Carter’s specialty is reeling in grants to support students in the Omaha Nation school district, where she is a finance manager. One paid for the garden that sits next to the district’s campus. Another allowed the school system, in one of Nebraska’s lowest-income counties, to pay students to maintain it.

“They’re out in the sun. They’re watering plants,” she said. “It’s the first time they get a paycheck in their life.”

Carter, 41, is paralyzed from the chest down, an injury she’s lived with since a fall in her early 20s. It didn’t slow her down as she built her accounting career and got a master’s degree in human resource management.

But in November 2023, Carter — who lives in Sioux City, Iowa — got a letter from Iowa’s Department of Health and Human Services. It said that her income was too high for her to stay on Medicaid and that she might lose her benefits in two weeks if she didn’t take action.

States are scrambling to get ready for a new federal requirement to double-check that many people on Medicaid qualify for the benefit, by showing they are working, volunteering, or studying at least 80 hours per month. Politicians’ focus on requiring work has angered many people with disabilities who have Medicaid and say current policies that apply to them have the opposite effect — making them choose between working or receiving benefits.

‘I Have No Options’

When Carter got the letter, she was making $110,000 a year, well above Iowa’s 2023 income limit for working people with disabilities: $36,450 for a household of one.

“I had no time at all to prepare,” she said. “I had a decision to make.”

At the time, Carter got her health coverage through Iowa’s , a buy-in program that allows working disabled Iowans to pay part of their income to the state to maintain access to Medicaid benefits. Forty-seven states offer , but eligibility through limits on income and assets.

For years, disability rights advocates have pushed state legislatures to change the limits, arguing they prevent people like Carter from accepting raises or building savings, for fear of losing crucial medical benefits. Massachusetts, Minnesota, New Jersey, and Rhode Island have eliminated such limits over the past five years.

To keep her Medicaid coverage, Carter would’ve had to find a job paying her far less than she was making. Or she could drop her Medicaid coverage and enroll in the school district’s health plan. But that plan didn’t cover many of the disability-related expenses that Medicaid did.

Carter decided to keep her job and leave the Medicaid buy-in program. In the end, the decision felt like a no-brainer, she said.

“I like getting up and going to work every day, and I really like what I do,” she said. “Why would I throw that away?”

But it’s been hard on her finances. Carter said she now spends about $35,000 a year out-of-pocket for expenses her old plan covered, such as the nurse who visits her three times a week, modifications to her car, and wheelchair repairs.

“I had the motors go out on my wheelchair,” she said. “So that was like $4,000 to fix.”

Over the next year, Carter picked up extra jobs and cashed in some of her retirement savings.

“I want to pay my own way. I don’t mind paying taxes,” she said. She doesn’t want to hide her income, either. “I just want an option,” she said. “I have no options right now.”

A Program Intended To Encourage Work

Congress to create Medicaid buy-in programs in the 1990s, intending to incentivize more people with disabilities to work. Iowa was one of the first states to adopt the program.

According to state data, 11,640 Iowans were participating in the buy-in program as of late January, or 1.7% of all Medicaid recipients in Iowa.

The income caps have inched up since Carter got her letter. , set at 250% of the federal poverty level, is $39,900 for a household of one this year.

The rules also restrict recipients from accumulating too much in assets. The is $12,000 for an individual or $24,000 for a married couple, excluding some assets, such as a primary home or vehicle.

Carlyn Crowe, the public policy manager at the , said the limits can prevent disabled Iowans from reaching their goals. “Work full-time and be able to buy a house, live in the community, buy a car,” she said. “Those limits placed on what they can earn and save are keeping them from doing that.”

Crowe’s organization, which has counterparts in every state, is and advocates for people with disabilities. In Iowa, such advocates have asked legislators to drop the hard limits on income and assets. Instead, they suggest that disabled Iowans pay 6% of their income to buy into the Medicaid program, an approach modeled after a 2024 that created a Medicaid buy-in program with no income and asset limits. (Tennessee is waiting on federal approval before starting its program.)

In recent years, these efforts have built bipartisan support and gained traction. An Iowa House committee unanimously in 2025 to remove the income and asset caps, but the bill died after failing to move forward during this spring’s legislative session.

State legislatures now in Medicaid spending estimated at more than $900 billion over 10 years, as part of the One Big Beautiful Bill Act.

, an associate director of KFF’s Program on Medicaid and the Uninsured, said the specific worry is that buy-in programs, though they’re a small part of the larger Medicaid system, could increase overall Medicaid spending if eligibility changes.

“The premiums charged in buy-in programs are nowhere near close to the expected costs of covering people,” Burns said. (KFF is a health policy research, polling, and news organization that includes ³Ô¹Ï²»´òìÈ.)

Focusing on initial cost increases is myopic, said , the director of disability policy at at Iowa’s Drake University. More workers mean additional income tax revenue for states. It also enables some people with disabilities to earn enough to transition off other government assistance programs, such as the Supplemental Nutrition Assistance Program.

“Three, five, seven years from now, you may be recouping those expenses by having people be able to work their way off,” Van Sant said.

Falling Through the Cracks

Iowa lawmakers tried a more modest adjustment during this year’s legislative session. Instead of removing the income limit entirely, they introduced legislation that would raise the cap to 300% of the federal poverty level and exempt pension accounts and a spouse’s income, among other things, from the asset cap.

In the end, the provision was stripped from a wide-ranging public assistance bill. If it had passed, the new income limit would have been one of the for a buy-in program, according to KFF.

, a former City Council member in Sioux City who was paralyzed from the chest down after a diving accident, told state lawmakers during a hearing in February that the proposal was a step in the right direction, but not enough.

“I fear that we’re going to lose people to other states,” said Watters, who added that he was considering moving to Minnesota, which never had an income cap and eliminated asset caps for its in 2024.

Even if Iowa had raised its income limit, Carter would still have been ineligible.

Carter remains committed to her primary job at the school district. She plans to keep working there and taking on additional jobs, seven days a week, so she can pay for her medical needs and continue helping students.

This article is from a partnership that includes , , and .

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

The 14-bed hospital, in Sigourney, doesn’t do surgeries or deliver babies. The small 24-hour emergency room is overseen by two full-time doctors.

CEO Matt Ives wants to hire a third doctor, but he said finding physicians for a rural area has been challenging since the covid-19 pandemic. He said several physicians at his hospital have retired since the start of the pandemic, and others have decided to stop practicing certain types of care, particularly emergency care.

Another rural hospital is down the road, about a 40-minute drive east. Washington County Hospital and Clinics has 22 beds and is experiencing similar staffing struggles. “Over the course of the last few years, we’ve had not only the pandemic, but we’ve had kind of an aging physician workforce that has been retiring,” said Todd Patterson, CEO.

The pandemic was difficult for health workers. Many endured long hours, and the stresses on the nation’s health care system prompted more workers than usual .

“There’s a chunk of workers that were lost and won’t come back,” said , who directs the at the University of California-San Francisco. “For a lot of the clinicians that decided and were able to stick it out and work through the pandemic, they have burned out,” Spetz said.

Five years after the World Health Organization declared covid a global pandemic and the first Trump administration announced a national emergency, the United States faces a crucial shortage of medical providers, for an aging population.

That could have , particularly in states like Iowa with significant rural populations. Experts say the problem has , but the effects of the pandemic accelerated the shortages by pushing many doctors over the edge .

“Some of them made it through covid like ‘Let’s get us through this public health crisis,’ and then they came out of it saying, ‘OK, and now? Now I’m exhausted,’” said Christina Taylor, president of the .

“Iowa is absolutely in the middle of a physician shortage,” Taylor said. “It’s a true crisis for us. We’re actually 44th in the country in terms of .”

A 2022 survey by the Centers for Disease Control and Prevention found a who reported feeling burned out and wanting a new job, compared with 2018. The number of people in health care has , said , an associate professor at the University of Minnesota’s School of Public Health, but the growth has not happened fast enough.

“We have an aging population. We have a lot of needs,” she said.

The projected last year that the U.S. of up to 86,000 physicians by 2036 — if lawmakers don’t invest more money in training doctors.

These shortages could push more people to seek care in ERs when they can’t see a local doctor, said , director of workforce studies at the AAMC.

“We’re already at a point where tens of millions of Americans every year can’t get medical care when they need it,” said Dill (no relation to Janette Dill). “If the shortage is sustained or gets even worse, then that problem gets worse too, and it disproportionately negatively impacts the most vulnerable amongst us.”

Iowa lawmakers made addressing the shortage in the current legislative session. They introduced bills aimed at increasing medical student loan forgiveness and requesting federal help to add residency training slots for medical students in the state.

Last year, Gov. Kim Reynolds that drops the residency requirement for some doctors who trained abroad to get a medical license. Lawmakers in at least eight other states have approved similar changes.

Patterson, of the Washington County hospital, appreciates that Iowa lawmakers are trying to increase the pipeline of doctors into Iowa but said it doesn’t address immediate shortages.

“You have a high school student who’s graduating right now; they’re probably nine to 11 years away from entering the workforce as a practicing physician. So it’s a long-term kind of problem,” he said.

For nurses, workforce experts say, the projected national outlook isn’t as dire as in recent years.

“Nursing education is back up. Nursing employment rates are back up. I think, for that workforce, we’ve largely nationally recovered from all the dislocations that occurred,” said Spetz, of the Institute for Health Policy Studies.

But getting nurses to move to the places that need them, like rural communities, will be difficult, she said.

Some rural hospitals in Iowa say an even bigger challenge right now is finding nurses to hire.

Some of that can be traced to the pandemic, said Sara Bruns, nurse manager at Keokuk County Hospital and Clinics. She recalled that some covid patients in critical condition died when they couldn’t be transferred to larger hospitals with more advanced intensive care unit equipment, because those hospitals didn’t have the staff to take on more patients.

“We had to make the horrible decision of ‘You’re probably not going to make it,’” Bruns recalled, saying many patients were then listed as DNR, for “do not resuscitate.”

“That took a big toll on a lot of nurses,” she said.

Another problem is persuading the area’s young nurses to stay, when they would rather live and work in more urban areas, Bruns said.

Her hospital still relies on contracts with travel nurses to fill some night shifts. That’s something the hospital never had to do before the pandemic, Bruns said. Travel nurses are , adding stress to a small hospital’s budget.

“I think some people just completely got out of nursing,” Bruns said. The pandemic took a special toll “because of the hours that they had to work, the conditions that they had to work.”

Policymakers and health care organizations can’t focus only on recruiting workers, according to Janette Dill at the University of Minnesota. “You also have to retain workers,” she said. “You can’t just recruit new people and then have them be miserable.”

Dill said workers report feeling that patients have been more disrespectful and challenging since the pandemic, and sometimes workers at work. “By ‘unsafe’ I mean physically unsafe. I think that is a very stressful part of the job,” she said.

Research has shown health workers of burnout and poor mental health since the pandemic — though the risks decreased if workers felt supported by their managers.

Gail Grimes, an intensive care nurse in Des Moines, felt more supported by her employer during the worst parts of the pandemic than she does now, she said. Some hospitals offered pay bumps and more to keep nurses on staff.

“We were getting better bonus pay,” Grimes recalled. “We were getting these specialized contracts we could fulfill that were often more worth our time to be able to come in, to miss our families and be there.”

Grimes said she’s seen nurses leave Iowa for neighboring states with better average pay. This creates shortages that she believes affect the care she gives her own patients.

“A nurse taking care of five patients will always be able to provide better care than a nurse taking care of 10 patients,” she said.

She thinks many hospitals have simply accepted staff burnout as a fact, rather than try to prevent it.

“It really is significantly impactful to your mental health when you come home every day and you feel guilty about the things you have not been able to provide to people,” she said.

This article is from a partnership that includes , , and ³Ô¹Ï²»´òìÈ.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .