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CDC Firings Fray Lifelines to Local Health Departments

The U.S. public health system has long been under strain, stymied by declines in funding as well as employees. And so state and local public health departments around the nation — tasked with monitoring and responding to disease outbreaks that threaten to sicken the masses — have relied on workers from the Centers for Disease Control and Prevention to help.

In February, the Trump administration abruptly fired many of them, a move that local and state officials said would undermine the nation’s continual effort to control the spread of infectious disease.

A few examples: Terminated CDC employees had helped prevent and respond to outbreaks such as dengue fever and the flu. They worked with local officials to quickly test for viruses — including Oropouche, an illness that doesn’t have a vaccine or effective treatment — and ensure that testing in public health labs complies with federal regulations. Others monitored potential cases of tuberculosis or provided health education to adolescents to prevent sexually transmitted infections.

The Trump administration’s Department of Government Efficiency, spearheaded by billionaire Elon Musk, is trying to slash the workforce across the Department of Health and Human Services and other federal agencies. The swift staff reductions targeted probationary employees, many hired within the past two years, who lack civil service protections against firings.

My colleague Noam N. Levey reported this week on layoffs at a division of the Centers for Medicare & Medicaid Services — the Center for Consumer Information and Insurance Oversight — that could hinder enforcement of a law to prevent surprise medical bills that Trump himself signed in his first term.

One of the CDC trainees let go was Gaël Cruanes, who had been working at New York City’s Department of Health and Mental Hygiene to detect cases of tuberculosis. Cruanes, who called the firings “unconscionable,” contacted newly arrived immigrants and refugees potentially at risk of spreading TB in hopes of getting them into the city’s clinics for screening. “It’s purely for the safety of the public at the end of the day,” Cruanes said.

The firings were communicated in mid-February in notices with identical language alleging workers had displayed poor performance and that their skills weren’t a match for the department’s current needs. Several people interviewed by KFF Health News disputed that characterization.

After our reporting was published, fired CDC workers in the training programs were notified March 4 that their terminations were rescinded and that they should start work again March 5, according to emails viewed by KFF Health News. “We apologize for any disruption that this may have caused,” said the emails, which were unsigned and sent from an internal CDC email address. The CDC didn’t respond to requests for comment.

The reversal came less than a week after a federal judge ruled the Trump administration’s widespread firings of probationary employees were likely illegal. But there’s still uncertainty. Although some workers were rehired, federal agencies are still drawing up plans for large-scale layoffs, a move that could encompass a much broader swath of workers.

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

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

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Marty Makary, Often Wrong as Pandemic Critic, Is Poised To Lead the FDA He Railed Against

Panelists at a covid conference last fall were asked to voice their regrets — policies they had supported during the pandemic but had come to see as misguided. Covid contact tracing, one said. Closing schools, another said. Vaccine mandates, a third said.

When Marty Makary’s turn came, the Johns Hopkins University surgeon said, “I can’t think of anything,” adding, “The entire covid policy of three to four years felt like a horror movie I was forced to watch.”

It was a characteristic response for Makary, President Donald Trump’s nominee to lead the Food and Drug Administration, who looks set to be confirmed after a Senate committee hearing on Thursday. A decorated doctor and a brash critic of many of his medical colleagues, Makary drew Trump’s attention during the pandemic with frequent appearances on Fox News shows such as “Tucker Carlson Tonight,” in which he excoriated public health officials over their handling of covid.

Many former FDA officials and scientists with knowledge of the agency are optimistic about Makary — to a degree.

“He’s a world-class surgeon, and he has health policy expertise,” said Jennifer Nuzzo, a Brown University professor of epidemiology and former colleague of Makary’s at Johns Hopkins. “If you have pancreatic cancer, he’s the person you want to operate on you. The university is probably losing a lot of money to not have him doing that work.”

His critics say he at times exaggerated the harms of the covid vaccine and undersold the dangers of the virus, contributing to a pandemic narrative that led many Americans to shun the shots and other practices intended to curb transmission and reduce hospitalizations and deaths.

Should he take the reins at the FDA, transitioning from gadfly to the head of an agency that regulates a fifth of the U.S. economy, Makary would have to engage in the thorny challenges of governing.

“Makary spent the pandemic raving against the medical establishment as if he were an outsider, which he wasn’t,” said Jonathan Howard, a New York City neurologist and the author of “We Want Them Infected,” a book that criticizes Makary and other academics who opposed government policies. “Now he really is the establishment. Everything that happens is going to be his responsibility.”

At his confirmation hearing, Makary sounded a lower-key tone, extolling the FDA’s professional staff and promising to apply good science and common sense in the service of attacking chronic disease in the U.S., including by studying food additives and chemicals that could be contributing to poor health.

“We need more humility in the medical establishment. You have to be willing to evolve your position as new data comes in,” he testified. What makes a great doctor “is not how much you know; it’s your humility and your willingness to learn, as you go, from patients.”

Colleagues have applauded Makary’s skill and intelligence as a surgeon and medical policy thinker. He contributed to a 2009 surgery checklist believed to have prevented thousands of mistakes and infections in operating rooms. He wrote a widely cited 2016 paper claiming that medical errors were the third-leading cause of death in the United States, although some researchers said the assertion was overblown. He’s also founded or been a director for companies and said in the hearing that a surgical technique he invented eventually could help cure diabetes.

Humility, however, has not been Makary’s most obvious trait.

During the pandemic, he took to op-eds and conservative media with controversial positions on public health policy. Some proved astute, while others look less prescient in hindsight.

In December 2020, Makary defied established scientific knowledge and said that vaccination of 20% of the population would be enough to create “herd immunity.” In a February 2021 Wall Street Journal piece, he predicted that covid would virtually disappear by April because so many people would have become immune through infection or vaccination. The U.S. death toll from covid stood at 560,000 that April, with an additional 650,000 deaths to come. In June 2021, he said he had been unable to find evidence of a single covid death of a previously healthy child. By then there were many reports of such deaths, although children were much less likely than older people to suffer severe disease.

In February 2023, Makary testified in Congress that the lab-leak theory of covid’s origin was a “no brainer,” a surprisingly unequivocal statement for a scientist discussing a scientifically unresolved issue.

Some public health officials felt Makary gratuitously attacked authorities working in difficult circumstances.

“He went from being a pretty reasonable person to saying a lot of things that were over the top and unnecessary,” said Ashish Jha, dean of the Brown University School of Public Health, who was the White House covid-19 response coordinator under President Joe Biden.

And while almost everyone involved in fighting covid has admitted to getting things wrong during the pandemic, Jha said, “I never had any sense from Marty that he did.”

Makary did not respond to requests for comment.

Makary accused Biden administration officials of ignoring emerging evidence that previous infection with covid could be as or more effective against future infection than vaccination. While he was probably right, Nuzzo said, his statements seemed to encourage people to get infected.

“It’s reasonable to say that vaccine mandates weren’t the right approach,” she said. “But you can also understand that people were trying to blindly stumble our way out of the situation, and some people thought vaccine mandates would be expedient.”

At Johns Hopkins, for example, Nuzzo opposed a booster mandate for the campus in 2022 but understood the final decision to require it. School authorities were intent on bringing students back to campus and worried that outbreaks would force them to shut down again, she said.

“You can argue that seat belt laws are bad because they impinge on civil rights,” Howard said. “But a better thing to do would be to urge people to wear seat belts.”

Makary’s statements had “no grace,” he said. “These were people dealing with an overwhelming virus, and he constantly accused them of lying.”

Several public health officials were particularly upset by the way Makary cast aspersions on the Centers for Disease Control and Prevention’s vaccine safety program. In a Jan. 16, 2023, appearance on Tucker Carlson’s Fox News show, Makary said the CDC had “tried to quickly downplay” evidence of an increased risk of stroke in Medicare beneficiaries who got a covid booster. In fact, the CDC had detected a potential signal for additional strokes in one database, and in the interest of transparency it released that information, Nuzzo said. Further investigation found that there was no actual risk.

During Thursday’s hearing, Makary’s pandemic views were mostly left unexplored, but Democratic and Republican senators repeatedly probed for his views on the abortion drug mifepristone, which became easier to use without direct medical supervision because of a 2021 FDA ruling. Many Republicans want to reverse the FDA ruling; Democrats say there are reams of evidence that support the drug’s safety when taken by a woman at home.

Makary tried to satisfy both parties. He told Sen. Maggie Hassan (D-N.H.) he would be led by science and had no preconceived ideas about mifepristone’s safety. Questioned by Republican Bill Cassidy, chair of the Health, Education, Labor and Pensions Committee and an abortion foe, he said he would examine ongoing data on the drug from the FDA’s risk evaluation system, which gathers reports from the field.

The abortion pill question exemplifies the kind of dilemmas Makary will face at the FDA, Jha said.

“He’s going to have to decide whether he listens to the scientists in his administration, or his boss, who often disagrees with science,” he said. “He’s a smart, thoughtful guy and my hope is he’ll find his way through.”

“The two most important organs for the FDA commissioner are the brain and the spine,” said former FDA deputy commissioner Joshua Sharfstein. “The spine because there’s attempted influence coming from many directions, not just political but also commercial and from multiple advocacy communities. It’s very important to stand up for the agency’s success.”

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CDC Firings Undermine Public Health Work Far Beyond Washington

The Trump administration’s sudden firing of Centers for Disease Control and Prevention employees gutted training programs across the nation whose participants bolstered the workforce of state and local public health departments that for decades have been starved of resources.

The programs are designed to cultivate a new generation of public health leaders, many of whom have gone on to work at the CDC. That was far from its only purpose. Local and state officials said the departures threaten to undermine the nation’s constant effort to identify and control infectious disease outbreaks.

The terminated CDC employees helped prevent and respond to outbreaks such as dengue fever and the flu. They worked with local officials to quickly test for viruses and ensure that testing in public health labs complies with federal regulations. Others monitored potential cases of tuberculosis or provided health education to adolescents to prevent sexually transmitted infections, according to interviews with fired workers and local public health officials.

As a CDC public health adviser, Gaël Cruanes had been working at New York City’s Department of Health and Mental Hygiene to detect cases of tuberculosis, a serious illness that spreads through the air and usually attacks the lungs.

The Public Health Associate Program deploys recent college graduates and other early-career workers for two years. After starting his job in October, Cruanes said, he contacted newly arrived immigrants and refugees potentially at risk of spreading TB in hopes of getting them into the city’s clinics for screening.

“It’s purely for the safety of the public at the end of the day,” Cruanes said. He and other trainees were fired in mid-February.

“It’s unconscionable,” he said.

A spokesperson for the Department of Health and Human Services, Andrew Nixon, declined to comment. The White House and CDC didn’t respond to requests for comment.

The Trump administration’s swift staff reductions in February targeted probationary employees, many hired in the past two years, who lack civil service protections against firings. The administration on Feb. 26 ordered federal agencies to submit plans by mid-March for large-scale layoffs, a move that could encompass a much broader swath of workers.

After CNN published this article, at least some fired CDC workers in the training programs were notified on March 4 that their terminations had been rescinded.

Affected employees were cleared to work on March 5, according to emails viewed by KFF Health News. “You should return to duty under your previous work schedule. We apologize for any disruption that this may have caused,” said the emails, which were unsigned and sent from an internal CDC email address.

The reversal came less than a week after a federal judge ruled that the Trump administration’s widespread terminations of probationary employees were likely illegal.

Seven CDC employees — including from the associate program — assigned to the New York City health department were originally terminated, Michelle Morse, the agency’s acting commissioner, testified during a City Council hearing Feb. 19.

In an interview, Morse said the health department was exploring how to retain them.

“We’re looking into what the CDC could do,” she said, “but we are really just trying to use our own levers that we have within the health department to see what’s possible for those staff.”

Since its creation in 2007, the Public Health Associate Program has placed 1,800 people in nearly every state and territory, plus the District of Columbia, according to the CDC.

The sudden firings meant “there was no lead time to try to figure out what we’re going to do,” said Anissa Davis, the city health officer at the Long Beach Department of Health and Human Services in California.

Three participants of the associate program worked at the Long Beach department, Davis said. A CDC public health adviser was one of four employees working on sexually transmitted infections and HIV surveillance. Two others were with the 13-person communicable disease control team, which includes staff who respond to outbreaks in nursing homes, hospitals, restaurants, and schools, Davis said.

“They are invaluable,” Davis said. “Public health is always under-resourced so having these people really helps us.”

The U.S. public health system was already under severe strain at the onset of the covid-19 pandemic — tens of thousands of jobs disappeared after the 2007-09 recession hit, and spending also dropped significantly for state and local health departments, according to a KFF Health News investigation. The backlash against pandemic-era restrictions drove many more officials to resign or retire. Others were fired. Still, officials said the pandemic also inspired some to pursue public health careers.

Scientists in the CDC’s Laboratory Leadership Service program were also fired in February. The CDC in 2015 started the two-year training fellowship to improve lab safety and quality following a series of failures, including in 2014 when CDC staff in Atlanta were potentially exposed to anthrax. The program each year recruits a small number of doctorate-level scientists; several work in state or local health departments.

At least 16 of 24 fellows in the program were fired in mid-February, according to two scientists who were terminated and spoke on the condition of anonymity for fear of professional retaliation. “Now we can’t be a resource for these labs anymore,” one of them said.

Public health labs need the CDC scientists “because they’re underfunded, understaffed,” the other said. “They are at their capacity already.”

Lab fellows’ responsibilities included helping with outbreak investigations and responses, including by training local staff on how to safely run tests or analyzing samples to identify the cause of an illness. Fellows were recently involved in setting up a new test in Florida to detect Oropouche, a relatively unknown insect-borne disease that has no vaccine or effective treatment. The World Health Organization in December said more than 11,600 cases had been reported in 2024 in South America, the Caribbean, the U.S., Europe, Canada, and Panama. The Florida Department of Health didn’t respond to a request for comment.

Fellows also helped develop the capacity to test for dengue fever in American Samoa, one of them said.

“When new stuff happens that’s urgent, it’s almost all the time we get pivoted to it,” the person said.

Participants in different training programs received the same form letter notifying them of their terminations, according to documents viewed by KFF Health News.

The letters said that terminated people had shown poor performance: “Unfortunately, the Agency finds that you are not fit for continued employment because your ability, knowledge and skills do not fit the Agency’s current needs, and your performance has not been adequate to justify further employment at the Agency.”

However, the fellows’ supervisors had written memos and emails saying they were in good standing, according to documents viewed by KFF Health News. Cruanes said he had not had a performance evaluation when he was terminated — his first was supposed to be Feb. 18, three days after he received his notice. He was among the CDC staff reinstated on March 4.

In Minneapolis, a CDC public health adviser had been providing sexual and reproductive health education in two high schools, as well as doing citywide work on STI testing, said Barbara Kyle, the city’s school-based clinic manager. The department was trying to shift those responsibilities to remaining personnel. “We’re right now just scrambling,” she said.

The city has relied on trainees through the CDC program for more than a decade, Kyle said.

“These two years of learning public health, on-the-ground experience, has really been such a positive move for our country,” she said. “So that concerns me if we lose that pipeline.”

Healthbeat reporter Eliza Fawcett contributed to this report from New York City.

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UnitedHealth Wins Ruling Over $2B in Alleged Medicare Advantage Overpayments

The Justice Department’s years-long court battle to force UnitedHealth Group to return billions of dollars in alleged Medicare Advantage overpayments hit a major setback Monday when a special master ruled the government had failed to prove its case.

In finding for UnitedHealth, Special Master Suzanne Segal found that the DOJ had not presented evidence to support its claim that the giant health insurer exaggerated how sick patients were to illegally pocket more than $2 billion in overpayments.

“A mere possibility of an overpayment is not enough for the government to carry its burden,” Segal wrote in an initial ruling. She recommended that UnitedHealth’s motion to dismiss the case be granted. The recommendation, which is to be presented to the federal judge handling the case, can be appealed within two weeks.

The civil fraud case against UnitedHealth Group, the nation’s largest Medicare Advantage insurer, was filed in 2011 by whistleblower Benjamin Poehling, a former company employee. The DOJ took over the case in 2017. Medicare Advantage is the privately run alternative to the traditional Medicare program for seniors.

“After more than a decade of DOJ’s wasteful and expensive challenge to our Medicare Advantage business, the Special Master concluded there was no evidence to support the DOJ’s claims we were overpaid or that we did anything wrong,” UnitedHealth spokesperson Heather Soule said in a statement.

Wyn Hornbuckle, a spokesperson for the Justice Department, said the agency wouldn’t comment on the ruling, which was filed in federal court in Los Angeles. Attorneys for whistleblower Poehling had no comment.

Medicare pays Advantage health plans higher rates to cover sicker patients but requires that their conditions be properly documented in medical records.

The DOJ alleges Medicare paid UnitedHealth Group more than $7.2 billion from 2009 through 2016 based on the company’s efforts to boost revenue by reviewing patient records to find additional diagnoses and adding medical billing codes to their files. According to the DOJ, Medicare would have paid the company $2.1 billion less if it had deleted unsupported billing codes.

The Justice Department also alleged that in these chart reviews, the health insurance giant ignored overcharges that might have reduced bills.

But the special master, who was appointed by U.S. District Judge Fernando Olguin, concluded the government’s case “depends entirely on speculation and assumptions about what the codes found by the United coders actually mean.”

“If this stands, I think it is a major defeat for the government,” said William Hanagami, an attorney who represented a different whistleblower in one of the earliest cases alleging billing fraud by a Medicare Advantage insurance company. Hanagami said he expects the government to appeal the decision.

Segal noted that UnitedHealth executives told Centers for Medicare & Medicaid Services officials about its chart review policies at an April 2014 meeting. At the time, CMS was considering a regulation to restrict use of chart reviews, but the agency backed off the regulation under pressure from the insurance industry. At the time, a CMS official described the industry’s response as an “uproar.”

The special master noted that United had requested the meeting with CMS officials, which she called “the opposite of concealment.”

“The problem with the government’s allegations is that the government knew of the very chart review practices which it now claims United prevented it from learning, and thus the government cannot have been duped into relying on any action or inaction by United in determining whether it had been the victim of overpayments,” Segal wrote.

Segal noted CMS audits of UnitedHealth’s Medicare Advantage plans had found that about 89% of billing codes were supported by patient medical records. The audit findings “undercut” the government’s claim that the company engaged in widespread overbilling.

“This litigation has been pending for more than a decade,” she wrote, “and the government has had ample opportunity to develop evidence in support of its theories. It has not.”

The decision comes as UnitedHealth faces renewed investigations into its handling of Medicare Advantage coding, including a new Justice Department review.

Medicare Advantage insurance plans have grown explosively in recent years and now enroll about 33 million members, more than half of people eligible for Medicare.

The industry has been the target of dozens of whistleblower lawsuits and government audits alleging that the plans cost taxpayers too much money, including a demand last month by Senate Judiciary Committee chair Chuck Grassley (R-Iowa) that UnitedHealth explain its billing practices.

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Para enfrentar la escasez, estados buscan facilitar que médicos extranjeros ejerzan en el país

Cada vez más estados están facilitando que médicos que se formaron en otros países obtengan licencias médicas, un cambio que, según los partidarios, podría aliviar la escasez de doctores en áreas rurales.

Los cambios involucran a los programas de residencia: la experiencia práctica y supervisada que los médicos deben completar después de graduarse de la escuela de medicina. Hasta hace poco, todos los estados exigían que los médicos que completaban una residencia o una capacitación similar en el extranjero repitieran el proceso aquí en Estados Unidos, antes de obtener una licencia médica completa.

Pero desde 2023, al menos nueve estados han eliminado este requisito para algunos médicos con formación internacional, según la Federación de Juntas Médicas Estatales. Más de una docena de otros estados están considerando legislaciones similares.

Alrededor del 26% de los médicos que ejercen en el país nacieron en otro lugar, según el Instituto de Política Migratoria. Necesitan visas para vivir en Estados Unidos, además de licencias estatales para ejercer la medicina.

Defensores de las nuevas leyes dicen que los médicos calificados no deberían tener que pasar años completando una segunda residencia. Los opositores se preocupan por la seguridad del paciente y dudan que el cambio de licencia alivie la escasez de médicos.

Tanto legisladores de estados con tendencia republicana como demócrata han aprobado la idea en un momento en que muchos otros programas relacionados con la inmigración están bajo ataque. Entre ellos se incluyen Florida, Iowa, Idaho, Illinois, Louisiana, Massachusetts, Tennessee, Virginia y Wisconsin.

El presidente Donald Trump ha defendido un programa de visas federales del que dependen muchos médicos extranjeros, pero aún podrían verse obstaculizados por sus amplios esfuerzos por endurecer las normas de inmigración.

Entre los partidarios de facilitar la obtención de licencias se encuentra Zalmai Afzali, médico de medicina interna que terminó la escuela de medicina y un programa de residencia en Afganistán antes de huir de los talibanes y venir a Estados Unidos en 2001.

Dijo que la mayoría de los médicos formados en otros lugares estarían encantados de trabajar en zonas rurales u otras zonas desatendidas.

“Iría a cualquier parte siempre que me dejaran trabajar”, dijo Afzali, que ahora trata a pacientes que viven en zonas rurales y pequeñas ciudades del noreste de Virginia. “Extrañaba ser médico. Extrañaba lo que hacía”.

Afzali tardó 12 años en obtener copias de su diploma y expediente académico, estudiar para los exámenes y terminar un programa de residencia de tres años en Estados Unidos, antes de poder obtener la licencia completa para ejercer como médico en su nuevo país.

Pero una comisión de organizaciones nacionales de salud se pregunta si la flexibilización de los requisitos de residencia para los médicos formados en el extranjero aliviaría la escasez. Los médicos de estos programas podrían seguir enfrentándose a barreras de licencia y empleo, escribió en un informe que hace recomendaciones sin adoptar una postura sobre dicha legislación.

Erin Fraher, profesora de política sanitaria de la Universidad de Carolina del Norte que asesora a la comisión y estudia el tema, dijo que los legisladores que apoyan los cambios predicen que impulsarán la fuerza laboral sanitaria rural. Pero no está claro si eso sucederá, dijo, porque los programas recién están comenzando.

“Creo que el potencial está ahí, pero tenemos que ver cómo se desarrolla esto”, dijo Fraher.

Afzali luchó para mantener a su familia mientras intentaba obtener su licencia médica. Sus trabajos incluyeron trabajar en una tienda departamental por $7.25 la hora y administrar quimioterapia por $20 la hora. Dijo que las enfermeras practicantes en este último trabajo tenían menos capacitación que él, pero ganaban casi cuatro veces más.

“No sé cómo lo hice”, dijo. “Te deprimes mucho”.

Muchos de los proyectos de ley estatales para aliviar los requisitos de residencia se han basado en la legislación modelo del Instituto Cicero, un grupo de expertos conservador que envió representantes a testificar ante las legislaturas después de proponer estos programas en 2020.

Las nuevas vías están abiertas solo para médicos capacitados internacionalmente que cumplan ciertas condiciones. Los requisitos comunes incluyen trabajar como médico durante varios años después de graduarse de una escuela de medicina y un programa de residencia con un rigor similar a los de aquí. También deben aprobar el examen estándar de tres partes que todos los médicos toman para obtener la licencia en Estados Unidos.

A los que califican se les otorga una licencia para ejercer restringida, y la mayoría de los estados les exigen que lo hagan bajo la supervisión de otro médico. Pueden recibir la licencia completa después de varios años.

Alrededor de 10 de las leyes o proyectos de ley también requieren que los médicos trabajen durante varios años en un área rural o desatendida.

Pero los estados sin este requisito, como Tennessee, pueden no ver un impacto en las áreas rurales, argumentaron investigadores de la Facultad de Medicina de Harvard y Rand Corp. en el New England Journal of Medicine. Además de incluir esa condición, los estados podrían ofrecer incentivos a los hospitales rurales que acepten contratar médicos de los nuevos programas de capacitación, escribieron.

Los legisladores, médicos y organizaciones de salud que se oponen a los cambios dicen que hay mejores formas de aumentar de forma segura el número de médicos rurales.

Barbara Parker es enfermera titulada y ex legisladora republicana en Arizona, donde la legislatura está considerando un proyecto de ley por al menos el cuarto año consecutivo.

“Es una respuesta realmente pobre a la escasez de médicos”, dijo Parker, quien votó en contra de la legislación el año pasado.

Parker dijo que facilitar que los médicos formados en el extranjero ejerzan en aquí sería una forma poco ética de robar médicos de países con mayores necesidades de atención médica. Y dijo que duda que todas las residencias internacionales estén a la par con las Estados Unidos, lo que podría repercutir en los pacientes.

También le preocupa que los hospitales estén tratando de ahorrar dinero al contratar médicos formados en el extranjero en lugar de los formados aquí. Los primeros a menudo aceptan salarios más bajos, dijo Parker.

“Esto está impulsado por la codicia corporativa”, agregó.

Parker dijo que las mejores maneras de aumentar el número de médicos rurales incluyen aumentar los salarios, expandir los programas de pago de préstamos para quienes ejercen en áreas rurales y crear una capacitación acelerada para enfermeras practicantes y asistentes médicos que quieran convertirse en médicos.

La comisión asesora, recientemente formada por la Federación de Juntas Médicas Estatales, el Consejo de Acreditación para la Educación Médica de Posgrado e Intealth, una organización sin fines de lucro que evalúa las escuelas de medicina internacionales y sus graduados, publicó sus recomendaciones para ayudar a los legisladores y las juntas médicas a asegurarse de que estas nuevas vías sean seguras y efectivas.

La comisión señaló que, si bien las juntas médicas estatales pueden confiar en una organización externa que evalúa la solidez de las escuelas de medicina extranjeras, no existe una clasificación similar para los programas de residencia. Se espera que tal esfuerzo se lance a mediados de 2025, dijo la comisión.

El grupo también dijo que los estados deberían exigir a los médicos supervisores que evalúen a los participantes antes que se les conceda una licencia completa.

Afzali, el médico de Afganistán, dijo que algunos médicos de atención primaria capacitados internacionalmente tienen más capacitación que sus contrapartes estadounidenses, porque tuvieron que practicar procedimientos que solo realizan especialistas en Estados Unidos.

Pero estuvo de acuerdo con la recomendación de la comisión de que los estados exijan que los médicos que hicieron residencias en el extranjero tengan supervisión mientras tengan una licencia provisional.

Eso ayudaría a garantizar la seguridad del paciente y, al mismo tiempo, ayudaría a los médicos a adaptarse a las diferencias culturales y aprender el aspecto técnico del sistema de salud estadounidense, como la facturación y los registros médicos electrónicos, escribió la comisión.

Fraher señaló que los médicos en programas con requisitos de supervisión deben encontrar un colega experimentado con el tiempo y el interés en brindar esta supervisión en un centro de salud dispuesto a contratarlos.

La comisión señaló otros obstáculos potenciales, como la posibilidad de que las aseguradoras de mala praxis se nieguen a cubrir a los médicos que obtengan licencias estatales sin completar una residencia en Estados Unidos. La comisión y la Junta Estadounidense de Especialidades Médicas también señalaron la cuestión de la certificación de especialidades, que está gestionada por organizaciones nacionales que tienen sus propios requisitos de residencia.

Los médicos que no sean elegibles para tomar los exámenes de la junta podrían perder oportunidades de empleo, y los pacientes podrían tener dudas sobre sus calificaciones, escribió la junta. Pero dijo que la mayoría de las juntas considerarían la certificación de estos médicos si los estados agregaran los requisitos que recomendó.

Los planes de los legisladores de utilizar estas nuevas vías de obtención de licencias para aumentar el número de médicos rurales requerirán que los médicos formados en el extranjero superen todos estos obstáculos e incógnitas, dijo Fraher.

“Hay muchas cosas que deben suceder para que esto se haga realidad”, dijo.

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Trump Vowed To End Surprise Medical Bills. The Office Working on That Just Got Slashed.

As President Donald Trump wrapped up his first term in 2020, he signed legislation to protect Americans from surprise medical bills. “This must end,” Trump said. “We’re going to hold insurance companies and hospitals totally accountable.”

But the president’s wide-ranging push to slash government spending, led by billionaire Elon Musk, is weakening the federal office charged with implementing the No Surprises Act.

Some 15% of those working at the federal Center for Consumer Information and Insurance Oversight, or CCIIO, were fired two weeks ago, according to the agency’s former deputy director in charge of operations, Jeff Grant.

And while the full impact of the cutbacks is still coming into focus, the retrenchment is threatening work at an agency already laboring to run an overstretched system for resolving sometimes very large bills from out-of-network medical providers.

“It’s a hot mess,” Grant said of the job cuts in an interview with KFF Health News. “The chaos has put everyone in a tailspin.”

The cuts, which affected 82 of the federal office’s employees, also risk delaying critical new rules designed to speed the process of adjudicating disputes over surprise bills between health plans and medical providers.

Grant, who was the top career official at CCIIO, retired last week after 41 years in government. He blasted the layoffs as a “grievous error” in a strongly worded letter to the acting human resources director, criticizing him for cutting jobs without regard for the qualifications of employees or the needs of the agency.

Health insurers have also raised concerns about maintaining the agency’s work on surprise bills.

Spokespeople for the Department of Health and Human Services, led by Robert F. Kennedy Jr., did not respond to questions about the job cuts.

The CCIIO, a small part of the federal health agency, was created by the 2010 Affordable Care Act and charged with ensuring that health insurance plans meet standards established by the law to protect patients.

After Congress passed the No Surprises Act in 2020, the office assumed additional responsibility for setting up and administering the complex process for protecting patients from surprise bills.

The work drew support from Democrats and Republicans, who’d been inundated with stories of patients hit by huge bills from emergency physicians, anesthesiologists, and other providers who were not in patients’ insurance networks, even when patients received care at in-network hospitals.

“We will end surprise medical billing,” Trump promised on the campaign trail in 2020. “The days of ripping off patients are over.”

The law barred medical providers in most cases from pursuing patients over surprise bills. This prohibition is not directly affected by the recent job cuts ordered by Musk’s Department of Government Efficiency, created by Trump through an executive order.

But the CCIIO had been working to streamline a system established by the No Surprises Act to resolve disagreements between health plans and medical providers over out-of-network bills. This key protection was put in place so patients would not be caught in the middle of billing disputes.

The system, known as independent dispute resolution, or IDR, has been inundated with hundreds of thousands of cases. In 2023, more than 650,000 new disputes were filed, according to a recent analysis published in the journal Health Affairs.

“The No Surprises Act has protected millions of Americans from receiving surprise medical bills,” said Jennifer Jones, who directs legislative policy at the Blue Cross Blue Shield Association, an insurance trade group. “But issues with the independent dispute resolution process,” she added, “are driving up costs for patients and employers.”

Also overwhelmed has been a consumer reporting system designed to allow patients to lodge complaints if they feel they have been unfairly targeted with a surprise bill.

Under former President Joe Biden, the CCIIO had been working on new rules to make dispute resolution more efficient, which experts said would make a difference.

“If this rule becomes final and works as well as intended, it should help more out-of-network claims get resolved,” said Jack Hoadley, an emeritus research professor at Georgetown University, who has studied surprise medical billing.

But the new rules weren’t finished before Biden left office. And the senior official overseeing this work left his job in January. The recent cuts hit the remaining CCIIO staffers working on the No Surprises Act, according to Grant and other sources familiar with the layoffs, who asked not to be identified out of fear of professional retaliation.

Grant said senior CCIIO officials were since able to shift some employees around and got permission to recall some of the 82 people let go. But he said there is no guarantee that all of them will want to come back to the diminished agency.

Even more concerning, Grant said, are deeper cuts that the White House has told federal agencies to prepare for by March 13.

“These cuts were pretty bad,” Grant said. “What happens next will be even more important.”

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States Facing Doctor Shortages Ease Licensing Rules for Foreign-Trained Physicians

A growing number of states have made it easier for doctors who trained in other countries to get medical licenses, a shift supporters say could ease physician shortages in rural areas.

The changes involve residency programs — the supervised, hands-on training experience that doctors must complete after graduating medical school. Until recently, every state required physicians who completed a residency or similar training abroad to repeat the process in the U.S. before obtaining a full medical license.

Since 2023, at least nine states have dropped this requirement for some doctors with international training, according to the Federation of State Medical Boards. More than a dozen other states are considering similar legislation.

About 26% of doctors who practice in the U.S. were born elsewhere, according to the Migration Policy Institute. They need federal visas to live in the U.S., plus state licenses to practice medicine.

Proponents of the new laws say qualified doctors shouldn’t have to spend years completing a second residency training. Opponents worry about patient safety and doubt the licensing change will ease the doctor shortage.

Lawmakers in Republican- and Democratic-leaning states have approved the idea at a time when many other immigration-related programs are under attack. They include Florida, Iowa, Idaho, Illinois, Louisiana, Massachusetts, Tennessee, Virginia, and Wisconsin.

President Donald Trump has defended a federal visa program that many foreign doctors rely on, but they could still be hampered by his broad efforts to tighten immigration rules.

Supporters of the new licensing laws include Zalmai Afzali, an internal medicine doctor who finished medical school and a residency program in Afghanistan before fleeing the Taliban and coming to the U.S. in 2001.

He said most physicians trained elsewhere would be happy to work in rural or other underserved areas.

“I would go anywhere as long as they let me work,” said Afzali, who now treats patients who live in rural areas and small cities in northeastern Virginia. “I missed being a physician. I missed what I did.”

It took Afzali 12 years to obtain copies of his diploma and transcript, study for exams, and finish a three-year U.S.-based residency program before he could be fully licensed to practice as a doctor in his new country.

But a commission of national health organizations questions whether loosening residency requirements for foreign-trained doctors would ease the shortage. Doctors in these programs could still face licensing and employment barriers, it wrote in a report that makes recommendations without taking a stance on such legislation.

Erin Fraher, a health policy professor at the University of North Carolina who advises the commission and studies the issue, said lawmakers who support the changes predict they will boost the rural health workforce. But it’s unclear whether that will happen, she said, because the programs are just getting started.

“I think the potential is there, but we need to see how this pans out,” Fraher said.

Afzali struggled to support his family while trying to get his medical license. His jobs included working at a department store for $7.25 an hour and administering chemotherapy for $20 an hour. Afzali said nurse practitioners at the latter job had less training than him but earned nearly four times as much.

“I do not know how I did it,” he said. “I mean, you get really depressed.”

Many of the state bills to ease residency requirements have been based on model legislation from the Cicero Institute, a conservative think tank that sent representatives to testify to legislatures after proposing such programs in 2020.

The new pathways are open only to internationally trained physicians who meet certain conditions. Common requirements include working as a physician for several years after graduating from a medical school and residency program with similar rigor to those found in the U.S. They also must pass the standard three-part exam that all physicians take to become licensed in the U.S.

Those who qualify are granted a restricted license to practice, and most states require them to do so under supervision of another physician. They can receive full licensure after several years.

About 10 of the laws or bills also require the doctors to work for several years in a rural or underserved area.

But states without this requirement, such as Tennessee, may not see an impact in rural areas, researchers from Harvard Medical School and Rand Corp. argued in the New England Journal of Medicine. In addition to including that condition, states could offer incentives to rural hospitals that agree to hire doctors from the new training pathways, they wrote.

Lawmakers, physicians, and health organizations that oppose the changes say there are better ways to safely increase the number of rural doctors.

Barbara Parker is a registered nurse and former Republican lawmaker in Arizona, where the legislature is considering a bill for at least the fourth year in a row.

“It’s a really poor answer to the doctor shortage,” said Parker, who voted against the legislation last year.

Parker said making it easier for foreign-trained physicians to practice in the U.S. would unethically poach doctors from countries with greater health care needs. And she said she doubts that all international residencies are on par with those in the U.S. and worries that granting licenses to physicians who trained in them could lead to poor care for patients.

She is also concerned that hospitals are trying to save money by recruiting internationally trained doctors over those trained in the U.S. The former often will accept lower pay, Parker said.

“This is driven by corporate greed,” she said.

Parker said better ways to increase the number of rural doctors include raising pay, expanding loan repayment programs for those who practice in rural areas, and creating accelerated training for nurse practitioners and physician assistants who want to become doctors.

The advisory commission — recently formed by the Federation of State Medical Boards, the Accreditation Council for Graduate Medical Education, and Intealth, a nonprofit that evaluates international medical schools and their graduates — published its recommendations to help lawmakers and medical boards make sure these new pathways are safe and effective.

The commission and Fraher said state medical boards should collect data on the new rules, such as how many doctors participate, what their specialties are, and where they work once they gain their full licenses. The results could be compared with other methods of easing the rural doctor shortage, such as adding residency programs at rural hospitals.

“What is the benefit of this particular pathway relative to other levers that they have?” Fraher said.

The commission noted that while state medical boards can rely on an outside organization that evaluates the strength of foreign medical schools, there isn’t a similar rating for residency programs. Such an effort is expected to launch in mid-2025, the commission said.

The group also said states should require supervising physicians to evaluate participants before they’re granted a full license.

Afzali, the physician from Afghanistan, said some internationally trained primary care doctors have more training than their U.S. counterparts, because they had to practice procedures that are done only by specialists in the U.S.

But he agreed with the commission’s recommendation that states require doctors who did residencies abroad to have supervision while they hold a provisional license. That would help ensure patient safety while also helping the physicians adjust to cultural differences and learn the technical side of the U.S. health system, such as billing and electronic health records, the commission wrote.

Fraher noted that doctors in programs with supervision requirements need to find an experienced colleague with the time and interest in providing this oversight at a health facility willing to hire them.

The commission pointed out other potential hurdles, such as malpractice insurers possibly declining to cover physicians who obtain state licenses without completing a U.S. residency. The commission and the American Board of Medical Specialties also pointed to the issue of specialty certification, which is managed by national organizations that have their own residency requirements.

Physicians who aren’t eligible to take board exams could lose out on employment opportunities, and patients might have concerns about their qualifications, the board wrote. But it said a majority of its member boards would consider certifying these doctors if states added requirements it recommended.

Lawmakers’ plans to use these new licensing pathways to increase the number of rural doctors will require the foreign-trained doctors to navigate all these obstacles and unknowns, Fraher said.

“There’s a lot of things that need to happen to make this a reality,” she said.

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