud rurales podrían cerrar o reestructurarse por los recortes de Medicaid.

Casi tres cuartas partes de los encuestados afirmaron que preveían despidos o licencias, incluso de profesionales de salud de primera línea.

Los departamentos de salud pública, que a menudo cubren las carencias en la atención médica, también se enfrentan a recortes en el financiamiento federal que redujeron su capacidad operativa.

En el condado de Cameron, al sur de Texas, el Departamento de Salud ha eliminado casi una docena de puestos, según afirmó su directora, Esmer Guajardo.

En el condado vecino de Hidalgo han despedido a más de 30 empleados, según Iván Meléndez, que colabora en la supervisión de la administración.

En julio, el Departamento de Servicios de Salud de Texas canceló  Operation Border Health, un multitudinario evento anual que el año anterior había brindado servicios de salud gratuitos a casi 6.000 residentes en el sur de Texas.

El Gateway Community Health Center, un centro de salud comunitario de Laredo, una ciudad fronteriza al norte del Valle del Río Grande, está en “modo de supervivencia”, según David Vásquez, su director de comunicaciones.

Aproximadamente un tercio de sus pacientes ya no tienen seguro médico, y muchos más tendrán dificultades para pagar la atención sanitaria si no se renuevan las subvenciones de ACA.

El centro está buscando otras formas de financiamiento para evitar despidos o recortes en los servicios, y ha suspendido todos los planes de expansión y contratación, agregó Vásquez.

Este achicamiento ocurre justo cuando más personas pierden su seguro y necesitan atención médica gratuita o a bajo costo.

Esther Rodríguez, de 39 años, residente de McAllen, lleva dos años sin empleo y su esposo gana $600 por semana trabajando en la construcción. Ninguno de los dos tiene seguro médico.

Medicaid cubrió los gastos del parto de sus cinco hijos. Ahora depende de una clínica móvil gestionada por una facultad de medicina local, donde debe pagar de su bolsillo las revisiones rutinarias y los medicamentos para controlar su diabetes tipo 2. Si necesitara más atención, dijo Rodríguez, iría a una sala de emergencias.

“Hay que saber adaptarse”, dijo.

Muerte por mil recortes

Que muchas personas no estén en condiciones de pagar genera una atención médica no remunerada, es decir, servicios por los que los hospitales, los médicos y las clínicas no reciben ningún pago. Estaba previsto, según una versión anterior del megaproyecto de ley, que esto aumentara en $204.000 millones durante la próxima década. La estimación es del Urban Institute, un grupo de expertos sin fines de lucro.

Pero la administración Trump también está recortando otras formas de ayuda que contribuían a compensar el costo de la atención médica de las personas que no pueden pagarla.

La nueva ley impone límites a programas federales que muchos prestadores de salud para personas de bajos ingresos han utilizado para equilibrar sus presupuestos, especialmente en áreas rurales.

Entre ellos se incluyen los impuestos a los hospitales, los planes de salud y otros proveedores que los estados utilizan para ayudar a financiar sus programas de Medicaid. Estos impuestos a los proveedores son un “truco financiero”, afirmó Desai.

Si bien la ley crea un fondo temporario de $50.000 millones para apoyar a médicos y hospitales rurales, esa cifra representa poco más de un tercio de las pérdidas estimadas en fondos de Medicaid en estas zonas, según la organización sin fines de lucro KFF.

Desai calificó el análisis como “defectuoso”.

Cualquier pérdida de ingresos podría suponer la ruina financiera, especialmente para los pequeños hospitales rurales, afirmó Quang Ngo, presidente de la Texas Organization of Rural & Community Hospitals Foundation.

“Es como si te fueran matando de a poquito con tantos recortes”, dijo. “Algunos probablemente no lo resistan”.

Todo indica que los golpes podrían continuar. La propuesta presupuestaria de la administración Trump para el próximo año fiscal contempla recortes a múltiples programas de salud rural ejecutados por la Health Resources and Services Administration (HRSA).

Desai aseguró que la inversión de la nueva ley en salud rural “supera por mucho” esos recortes.

En febrero, la administración Trump anunció un recorte del 90% al programa de navegadores de ACA, que ayuda a las personas a encontrar seguro médico.

Desai afirmó que ese programa ha sido “históricamente ineficiente”.

En diciembre de 2023, en Texas, casi tres millones de personas sin seguro médico reunían los requisitos para recibir subsidios de ACA, Medicaid o el Programa de Seguro Médico Infantil (CHIP), según Texas 2036, un grupo de expertos en políticas públicas.

María Salgado es una trabajadora de salud comunitaria, o promotora de salud, que pasa sus días laborales en eventos comunitarios, repartiendo volantes en consultorios médicos y reuniéndose con personas para ayudarlas a inscribirse en Medicaid o en planes de ACA a través de MHP Salud, una organización sin fines de lucro.

Salgado tiene miedo de que los recortes de fondos realmente frenen los esfuerzos de la organización: “Muchos miembros de nuestra comunidad van a quedar rezagados”, dijo.

Chris Casso, una médica de atención primaria que creció y ahora ejerce en McAllen, contuvo las lágrimas mientras hablaba de los pacientes que habían dejado de ir al médico porque no lo podían pagar, y eso había hecho que sus enfermedades prevenibles se volvieran más graves.

A Casso le preocupa el futuro de su comunidad, ya que se acentúa la escasez de médicos y podrían quedar pocos profesionales de salud para tratar a quienes han quedado sin cobertura.

“Parte el alma”, dijo, sentada en un pequeño cuarto detrás de su consultorio, ubicado en un centro comercial suburbano, entre una tienda Kohl’s y una Shoe Carnival. “Son personas muy trabajadoras”, afirmó. “Hacen todo lo posible para cuidarse”.

Casso contó que su propia hermana, que trabajaba como facturadora médica en un consultorio, no tenía seguro. Postergó la atención y murió a los 45 años por complicaciones de la diabetes y una enfermedad cardíaca. Casso teme que ese sea el destino de muchas otras personas en el futuro.

“Nuestra comunidad la va a pasar mal”, aseguró. “Va a ser un desastre”.

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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