Medicaid Archives - ³Ô¹Ï²»´òìÈ /topics/medicaid/ ³Ô¹Ï²»´òìÈ produces in-depth journalism on health issues and is a core operating program of KFF. Wed, 21 Oct 2026 20:46:46 +0000 en-US hourly 1 https://wordpress.org/?v=6.8.11 /wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=32 Medicaid Archives - ³Ô¹Ï²»´òìÈ /topics/medicaid/ 32 32 257378068 New Arrivals in the ER? Georgia Gears Up To Solve Rural Maternal Health Crisis /health-industry/obstetric-carts-georgia-maternal-health-labor-delivery-rural-hospitals-south-carolina/ Wed, 21 Oct 2026 09:00:00 +0000 /?p=2296603 LAVONIA, Ga. — It had been a decade since Kara Holden last had a baby. But as the former obstetric nurse prepared for her fourth child, her head was swimming with contingency plans.

The labor and delivery unit where she used to work in this rural northeastern Georgia community is no longer open. So, she asked former co-workers to be on standby around her anticipated due date. She and her midwife mapped out emergency rooms along the more-than-50-mile trek to the hospital in Greenville, South Carolina, where she planned to give birth. And, to prepare for a worst-case scenario, she curated items to keep in the car in case she went into labor en route.

“That’s a horrible place to put a pregnant woman in,” said Holden, who on Oct. 11 made the painful, hourlong trip to Greenville Memorial Hospital to deliver her son Tucker.

Holden lives roughly midway between Athens and Greenville, two of the nearest cities with labor and delivery units. Owing partly to Medicaid cuts from President Donald Trump’s One Big Beautiful Bill Act, St. Mary’s Sacred Heart Hospital in Lavonia nearly a year ago. Its closure is part of a trend touching rural communities nationwide. From South Dakota to and from to , low Medicaid reimbursement and dwindling birth rates are pushing hospitals to shutter these services. Today, of rural hospitals offer labor and delivery services.

A newborn baby in a sage green jumper lays on a hospital baby bed.
Kara Holden welcomed her fourth child, Tucker, on Oct. 11. Holden lives roughly midway between Athens, Georgia, and Greenville, South Carolina, two of the nearest cities with labor and delivery units. She traveled more than 50 miles to Greenville Memorial Hospital to give birth. (Kara Holden)

In Georgia, only 36% of rural hospitals have a labor and delivery unit, and four have closed since 2020, according to data from the .

To address the challenge the closings pose to patients seeking care, the state — which ranks among the for maternal health outcomes — has turned to federal money from the $50 billion . This fund was created by congressional Republicans to offset concerns about the outsize fallout Trump’s signature legislation would have in rural communities.

More than $12 million — out of the nearly $219 million approved for Georgia in the program’s first year — will be allocated toward placing obstetric carts in 43 rural hospitals without labor and delivery units. The carts will be outfitted with supplies needed for a birth or obstetric emergency. For example, they’ll have neonatal resuscitation tools, thermal blankets, and essential medications such as oxytocin, which stimulates contractions, and magnesium sulfate, used to treat seizures in pregnant people with high blood pressure.

The delivery carts sound fine, in theory, said Justin Peterson, an OB-GYN who practices in southern Georgia and has seen the pressures rural health institutions face providing maternal care.

Like Holden, Peterson worries that the carts, while helpful, will put supplies in the hands of ER doctors lacking extensive obstetric experience. Instead, he wants the state to fill coverage gaps by investing more to prevent the closure of labor and delivery units in rural areas.

“You’re putting a band-aid on a hemorrhage,” he said.

The entry sign to St. Mary's Sacred Heart Hospital. A lush green lawn surrounds a large white sign.
St. Mary’s Sacred Heart Hospital in Lavonia, Georgia, stopped providing labor and delivery services in October 2025. Hospital leadership cited Medicaid cuts in the One Big Beautiful Bill Act as the final straw. (Briah Lumpkins/³Ô¹Ï²»´òìÈ)

‘Can’t Practice Scared’

Brittany Mitchell was about seven months pregnant when Sacred Heart’s labor and delivery unit closed. She was reassigned to an OB-GYN in Athens, even though the nearly 50-mile drive from Lavonia was stressful and inconvenient.

That OB-GYN wanted to see Mitchell weekly after finding high levels of protein in her urine — a warning sign of preeclampsia, which can cause organ damage, seizures, and other complications. To make it to those prenatal appointments, she routinely gave up a day of work as a home health aide, a job she said already didn’t pay much.

But if Mitchell were to have another baby, she said, she’d still prefer to drive to Athens to see an OB-GYN than be treated by an ER doctor. When she had her first child nine years ago, the local OB-GYN had to act quickly when her daughter briefly lost oxygen.

“If they were in that situation,” she wondered of ER doctors, “would they know how to do all that?”

In written responses to ³Ô¹Ï²»´òìÈ, Lauren Williams, director of communications for the Georgia Department of Community Health, said that training ER medical staff is the main goal of the obstetric cart initiative. The rollout will include simulation drills, during which ER staff will practice high-risk procedures.

The Georgia Hospital Association will procure and distribute the carts. When exactly that will happen is unknown, but the grant funding must be spent by Sept. 30, 2027, said Anna Adams, the organization’s chief government relations officer.

The concept of obstetric carts is great, said Justin Law, an emergency doctor with SouthlandMD, a physician-owned and -operated healthcare management and staffing company. Most items planned for the carts are already available in ERs. But having them in one organized spot will be helpful, he said.

Still, while ER doctors are more frequently positioned at the front lines as labor and delivery closures persist, advocates argue that they shouldn’t be used as a stopgap in obstetric care.

In the decade he’s worked across rural Georgia, Law said, he’s never delivered a baby in the ER even though he’s trained in emergency obstetrics and has experience delivering babies as a paramedic. When a mother needs an emergency cesarean section or has another high-risk complication, she would likely be transferred to a hospital with labor and delivery capabilities, Law said.

Holden, the former obstetric nurse, said familiarity with obstetric delivery practices and procedures is essential because some complications can’t wait for a transfer. “You’re not going to save anybody’s life just because you got access to some equipment,” she said.

Adams understands the concerns and acknowledged that the ER is not the ideal location for delivering a baby. “But sometimes things happen that are outside of our control,” she said. “And when it does, we want to make sure those hospitals are prepared.”

Robin Clyatt, maternal health community outreach coordinator for , said ER doctors have vast knowledge. But they might see someone with a major maternal health complication, such as a hemorrhage, only a few times a year, and therefore may lack the skills to act immediately, she said.

“You can’t practice scared when it comes to obstetrics,” Clyatt said. “And that’s important, because when you practice scared, you do stupid things.”

A pregnant woman leans over to adjust baby clothes on a hanger.
When Holden was pregnant with her other children, the OB-GYN was only a five-minute drive away. But after the local hospital cut its labor and delivery service, she took extra precautions to ensure she was logistically prepared for the arrival of “baby Tucker.” (Briah Lumpkins/³Ô¹Ï²»´òìÈ)
Vintage trinkets and family heirlooms adorn the shelves of a nursery room.
Holden adorned a nursery with vintage trinkets and family heirlooms in anticipation of the arrival of Tucker. (Briah Lumpkins/³Ô¹Ï²»´òìÈ)

Ways To Keep Access

The labor and delivery unit at the Coffee Regional Medical Center in Douglas serves six counties in southern Georgia. The number of live births there increased from to , which shows the impact when nearby facilities close, said Peterson, who practices at the Coffee Regional Hospital Women’s Center.

While he understands that hospitals must consider their bottom lines, business decisions in recent years have often taken precedence over patient care, he said.

“They just say, ‘Oh, you know, the numbers aren’t there. We’re closing,’” he said, adding that when rural labor and delivery units shutter, the chance they’ll reopen is small.

Mark Ralston, public relations manager for St. Mary’s Health Care System, which owns Sacred Heart, did not respond to multiple requests to further discuss the unit’s closure. But in its announcement, the system said the decision followed “an extensive 18-month discernment process that included intensive efforts to recruit additional physicians, create new partnerships, and pursue incremental funding sources.”

Nationwide, states are attempting to narrow gaps in maternal healthcare using federal funds. will establish maternal health hubs to determine where resources are needed and help mothers navigate the health system. in rural communities.

In its proposal for federal rural transformation money, Georgia included incentives such as funding 75 new residency slots in various specialties and creating a grant program that would reimburse physicians up to $250,000 in relocation fees if they chose to practice in rural areas.

State legislators could incentivize doctors to stay in rural areas, offer higher reimbursement rates for hospitals, and provide loan forgiveness for physicians, Peterson said. Communities should also look to incorporate certified midwives and community health workers, Holden and Clyatt said, though for both groups to practice. Currently, certified nurse midwives are allowed to practice only in partnership with a physician, which maternal health advocates argue creates a .

Holden had the ability to send her vitals to her doctor and meet with them virtually for prenatal care.

As she adorned bookshelves in baby Tucker’s cozy, sage-green nursery with vintage trinkets and family heirlooms, she said she thought of less-resourced mothers in the area, who may be on Medicaid or not have the luxury to travel an hour for a prenatal appointment.

Holden worries that without prenatal care, conditions like preeclampsia could go undiagnosed more often. “They don’t make it, and their baby doesn’t make it, because they never got that diagnosed and managed,” she said.

People like to remain optimistic that everything will go as planned, but “there are so many things that can go wrong,” she said. “And they can go wrong really quick.”

The town entry sign for Lavonia, GA. It is a white wooden sign posted in lush green grass.
Lavonia is a small city near the Georgia-South Carolina border. The local St. Mary’s Sacred Heart Hospital stopped providing obstetric services in October 2025, citing Medicaid cuts. Two of the nearest cities with labor and delivery units are each about an hour away. (Briah Lumpkins/³Ô¹Ï²»´òìÈ)
³Ô¹Ï²»´òìÈ 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 .

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

]]> 2296603 Democrats Demand Tougher Standards for Companies Running Medicaid Systems /medicaid/medicaid-eligibility-computer-systems-deloitte-democratic-senators-demand-tougher-standards/ Tue, 20 Oct 2026 09:01:00 +0000 /?p=2298124 A group of Democratic senators is demanding that the federal agency overseeing Medicaid — the health coverage program for people with low incomes or disabilities — institute tougher standards for government contractors running complex computer systems that millions of people rely on to get benefits.

Three Democratic senators issued recommendations a year after launching an inquiry into companies — Deloitte, General Dynamics Information Technology, Gainwell Technologies, and Conduent — that are paid billions in taxpayer dollars to build or run eligibility systems for safety net health coverage. Those benefits, provided to the poorest Americans, can mean the difference between having medical care or going without.

A handful of states directly operate their Medicaid eligibility systems, but most rely on contractors to build and run them. ³Ô¹Ï²»´òìÈ found that Deloitte dominates this slice of government business. Deloitte-run systems have been plagued by errors that can result in eligible people losing their health coverage, previous ³Ô¹Ï²»´òìÈ investigations have shown. Malfunctions can cost millions of taxpayer dollars and take years to fix.

“Administrative errors in this line of work are not like errors in other fields,” the senators . “There are life-and-death consequences for sick Americans who seek care only to find that their Medicaid coverage has been terminated.”

President Donald Trump’s signature tax and domestic policy law has mandated Medicaid changes that are forcing states to adapt their computer systems on a compressed timeline. Medicaid policies under the One Big Beautiful Bill Act add red tape and restrictions that make it harder for people to stay enrolled.

Those include the first federally mandated work requirements in Medicaid’s history. Next year, to keep benefits, millions of adult Medicaid enrollees in more than 40 states must prove they’re working or doing a similar activity for at least 80 hours a month, unless they qualify for an exemption.

Democratic senators Ron Wyden of Oregon, Elizabeth Warren of Massachusetts, and Raphael Warnock of Georgia say the new restrictions — layered atop computer systems with histories of problems — will result in large numbers of people improperly losing health coverage.

State eligibility systems “have been built up, patched, and frankensteined for decades,” the senators said.

The senators sit on the powerful Senate Finance Committee, which oversees government health programs such as Medicare and Medicaid. Many of their recommendations target the Centers for Medicare & Medicaid Services. Their ideas face long odds at the moment. Republicans control executive branch agencies, and any potential legislation would need to advance in a Republican-controlled Congress.

That balance of power could shift if Democrats win a majority of Senate seats in November’s midterm elections. The three lawmakers called on CMS to establish mandatory standards in state contracts with companies so states can receive federal funds.

These companies sign contracts with state governments, but the federal government approves them and pays the bulk of the cost. The federal government covers 90% of state costs to develop and implement state Medicaid eligibility systems and 75% of ongoing maintenance and operations expenses, according to federal regulations.

The lawmakers also said CMS should publicize the contracts and contract amendments. Currently, those documents can be obtained from state governments, but accessibility varies significantly.

The senators also said CMS should publicly disclose companies’ performance data and change orders. Change orders are used to adjust computer systems, and states set aside millions of dollars for them. But systems may require fixes beyond the agreed-upon work.

“The millions of Medicaid enrollees who will be required to prove their eligibility every six months, to document every hour of work on a glitchy portal, to find a doctor willing to certify that their cancer or their chronic condition is bad enough to qualify for an exemption — deserve contractors who are accountable for what happens when the system fails them,” they wrote.

In October 2025, the three Democratic senators, as well as Sen. Bernie Sanders (I-Vt.), sent letters to several companies that CMS identified as eligibility system contractors. At the time, they wrote that it is each company’s responsibility to build functioning eligibility systems, “rather than to prioritize their bottom line.”

As of June, were enrolled in Medicaid, according to CMS.

The lawmakers had asked the companies about their contracts, lobbying expenditures, and protocols for making changes in light of system errors, among other issues. The companies provided the lawmakers with some details but often did not answer their questions.

The companies said states are responsible for making the final call on whether a person receives benefits. State workers approve or deny eligibility, Deloitte said in its response letter, “not a private contractor or an automated system acting alone.”

The companies did not provide the senators with specific details about documents or processes they use to help states make eligibility determinations.

The companies also denied they have any financial incentives to remove people from Medicaid. Conduent said it gets paid less if enrollment drops.

The companies did not say whether states are on the hook for paying to fix the companies’ errors.

Deloitte, Gainwell, GDIT, and Conduent said it’s common for states to require that they meet certain performance metrics.

Gainwell told lawmakers, “We take seriously the issues raised.”

GDIT said it would answer additional questions from lawmakers and told ³Ô¹Ï²»´òìÈ that it “has a strong track record” of supporting Medicaid programs. In New York, GDIT said it has a “limited role” in determining eligibility because it relies on rules provided by the state. GDIT operates New York’s online Affordable Care Act marketplace, where New Yorkers can enroll in various health plans, including Medicaid.

Deloitte said in its response to the lawmakers: “We are proud of our work serving individuals and families across the U.S.”

CMS did not respond to a request for comment.

CMS takes steps to check whether Medicaid eligibility systems are working properly. As part of the process for certifying states’ systems, federal officials . They include whether states are correctly calculating people’s incomes, whether individuals are given timely eligibility decisions, and whether eligibility categories are accurate. However, it is rare for the federal government to withdraw federal money from states for falling short.

In August, CMS announced it intends to for Medicaid systems. The ultimate goal is to improve enrollees’ access to care and their experiences with these systems, CMS said. The agency also has said the standards will hold companies accountable to deliver systems that are “continuously improving” and have a “stronger capacity to implement critical policy changes.”

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2298124 Next Governor To Face Thorny Choices After California’s Rapid Medicaid Expansion /elections/medicaid-cuts-medi-cal-insurance-immigrants-hilton-becerra-california-governor/ Fri, 16 Oct 2026 09:00:00 +0000 /?p=2292860 In March 2025, when California ran out of Medicaid funds to pay doctors and hospitals, the state borrowed $3.4 billion to keep the program afloat. It was, as a spokesperson for Gov. Gavin Newsom insisted, nothing new. Indeed, a handful of times over the years, the state had taken out internal, short-term loans to sustain its healthcare program for the poor and disabled.

The unprecedented move came a few months later, when Newsom and Democratic state lawmakers agreed to pay down the loan — which grew to $4.4 billion — instead of later in the year. California’s healthcare safety net, it seemed, was buckling.

Rising healthcare costs systemwide were partly to blame. But so were several state-led expansions that made California’s Medicaid program, known as Medi-Cal, one of the nation’s most generous.

Now, with congressional Republicans’ One Big Beautiful Bill Act expected to reduce federal Medicaid spending by more than $900 billion over 10 years, California and dozens of other states must contemplate the limits of their generosity. The problem is particularly acute in the nation’s most populous state, which spends more on Medicaid than combined.

“We know we can’t afford to serve everybody we want to serve in the model that we have today,” said Mark Ghaly, the former top Newsom health official who now co-chairs , a 29-person panel with the goal of modernizing and sustaining California’s Medicaid program for those who need it. “What can we do differently? What can we do smarter?”

The 2025 law that Newsom, a Democrat, has dubbed President Donald Trump’s is expected to leave millions more Americans without health insurance, mostly because of new . It also curbs the use of healthcare provider taxes and other strategies states have deployed to maximize federal funds. Some state lawmakers and consumer advocates have argued the federal cuts, along with rising costs, present an opportunity for the next governor to overhaul a program plagued by long appointment wait times, low reimbursement rates for healthcare providers, and volatile financing.

“If we continue to just give millions and millions into the same system and expect something different — I’m sick and tired of that,” said Caroline Menjivar, a Democratic state senator representing a Los Angeles-area district where roughly half of constituents rely on Medi-Cal.

Democratic lawmakers, who have often clashed with Newsom on Medi-Cal rollbacks, succeeded in getting him to delay a number of painful cuts until 2027 in hopes that a new governor might reverse them.

So far, neither of the candidates running in the November election to replace Newsom have offered substantive proposals for weathering the upheaval health policy experts say is on the horizon for a program that covers 1 in 3 Californians — roughly 13.6 million people.

Republican Steve Hilton, a former Fox News commentator, wants to pare back Medi-Cal eligibility and has promised to end coverage for immigrants without legal status, citing that benefit as an example of “wildly unsustainable” state spending. Democrat Xavier Becerra, who has spent decades trying to , has promised to protect Californians from the massive federal cuts.

Expanding Coverage

President Lyndon B. Johnson that established Medicaid and Medicare in 1965 to cover certain low-income groups, such as families with children, older people, and those with disabilities. Over the past six decades, states have substantially widened that pool, most notably under the Affordable Care Act’s Medicaid expansion to childless adults.

Starting in 2024, California offered healthcare coverage to all low-income residents, regardless of age or immigration status, although lawmakers scaled that back this year. At the same time, the state opted to cover a slew of non-mandated benefits such as physical therapy, hospice care, and housing assistance.

“California has always struggled with wanting to have as broad a program as possible but then having to figure out a way to pay,” said Jennifer Kent, who oversaw Medi-Cal under Gov. Jerry Brown, a Democrat. “There is no population that we have met that we don’t want to offer coverage to, and we’ve never met a benefit that we don’t like.”

Since 2010, California’s Medi-Cal enrollment has nearly doubled while spending has ballooned from $50 billion a year to . It now makes up more than 40% of overall state spending, according to the .

Conservatives argue the program is . They say the federal changes will force states to refocus resources on the neediest.

“The role of the safety net programs was just that — to be a safety net,” Hilton said in an interview. “I don’t think it’s a particularly positive boast to say 40% of Californians should be on a program that was designed for people living in poverty.”

Becerra declined an interview request.

Nelly, a 59-year-old from Los Angeles County, was one of millions who have benefited from the state’s Medi-Cal expansion, but she was initially reluctant to sign up.

For years after she left her corporate job to care for her ailing mother, Nelly said, she didn’t consider applying. She remained uninsured until three years ago, when she woke up and couldn’t see out of her left eye.

She enrolled in Medi-Cal in the emergency room. It now covers her appointments with specialists and transportation to and from. While her condition may exempt her from the new Medicaid work requirements, Nelly said, she’s still worried about losing coverage after experiencing numerous paperwork hiccups simply trying to renew.

Nelly, who asked that her full name not be used, because she hasn’t told her family about her condition, said she understands not everyone on the program may need it. But, she added, “it should be there for someone like me.”

Tough Choices Ahead

When Republican state lawmakers got wind of Newsom’s plan to stretch the debt repayment over a decade, they accused Democrats of trying to “paper over” the state’s structural deficit.

“This leaves future governors and legislatures to clean up the mess,” stated from GOP senators. The Legislative Analyst’s Office later called the maneuver “unusual.” That could leave Becerra, the favorite to succeed Newsom in the overwhelmingly liberal state, as the face of staggering changes to a program he spent his career defending.

More than 2 million Californians under age 65 could lose health coverage over the next four years as a result of the state and federal policy changes, according to by the University of California-Berkeley Labor Center and the UCLA Center for Health Policy Research. At least 730,000 residents have already disenrolled since June 2025.

State agencies are scrambling to implement new federal work requirement rules for adult Medicaid enrollees under 65, hoping to automate as much verification as possible to blunt coverage losses. And in 2028, states will be required to charge some enrollees fees for many services, making it harder for them to maintain coverage.

Disability rights activists say new asset limits will prevent Californians from getting needed home care, which they say is more cost-effective and humane than nursing homes. Counties, deemed by state law to be healthcare providers of last resort, say they need immediate funding for the millions of uninsured patients they anticipate in the new year.

Hospital administrators have urged policymakers to help them keep their facilities stable, and the state’s most recent budget included some $390 million to assist public and .

Martin Luther King Jr. Community Hospital in Los Angeles treats five times the patients it was designed to serve, and 80% of patients are uninsured or on Medi-Cal. Demand is so high in the chronically underserved area, MLK Community Healthcare CEO Elaine Batchlor said, that the hospital has erected tents in the parking lot. Most emergency room patients are now treated there.

“We already have an extremely overcrowded, overburdened emergency department,” Batchlor said. “Insured care will turn into uncompensated care, and the financial burden for that will fall on providers.”

Becerra has said he opposes the state’s recent freeze on enrollment for adult immigrants without legal status, as well as new monthly premiums set to take effect next year, saying such moves will only saddle taxpayers with higher bills for ER care.

If elected, Becerra will probably need to wade into the politically toxic debate over whether to raise more revenue, , or do both.

Aside from promising to find and eliminate billions in administrative waste from the industry, the nation’s former top health official has not explained how he would cobble together the tens of billions of dollars the state is likely to need just to maintain status quo.

The next governor must tread carefully, Kent warned. “When people come and say, ‘Well, you should just do this because it’s the right thing,’” she said, “all of those right things have fiscal consequences.”

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2292860 California’s Billionaire Tax Promises Healthcare Relief. The Fine Print Is Murkier. /elections/california-billionaire-wealth-tax-healthcare-cuts-competing-ballot-measures/ Wed, 14 Oct 2026 09:00:00 +0000 /?p=2287931 The pitch behind California’s is simple: Tax the richest residents in the nation’s wealthiest state to offset steep federal cuts to healthcare, food assistance, and education.

But if approved by voters in November, it’s unclear how much money the ballot initiative would raise, how quickly the funding would become available, and how lawmakers would spend it.

The measure would steer proceeds from a first-in-the-nation wealth tax to a state healthcare fund, giving the governor and lawmakers the power to decide how to spend what California’s nonpartisan legislative analyst “tens of billions of dollars.” Backers say it could raise up to $100 billion over five years to keep hospitals and emergency rooms open and preserve insurance coverage for millions of Californians. Yet, community health centers, doctors, and other healthcare entities that might benefit from such a cash infusion argue that the union spearheading the measure has readied a blank check for politicians.

“I’m not sure that you can say, with full security, that this will stop clinics from being closed or healthcare workers from being laid off, or people from losing their healthcare,” said Chris Hoene, executive director of the California Budget & Policy Center, a left-leaning nonprofit.

Can’t see the audio player? Visit kffhealthnews.org to listen.

Taxing the Ultrarich

Put on the ballot by one of California’s largest healthcare unions, Proposition 40 would impose a one-time 5% tax on with a net worth of at least $1 billion, including most of their stock holdings, yachts, and artwork. It would apply to those who were residents of California on Jan. 1, 2026. Real estate, pensions, and retirement accounts would generally be exempt.

The revenue raised is intended to offset the roughly in anticipated losses to the Golden State from congressional Republicans’ One Big Beautiful Bill Act. Over the next four years, state and federal funding cuts are projected to nearly double California’s uninsured population, which stands at , according to the University of California-Berkeley Labor Center.

Securing additional tax revenue is essential because state lawmakers have yet to come up with a way to pay for healthcare services that will be affected by the cuts, said Dave Regan, president of Service Employees International Union-United Healthcare Workers West, which represents hospital workers and got the wealth tax on the ballot. It would earmark 90% of the tax revenue for healthcare, while the remaining 10% would be split between food assistance and education at lawmakers’ discretion. Regan said such broad categories would give politicians flexibility to be more responsive to the looming cuts.

“Figuring out or predicting exactly what the fallout will be, of where reductions and cuts get made, in a complicated healthcare system, it’s just too difficult to predict,” Regan said.

Among the choices the next governor and lawmakers will face are whether to provide healthcare to people cut off by the new federal Medicaid work requirements, reverse state rollbacks limiting coverage for immigrants with legal status, or raise the low physician reimbursement rates that make some providers reluctant to accept patients enrolled in Medi-Cal, the state’s version of Medicaid.

Lawmakers could also shore up subsidies on Covered California, the state’s health insurance marketplace, whose enrollees have seen their premiums skyrocket after losing millions in federal assistance after Congress last year let enhanced subsides expire.

Most of the money must be spent on health, but healthcare experts said the measure’s ambiguous language could allow lawmakers to use the new billionaire health fund to replace existing state dollars, contrary to the text of the proposition.

“A lot of times these propositions are written in a way to get attention and get support,” said Glenn Melnick, a healthcare economist at the University of Southern California. “But in fact, they can be used for other things later.”

Instead, the healthcare industry is pushing for a long-term funding plan. René Bravo, a pediatrician in San Luis Obispo County and the president of the California Medical Association, worries that a one-time infusion of tax dollars “is going to run out.”

“We need to work on a more sustainable, durable funding mechanism for the Medi-Cal system,” he said.

At the same time, doctors are asking him what will happen when the biggest Medi-Cal eligibility cuts begin to take effect next year. Even if voters approve the ballot measure, the money wouldn’t be available for at least a few months while the state collects the tax. And billionaires could spread their payments over five years.

Californians Divided

Pasadena resident Lynne Wines, a 72-year-old retired banker, knows the state needs the money. But she worries that wealthy investors will see the measure as a precedent and flee the state. Even though the ballot measure is clear that it’s a one-time tax, Wines said it’s a slippery slope.

“Taxes have a way of being needed over and over, and politicians have a way of finding those needs,” Wines said. “So, I don’t really feel secure that this is just a one-time thing.”

She noted that Google co-founder and billionaire Sergey Brin bought a home in Nevada and moved some of his businesses to the Silver State late last year. He is backing ad campaigns opposing the measure. Brin has given more than $100 million to a nonprofit promoting two competing measures, Propositions 41 and 42, designed to blunt or block it, according to contributions filed with the secretary of state’s office. One would count some new state taxes toward California’s overall spending limit and require the state auditor to review new state tax proposals before voters weigh in. The other would prohibit new state taxes on personal property, intellectual property, retirement accounts, and other assets.

GOP gubernatorial candidate Steve Hilton, who has been endorsed by President Donald Trump, warned on CNN in June that just the threat of the tax “has sent trillions of dollars, by some estimates, of wealth leaving the state.” A March study by the conservative Hoover Institution at Stanford University projected that the billionaire tax would , citing, in part, the lost revenue from billionaires who have already left the state.

California voters appear torn over departing billionaires. Two independent September polls suggested voter support for Proposition 40 varied from a to a .

Pasadena resident Steve Erler, 74, works full-time as a building manager because he can’t afford to retire. He worries that federal cuts will hurt children and seniors.

A middle-aged man kneels on lush green grass with his medium-sized dog on a leash beside him.
Steve Erler of Pasadena, California, works full-time as a building manager because he can’t afford to retire. He worries that federal cuts will hurt children and seniors, and he supports a California ballot measure that would tax billionaires. (Jackie Fortiér/³Ô¹Ï²»´òìÈ)

“These people who are making all this money, they can never spend it all. What are they going to do, buy another house in the Hamptons, buy another jet? They don’t need that,” Erler said while out walking his dog in August. “They need to be able to say when they go to bed at night, ‘I helped a child with healthcare. I helped a senior get fed.’ That’s what’s important,” he said.

Democrats are divided — one of many ideological fights playing out nationwide this election cycle as progressives take on more centrist candidates. U.S. Sen. (I-Vt.) and the have endorsed Proposition 40, while Gov. Gavin Newsom, who is exploring a presidential bid, and Democratic gubernatorial nominee Xavier Becerra oppose it while saying that ultrawealthy or high-earning people should pay more. “It’s time for an economic reset, a true minimum tax on billionaires that, well, ensures the people at the very top pay at least the tax rate their own workers pay,” said Newsom, who supports a , although legislation for a federal has stalled.

If voters approve the ballot measure, political analysts said, it could show other states that taxing the wealthy may help close budget gaps and pay for essential services. Already several Democratic states, including , , , and , have approved millionaire taxes, but those have been limited to income, not overall wealth. Voters in Washington state will decide this fall whether to .

“I do think this is just the beginning of these proposals nationwide,” said Melnick, the USC healthcare economist.

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2287931 Midterms Have Revived Universal Healthcare Debate. These States Are Ahead of Everyone. /elections/single-payer-universal-healthcare-debate-midterms-oregon-proposal/ Fri, 02 Oct 2026 09:00:00 +0000 /?p=2290549 Democratic congressional members and candidates are already planning to use any midterm election gains to , including boosting Affordable Care Act subsidies, reversing Medicaid cuts, and lowering the Medicare eligibility age.

But Democratic strongholds across the country — including Oregon, California, , and — have more ambitious goals: single-payer, universal healthcare systems.

No state is closer to that goal than Oregon. A panel created by the state legislature in 2023 is slated to send lawmakers its proposal for a universal health plan by Dec. 1. The nine-person seeks to establish, starting in 2032, medical, vision, dental, and mental health benefits for every state resident from cradle to grave — with no premiums, deductibles, or copayments. Lawmakers could vote on a plan during the 2027 legislative session or refer it to voters as a ballot measure in 2028.

If approved, the state would be the first in the U.S. to implement what’s called a single-payer health coverage system. It could serve as a model for other states — and potentially the nation.

Proponents of the proposal argue that the public supports universal healthcare more than ever as healthcare spending and complexity grow. patients often delay care due to out-of-pocket costs. And medical debt remains a in the nation.

States have often served as laboratories to test health policies later implemented nationally. The Affordable Care Act was modeled after Massachusetts’ attempt to achieve universal health insurance coverage, once single-payer efforts there stalled. And Canada’s universal healthcare system began with a provincial plan in Saskatchewan.

“In the short to medium term, there is no chance that ‘Medicare for All’ can be passed at the national level,” said , a University of North Carolina health policy professor. “That’s where the states come in. A state like Oregon provides a more hospitable political environment and a more realistic path to single-payer reform.”

But advocates of the plan expect a significant fight from healthcare behemoths, including large hospital systems, seeking to sour public opinion on making such widespread changes. are health insurers. The industry’s deep pockets have helped derail myriad universal healthcare efforts at the federal and state levels.

In 2011, the Vermont Legislature voted to implement a universal healthcare plan but, three years later, Democratic Gov. Peter Shumlin, who had campaigned on the promise of single-payer, pulled the plug, citing “potential economic disruption.”

States that took the issue directly to voters have fared no better. Ballot measures in in 2016, in 2002, and in 1994 all failed by large margins.

“The aspirations of progressive reformers usually run smack into sobering political realities,” Oberlander said. “Translating a slogan into a legislative and political reality is a daunting task.”

A man wearing a blazer over a bright red shirt stands in front of a crowd while speaking into a microphone in an outdoor setting.
Valdez Bravo, president of Health Care for All Oregon, speaks at the nonprofit’s annual garden party in Portland on Sept. 12. The state will soon consider a plan for universal health coverage that the state legislature ordered in 2023. (Christena Dowsett for ³Ô¹Ï²»´òìÈ)

Redirected Healthcare Dollars

Oregon’s proposal seeks to maintain the current level of spending on healthcare by government, business, and consumers with new corporate and personal taxes to replace insurance premiums and other out-of-pocket costs. Those would be combined with federal and state spending to create a single fund from which all hospitals, doctors, and other practitioners would be paid.

Board members said savings from cutting red tape, reducing fraud, and negotiating drug costs should allow the state to provide better benefits to more people.

In , the board estimated that a 30-year-old making $55,000 and purchasing a benchmark silver-level plan through the Affordable Care Act now pays $5,478 a year for insurance premiums in Oregon, but instead could pay $2,331 in taxes under the proposed plan.

Someone making $55,000 a year with coverage through their employer now pays $3,063 in premiums and out-of-pocket costs. Under the draft plan, that person could pay nothing for health services and could see any doctor in the state.

Currently, many employers pay much of the health insurance costs for their workers. The plan seeks to maintain those contributions by establishing a corporate payroll tax for companies whose payrolls exceed $500,000. Their employees could receive a partial tax credit for the taxes their employers pay. As a result, 31% to 60% of Oregonians wouldn’t pay anything for health benefits.

More affluent people, however, could end up paying more than they do now. The exact numbers would depend on how lawmakers set tax rates and payment thresholds.

“What we are proposing is something very different,” said , executive director of the Oregon board. “Everyone contributes based on the amount that they are able to contribute and not based on utilization.”

A man stands at a vendor table outdoors. He has signs, pins, and other information about "Health Care for All Oregon."
A work group created by the state legislature in 2023 is slated to send lawmakers its proposal for a universal health plan by Dec. 1. Lawmakers could vote on the plan as soon as the next legislative session or refer it to a ballot measure in 2028. The nonprofit Health Care for All Oregon hosted a garden party on Sept. 12 ahead of the reveal. (Christena Dowsett for ³Ô¹Ï²»´òìÈ)
Pamphlets with information about "Health Care for All Oregon" are stacked on a red table.
Backers of the universal healthcare coverage plan will try to convince hospitals and health systems that they would benefit from reducing red tape and eliminating unpaid bills. (Christena Dowsett for ³Ô¹Ï²»´òìÈ)

Messaging Challenge Lies Ahead

The plan’s backers will try to convince hospitals and health systems that they would benefit from reducing red tape and eliminating unpaid bills. Currently, hospitals to bill dozens of public and private health plans, each with its own coverage and billing rules. A single plan covering everyone in the state could streamline the process, saving billions.

Rural hospitals could gain financial stability. They now often struggle to stay afloat because they typically have higher rates of patients who are uninsured or on Medicaid, with its often low reimbursement rates.

Hospitals aren’t so sure.

“The universal health plan proposal preserves much of the broken, fragmented status quo and adds new taxes and complexity that Oregonians can’t afford,” said Becky Hultberg, president and CEO of the . “With federal policy changes looming, we are entering a period of tremendous upheaval. This proposal could destabilize a system that is already struggling.”

Under the proposal, doctors and other practitioners would be paid somewhere between what Medicare pays on the low end and what private insurance pays on the high end. Although total payments to doctors would remain unchanged, rates would be negotiated with physician groups to shift more money into primary care and less into specialty services.

But it is unclear whether doctors would agree that more patient time, fewer administrative hurdles, and no more unpaid bills would be worth a payment structure that could cause specialists to lose out.

A woman with dark, straight black hair tied up in a bun stands for a photo. She has a plastic name tag attached to her shirt that says, "Healthcare for All Oregon / Rebecca Shcoon."
Rebecca Schoon, an associate professor at Pacific University who attended last month’s Health Care for All Oregon garden party, says that communicating what universal healthcare is will be one of the biggest challenges ahead for Oregon’s proposed plan. (Christena Dowsett for ³Ô¹Ï²»´òìÈ)

“There’s always winners and losers in designing something like this, and so how to distribute those is the hardest part,” said , an associate health policy professor at Pacific University who is slated to join the Oregon board in January. “But the second-hardest part is, I think, messaging this.”

Courtni Dresser, vice president of government relations for the , said her physicians group shares many of the board’s goals in improving access to care and reducing administrative burdens. But the group has yet to declare its support or opposition to the effort.

Health insurers haven’t formally weighed in on Oregon’s proposal either, but a single-payer system would, in essence, close off Oregon to any private healthcare plans.

“We expect insurance companies to put every ounce of money they can against this idea because our system is broken and they profit from it,” said Collin Stackhouse, communications coordinator for , a consumer group advocating for universal healthcare.

, a former insurance company executive who now works to expose industry influence, said he expects health plans to hammer the Oregon proposal with claims of high taxes, loss of choice, and the specter of “socialized medicine.”

“Most people go year to year without testing the limits of their health insurance policy,” Potter said. “And so, they’re easily scared into thinking that something valuable will be taken away from them, and that they will have something that’s inferior in its place.”

Health insurers argue their health plans help shield consumers from the full impact of rising healthcare costs.

“Americans consistently report strong satisfaction with their health coverage, including more than 180 million covered through work and 36 million who choose Medicare Advantage,” said Chris Bond, a spokesperson for the health insurance . “Policy solutions are needed to rein in the ever-higher prices charged by hospitals and drugmakers and make care more affordable for everyone.”

A man wearing plaid is holding a canned beverage while speaking to another man close beside him. A button is visible on the man in plaid's shirt, it says "Health Care for All Oregon."
Volunteers converse at the Sept. 12 garden party in Portland. Oregon’s legislature created a work group in 2023 to draw up a plan to create universal healthcare in the state. The proposal is due Dec. 1. (Christena Dowsett for ³Ô¹Ï²»´òìÈ)

Federal Approval Needed

It’s unclear whether Oregon could secure federal approval to redirect Medicare and Medicaid dollars into its universal plan. Backers of the proposal do not expect the Trump administration to be receptive but say it will be years before approval is needed and hope the 2028 presidential election ushers in a more supportive administration. If federal waivers are not secured, Oregon could proceed in stages, starting with the non-Medicare population.

In California, Democratic candidates for governor are not debating whether to implement single-payer but how. New York lawmakers are debating a single-payer bill called the . And in Washington, state legislators have created a commission to design a universal healthcare plan.

The Oregon board has had regular contact with teams working on single-payer proposals in California and Washington, sharing approaches and looking for ways to collaborate, McDonell said.

, an Oregon family physician and a member of Physicians for a National Health Program, said he could envision the other West Coast states joining Oregon in implementing single-payer, much as California, Washington, and ±á²¹·É²¹¾±â€˜i have in to counter changes in federal vaccine recommendations.

“If our four states could do it,” he said, “that would be the momentum we would need to get it nationally.”

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2290549 The MAHA Metamorphosis /podcast/what-the-health-465-maha-movement-rfk-jr-trump-hhs-spending-october-1-2026/ Thu, 01 Oct 2026 18:50:00 +0000 /?p=2292271&post_type=podcast&preview_id=2292271 The Host
Julie Rovner photo
Julie Rovner ³Ô¹Ï²»´òìÈ Read Julie's stories. Julie Rovner is chief Washington correspondent and host of ³Ô¹Ï²»´òìÈ’ 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.

The big “Make America Healthy Again” summit at a glitzy Washington, D.C., hotel this week highlighted a split in the movement between moms who want pesticides and artificial ingredients out of their kids’ food and wellness entrepreneurs who want to promote their products to government regulators.

Meanwhile, as the new fiscal year begins, the Trump administration is refusing for the second year in a row to spend hundreds of millions of dollars Congress approved for the Department of Health and Human Services — and daring lawmakers or the courts to try to do something about it.

This week’s panelists are Julie Rovner of ³Ô¹Ï²»´òìÈ, Shefali Luthra of The 19th, Rachana Pradhan of ³Ô¹Ï²»´òìÈ, and Rachel Roubein of The Washington Post.

Panelists

Shefali Luthra photo
Shefali Luthra The 19th
Rachana Pradhan photo
Rachana Pradhan ³Ô¹Ï²»´òìÈ Read Rachana's stories.
Rachel Roubein photo
Rachel Roubein The Washington Post

Among the takeaways from this week’s episode:

  • The transformation of the Make America Healthy Again movement was on display at a MAHA Institute meeting in Washington this week. The gathering featured wellness companies hawking their wares and largely steered clear of the movement’s core issues, such as vaccines and pesticides. Many MAHA adherents have expressed disillusionment with the Trump administration, seeing it as favoring corporate interests over their priorities, and some progressives are starting to make a play for the support of these disaffected activists.
  • The Trump administration is again attempting to cancel some congressionally appropriated health funding via a controversial strategy known as a pocket rescission. The 2026 fiscal year concluded this week, effectively running out the clock for Congress to force the Trump administration to distribute that money — and with the House already recessed until after the midterm elections.
  • And the Hyde Amendment turned 50 this week. The legislative measure prohibits federal funding from being used to pay for abortions, effectively banning Medicaid funding of pregnancy termination unless states opt to spend their own money to offer that benefit for those who are low-income or disabled.

Also this week, Rovner interviews Aaron Carroll, president and CEO of AcademyHealth, to discuss the Trump administration’s dismantling of the federal Agency for Healthcare Research and Quality.

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

Julie Rovner: The New York Times’ “,” by Madaleine Rubin.

Shefali Luthra: The Atlantic’s “,” by Caitlin Dickerson.

Rachana Pradhan: ³Ô¹Ï²»´òìÈ’ “US Poised To Boot Legal Immigrants From Medicaid, Including Refugees and Sex-Trafficking Victims,” by Phil Galewitz, Andrew Jones, and Claudia Boyd-Barrett.

Rachel Roubein: Stat’s “” by Elaine Chen.

Also mentioned in this week’s podcast:

  • The Washington Post’s “,” by Rachel Roubein.
  • The Washington Post’s “,” by Rachel Roubein.
  • The New York Times’ “,” by Apoorva Mandavilli.
Click to open the transcript Transcript: The MAHA Metamorphosis

[Editor’s note: This transcript was generated using transcription software. It has been edited for style and clarity.] 

Julie Rovner: Hello, from ³Ô¹Ï²»´òìÈ and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for ³Ô¹Ï²»´òìÈ. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, Oct. 1, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Rachel Roubein of The Washington Post. 

Rachel Roubein: Hey, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And my ³Ô¹Ï²»´òìÈ colleague Rachana Pradhan. 

Rachana Pradhan: Hi, Julie. 

Rovner: Later in this episode, we’ll have my interview with Dr. Aaron Carroll of AcademyHealth about the undoing of the federal Agency for Healthcare Research and Quality, AHRQ, where most of the staff has been laid off or retired, and hundreds of grants have been canceled midcycle. But first, this week’s news. 

So we haven’t talked about the Make America Healthy Again movement in a while. It was a big week for MAHA here in Washington, D.C., with a gigantic summit at what used to be the Trump [International] Hotel, down the street from the White House. But it was hardly the event you’d expect if you still think of MAHA as moms who want their kids to have access to healthier food grown with fewer pesticides. Rather, this event featured representatives from health companies with business before the federal government, paying sponsorships of up to $300,000 each to sit on panels with officials from said government to talk about everything from the use of psychedelic drugs to fraud-fighting to wearables and AI [artificial intelligence]. The panel featuring Medicare and Medicaid chief Dr. [Mehmet] Oz was somewhat bizarrely moderated by comedian Russell Brand, who’s awaiting trial on sexual misconduct charges back in England. What was this event supposed to accomplish? 

Roubein: I think you kind of hit the nail on the head in terms of just thinking about the MAHA movement and sort of where it’s going next, because you had some people, more sort of MAHA activists, who were upset that it didn’t talk about some of the core issues of the MAHA base, like vaccines, like pesticides. There have been some influential MAHA activists who’ve been upset at the administration and disillusioned that it hasn’t done more to crack down on pesticide use, etc., have been upset at the Trump administration, and have been saying just weeks before the midterm elections that Republicans may lose some of these votes, and some so-called MAHA moms might sit out the elections. And I don’t think this summit did anything to persuade them to go and vote Republican in the midterms. 

Rovner: Yeah, it did seem, it seemed a great get-together if you wanted to sort of commune with the people who regulate your products, on a public stage. But both the president and Health and Human Services Secretary Robert F. Kennedy Jr. have felt free of late to talk about vaccines, although obviously not at this summit. But it seems that the issue that had united most of MAHA that we were just talking about, pesticides and ultraprocessed food, have been back-burnered by the White House. Rachel, you wrote a . What happened to the food agenda? 

Roubein: Pretty notably, one of the big potential parts of the food agenda is this petition that was filed by David Kessler. He’s the former head of the FDA [Food and Drug Administration] under both Republican and Democratic administrations. And his petition, essentially — I talked to food safety experts about it — could have launched a process that could have forced the industry to reformulate some ultraprocessed foods eventually. So that could have been a big deal. The status of it: It was filed August 2025, and Kennedy earlier this year had done a response to it, where he wanted to have food companies produce any detailed safety studies showing that certain ingredients common in ultraprocessed foods are generally safe. And what I had heard from talking to people is that that potential push had been slow-walked at the White House. I obtained a March draft of the letter that Kennedy sent to the White House for review. Now, HHS pushed back on the assertion that it was slow-walked, but this isn’t the first time that administration officials had wanted to and planned to announce something. They had been working on a definition of ultraprocessed foods that they wanted to release back in August, and that was delayed at the last minute, them just putting out more information about this draft definition. 

Rovner: I feel like there’s this tension between the MAHA movement, which started as a grassroots movement to crack down on corporate power, and the White House is sort of wanting to deregulate everything. Those two things seem to be kind of at loggerheads, and it looks for now like the corporations are winning. We saw this with the pesticides earlier in the year, with glyphosate, that the agricultural community fought back and said, You can’t make us stop using it, because we need it to produce food. And now it seems that the food producers are saying: You have a deregulatory agenda. Why are you talking about regulating us more? Is that, am I reading this right that the corporate power is winning, at least so far? 

Pradhan: It’s still a Republican administration, right? Regardless of Secretary Kennedy’s sort of mandate and passions, he’s still working with and for people who do not like to use government to restrict or regulate or ban things. Even, if you think about, we’ve come a long way since this point. But when former first lady Michelle Obama tried to put healthier foods in schools, she was roundly criticized for embodying a nanny state and all these things. And now, the political winds have shifted. But I still think to go up against the party’s kind of traditional views on regulating business and corporate interests, it’s a swamp. What are you going to do? They’re not going to want to regulate a lot. And like you said, Julie, there are ample actions to date that show that there isn’t necessarily a desire to impose more regulations. It’s also an election year. They may not want to antagonize corporate interests when you’re trying to not see huge losses, especially in potentially the House and maybe even the Senate. 

Rovner: Yeah, they have enough people who are mad at them. They don’t want to add to it. 

Pradhan: Exactly. 

Rovner: Well, of course, with every political split comes a new political opportunity. In Michigan, Democratic Senate nominee Abdul El-Sayed, who’s a prominent supporter of “Medicare for All,” is now trying to grab back some of those Democrats who gravitated to MAHA by unveiling something he’s calling the “Building a Healthier America” agenda, focusing on fewer pesticides, cleaner water, and healthier food. Rachel, you . Might it work? Might Democrats be able to sort of reclaim some of these people who drifted to the Republicans along with RFK Jr.? 

Roubein: I think it’s something that particularly some progressive Democrats are looking to, and they might look to do if they win back the House. In the Farm Bill, you saw Republicans and — some Republicans — and Democrats push back against giving pesticide makers immunity liability shields. But I think it remains an open question. And I think it also depends on the different groups, in terms of MAHA. Tony Lyons at MAHA Action has said that they want there to be an alliance with Republicans. But you also see this with Rep. Alexandria Ocasio-Cortez trying to court some MAHA activists her way. So I think it’s an open question in terms of how this movement unfolds and whether there are any deviations towards the left. But it is a hard sell in some ways. Vaccines are a big part of a lot of people in the MAHA base. And when I asked El-Sayed about this, he said they’re, like, We’re going to agree to disagree on vaccines. 

Rovner: Yeah, he’s trained as a doctor and he does believe in vaccines. And he was the head of public health at the city of Detroit. He’s definitely not with the anti-vaccine types. But it’s important to remember that the original anti-vax movement was a combination of people from the far right and from the far left. So there have always been a lot of Democrats in the anti-vax movement, and this has been a group that’s been kind of up for grabs. And we will, I guess we’ll see how it will all shake out. 

Roubein: And some of the things on food Sen. Bernie Sanders has said for a long time, too. So there has always sort of been some of that intersection on certain issues. 

Rovner: Yeah. Well, originally RFK Jr. was running as a Democrat before he took up with the Trump team. All right. Moving on. Today is Oct. 1, the start of the fiscal year. Happy FY 2027, everyone. The Trump administration marked the day a little early, informing Congress last Friday that it was declining to spend more than $800 billion, in what’s called a pocket rescission. That’s when an administration declines to spend money appropriated by Congress so close to the end of the fiscal year that it basically can’t be spent at all and Congress doesn’t have time to disapprove it. The majority of this funding is from HHS, largely for programs to help noncitizens and for what the administration calls, quote, “overfunded and unaligned” HHS research programs. That includes many related to minority health. Congressional spending leaders, including Senate Appropriations Chair Susan Collins of Maine, complained that pocket rescissions are illegal under a law called the Impoundment Control Act, and the Government Accountability Office issued an opinion this week backing that claim up. But, as we know, this administration likes to dare courts to stop it from doing things that just about everybody else acknowledges is illegal. And I guess that’s where we are here? 

Luthra: No, I was just thinking, right? It’s October. Everything that happens now, we also think about in the context of an election, and I think a dynamic that we have talked about a lot is this effort by the administration to just sort of do what it would like to do with funding, even when many people might say that is not how the laws and separation of powers are supposed to work. And I think something really interesting for us to consider is whether those dynamics do, in fact, change in the new year. Given what Rachana mentioned earlier, there is a very good chance that Democrats control both chambers of Congress, not just one. And [does] that possibility of conflict with another branch in Washington change what behavior we see from the White House? I think that’s a really interesting question and something that we should be thinking about as the election gets closer, and then again depending on what the results end up being. 

Rovner: Yeah, one of the really weedy issues here is who gets to sue the administration to say that, Hey, you’re not allowed to not spend money that we’ve appropriated. It was important that they came out and said that this was illegal, because the GAO, under the law, has standing to sue. But they don’t have a confirmed leader at this point, and Susan Collins was asked about this and said they may be a little bit wary to kind of get out in front of Congress. But I think it’s probably fair to say that if Democrats take back the House and Senate, that they would be more likely to want to either — I think that the Congress itself can sue the administration, can go to court and say, Hey, you can’t do this, which obviously the Republican Congress hasn’t wanted to do. But a Democratic Congress might. 

Pradhan: What — has GAO ever been known to sue? 

Rovner: That’s a good question. I can’t remember. We’ve had fights about rescissions before. 

Pradhan: Yeah. 

Rovner: But it’s — Russell Vought, the head of the White House Office of Management and Budget, says publicly that he thinks that the Impoundment Control Act is unconstitutional and therefore they don’t have to obey it. That’s clearly something for a court to determine. That’s clearly something for the Supreme Court to determine. We haven’t gotten there yet, but most of the time, I think, we’ve had lower courts that have warned the administration: Um, hey, there’s this law that says you can’t do that. You have to spend money the way Congress says you should spend money. The last time we had a pocket rescission, I looked it up, was last year when this administration did the same thing. That was the USAID [U.S. Agency for International Development] money. So before that, I’m not sure when. I may go back and have a look. Shefali, to your point, that was my next question anyway. It’s like, I would think that the one thing that is likely to change if the Democrats take Congress — obviously, we have two more years of the Trump administration — but I would think they would be a lot more zealous in guarding their spending power than this Congress has been. 

Luthra: One would imagine. It seems hard to abdicate the power that one might want. That’s how separation of powers, in theory, is supposed to work. 

Rovner: And it is kind of written into the Constitution. 

Pradhan: I do wonder, though, if they think that, if they wouldn’t get a good, friendly decision from a court … 

Rovner: The Supreme Court. Yeah. 

Pradhan: Yeah. That could be far more damaging in the long term, right? 

Rovner: Yes. There is the concern that the Supreme Court would agree with Russell Vought that the Impoundment Control Act … 

Pradhan: Right. 

Rovner: … is unconstitutional. That is a risk that they would run. 

Pradhan: Right. 

Rovner: Well, that will happen. We will see what happens with that. All right. So, obviously these latest cuts aren’t the only ones to HHS that have been made since [President Donald] Trump returned to office in 2025. We will talk more about what’s happened at the Agency for Healthcare Research and Quality in this week’s interview, but I want to talk a little bit right now about the Centers for Disease Control and Prevention, whose workforce we now know is down by almost a third, according to . Quote: “The changes have hindered the C.D.C.’s ability to respond to outbreaks as measles spreads at home and Ebola abroad,” while, quote, “entire divisions have been shuttered, including teams that worked on smoking, sexual violence, child abuse and falls among older adults.” Separately, but not really separately, the CDC’s advisory committee on vaccine practices has ground to a halt after a judge struck down Kennedy’s replacement members as unqualified. Medical societies have stepped in with their own vaccine recommendations for this fall, but the official CDC guidance is already out of date because there’s no ACIP [Advisory Committee on Immunization Practices] to make recommendations. This is all going to come home to roost the next time we have a bad flu season, I imagine. 

Pradhan: Yeah, I think that the Times, the New York Times, story, what I thought was really, kind of what they led with, was that even though last year you had these widespread firings across HHS and different agencies, including the CDC — the CDC at that time we know lost about 1 in 5 workers — but really the true scale of the losses is much higher. It’s about 30% fewer employees. But the CDC has really had a rough go of it. I think it probably was the — it was the poster child for everything that went wrong during the pandemic, in Republicans’ view. And so they’ve been very keen on dismantling a lot of that agency, more so than the FDA and more so than the NIH [National Institutes of Health], for example, even though they’ve also seen a lot of staff reductions. But CDC, I think, has been so crippled for so long, both because of the staff reductions and just the awful morale at the agency because of everything that the current political leadership has done since. Yeah. 

Rovner: I would say, and the politicization of its leadership, things that were long run by career scientists in Democratic and Republican administrations that are now being run by political appointees, who are rather pointedly not scientists … 

Pradhan: Yeah. 

Rovner: … running this very scientifically driven agency. And of course we’ve had a fifth measles death in Pennsylvania now, that apparently the CDC is still not acknowledging the measles deaths in Pennsylvania. So there are still a lot of questions. The CDC does have, unlike several of the other HHS agencies, does have a Senate-confirmed leader. But so far, we haven’t heard very much from her. I guess we are all still sort of waiting to see what happens, but in the meantime, I can just imagine if we have a bad flu season or some other respiratory ailment that could have been prevented if CDC had been up to date with its vaccine recommendations, things could get rather loud and nasty later this winter. 

Roubein: Some of the vaccine recommendations, some of this is very much tied into the lawsuit, just like the high-level ACIP not putting more vaccine recommendations out. And this part has had somewhat of a snowball effect, like the Vaccines for Children Program, giving out free vaccines to uninsured, underinsured kids, that was held up for about a month. That is now going through, but they had to kind of work through: What are the recommendations going to be? And they ended up going with prior recommendations because there is not an ACIP to meet. So some of this has been tied up in legal limbo. And yeah, on the measles deaths, CDC is now acknowledging two out of the five that Pennsylvania has reported. 

Rovner: There we go. We’re finally hearing something. All right, we’re going to take a quick break. We will be right back. 

Turning to reproductive health, the Hyde Amendment — that’s the annual appropriations rider that bars federal funding for abortion in most cases — turns 50 this week, which, as one abortion rights group pointed out, means that the ban itself has now been in effect longer than Roe v. Wade was in force. Shefali, what’s been the impact of the Hyde Amendment on the ground? What does it actually mean for people who are seeking reproductive care? 

Luthra: It’s a bit more complicated than I think people might initially realize. The Hyde Amendment prohibits the use of federal funds to pay for abortion — functionally, Medicaid. And so Medicaid programs are jointly funded by state governments and federal governments. If you are in a state where the state government does not want to put money into paying for Medicaid coverage of abortion, your abortion will not be covered, especially if you are low-income. Most people who get abortions are people who cannot afford another child. They are parents already. They are largely people who are low-income and rely on something like Medicaid. However, there are states, the Californias, etc., of the world, that have made a point of putting state funds into their Medicaid programs. So in some states, you can get Medicaid to cover your abortion. That’s really helpful. It makes this procedure much more affordable. It can cost hundreds of dollars, sometimes a lot more, depending on where you are in your pregnancy, to get an abortion. But, of course, the fact that this has existed for so long has absolutely made it harder for people, often those who are most financially vulnerable, to get abortions. What you often hear from those patients, though, when I speak to them, is, like, This is something I really can’t afford right now, but I will pay for it anyway because I really can’t afford another child. I think the Hyde Amendment is really striking in that it makes this thing much harder to get. But for a lot of people, it doesn’t necessarily stop them from getting it, because it is just so important to them. 

Rovner: It’s ironic that something that has to, literally Congress has to pass every year — it is a rider on a spending bill. Democrats have tried various ways to get rid of it, always failed. Even when we had a Congress that supported abortion rights, they could not get this out. It is just sort of part of the landscape now, isn’t it? 

Luthra: And part of it is, I think, demonstrative of one of the more effective anti-abortion lines a lot of Republicans have. Abortion public opinion is very complicated. And people support abortion rights in the abstract, but when you get into more specifics, their views become more complicated. And one framing a lot of the GOP has really found success with is saying, We don’t support taxpayer funding of abortion. And that really works because people will hear that and they say: Oh, well, that sounds very extreme. I support this for other people, but, like, my tax dollars, they can’t fund that. And that is the line that has been used to keep Medicaid from paying for abortions, to keep the Hyde Amendment intact, and to keep other federal programs as well from making this more available. And I think it’s perhaps more politically complicated than first blush at abortion polling data might suggest to undo something like this, 

Rovner: I absolutely agree. Well, still, anti-abortion forces remain intent on cutting off the main remaining source of access to abortion, the abortion pill mifepristone. This week, the attorneys general of Louisiana, Alabama, and Arkansas filed suit in federal district court — not at the Supreme Court, which the group’s press release says — to strike down the shield laws in New York, Massachusetts, and California. Those are the laws that enable doctors in those states to provide telehealth appointments to people in ban states seeking to terminate their pregnancies. Shefali, there’s already a lawsuit on mifepristone making its way through the courts, and it’s from Louisiana. How is this one different? 

Luthra: This one is different because it specifically goes after shield laws and it challenges their constitutionality. That is a different argument. It is more sweeping. It could be the thing that finally gets the Supreme Court to weigh in on this issue. Right? It’s a very, very big legal question, something that constitutional scholars have believed, since the enactment of shield laws will ultimately be settled by the Supreme Court. However, I think it’s really important for us to take this suit with context. As you mentioned, there are so many cases making their way through the courts right now around how people get abortions, the provision of mifepristone, shield laws, etc., etc. We don’t know which one will end up at the Supreme Court. We don’t know how courts will rule. This is just one more quiver in the bow that abortion opponents are trying to use to stop this telehealth model that has found quite a bit of success. We will see which one lands. It very well could be this one, but, at this point, we just don’t know. 

Rovner: Yeah, and I should point out that the other Louisiana case is about FDA and its approval of mifepristone to be prescribed via telehealth. So, and of course, we’re also waiting for the administration to do, to finish its FDA safety review, which we expect to see sometime after the election. Speaking of which, abortion is not quite the high-profile electoral issue this year that it was in 2024, but there’s still several abortion-related ballot initiatives to be voted on this year. Shefali, any that you’re watching particularly closely? Or any of the others of you? 

Luthra: I am personally very interested in the Idaho measure and the Missouri one. I spent a bit of time in both of those states learning about what’s happening there over the past month. I think it’s really fascinating. In Missouri, it’s a very strange case. Two years ago, voters amended their constitution and said, We will protect abortion rights. Abortion is now legal in Missouri, a state run by very, very anti-abortion lawmakers. Those same lawmakers were horrified by this finding, and so they have put forth a new ballot measure that would overturn the 2024 result, and it would amend the state constitution to ban abortion. And if that passes, Missouri’s constitution would be the only state constitution to explicitly ban abortion. That’s a really big deal. If this passes, it could set an example to other states where voters have said, We support abortion rights and lawmakers have felt very frustrated by that. Polling right now is a very even split. There is a lot of money. We will see what happens. But I think this is a really interesting case for us to be following. 

Rovner: And it’s super confusing because they just voted on this. 

Luthra: It’s so confusing. And it’s called Amendment 3. If you look at two years ago, the abortion rights measure was also called Amendment 3, and so you might be like: Well, I just voted on Amendment 3. I voted for it. I should vote for it again. And in fact, that would be the opposite. And I’ve spoken to people … 

Pradhan: That’s very confusing. That’s very confusing. How are people supposed to keep up with all this? I can barely keep up with it. 

Luthra: How are they supposed to keep up with all of it? That’s such a good question. 

Pradhan: It’s a lot. 

Luthra: But no, and I’ve spoken to people who work in politics in the area, and they had no idea this was even on the ballot. And I was like, That’s also really striking that abortion has faded from a lot of the political consciousness. But actually there’s this measure that could have really sweeping consequences and really inspire similar action in other states. And the Idaho measure, I think, also very interesting. That would actually not amend the constitution. It would just pass a law that would overturn Idaho’s very, very strict abortion ban, which has sparked all these headlines — women being airlifted to Utah for medical emergencies, doctors leaving, labor and delivery wards shutting down because the law is so strict there. It’s really an open question, but there is some polling that suggests that this could pass. They have gotten a lot of support from Democrats, but also independents, also Republicans. A lot of people in Idaho who were never really politically engaged very deeply are, because this abortion ban has been so sweeping, affected so many of them so personally. If it passes, the legislature could vote to overturn it, and we’ve seen that happen in states around the country. But I think we don’t know, A) if it will pass and, B) if it did how lawmakers might react. There’s a real chance — right? — that they are just so surprised that this happens that maybe you do reconsider the politics of instituting an abortion ban when voters rejected one. But absolutely worth following and seeing what happens in this case, for political reasons but also because a lot of people’s lives could be really, really fundamentally changed as a result of it. 

Roubein: Missouri sounds like such an interesting test case, because I remember back in 2022, after the Supreme Court decision, abortion rights groups were really grasping for a strategy, so they were throwing a bunch of different things at the wall, lawsuits, and then they tried the ballot measures, and it just seemed to work and take off steam. So that’s pretty interesting. 

Rovner: Yeah, and of course, as you pointed out, Missouri has some of the most strident anti-abortion lawmakers in Congress. Josh Hawley, the senator whose wife is one of the lawyers for the anti-abortion, for the main anti-abortion legal group. So Missouri is one of those states that’s got all of the poles represented, and we will have to see how that all comes out. 

Pradhan: Can I make one last addendum on the abortion thing, which is because I’m a Virginia resident? Actually, I was talking to my husband the other day. I said, “Oh, this is how you know that Democrats are in charge,” or we have a relatively new Democratic governor. So now there’s a proposed constitutional amendment on the ballot to amend the state constitution to codify abortion being legal until 28 weeks, so basically through the first two trimesters. Which, you know, Virginia is interesting. I’m biased because I live here, but it’s, of course, trended blue with many prior elections, like leading up to now. But parts of the state are very, very conservative. 

Rovner: Yeah, Virginia is still the South in a lot of ways. 

Pradhan: Yeah. Oh, yeah. And it doesn’t take you long to figure that out once you leave the D.C. area, and there’s a lot of religious-based opposition to abortion. So I’m not sure how it’ll do, whether people will support it or not. 

Rovner: I’m curious whether — if we really are looking at a blue wave, and we certainly see a lot of Democrats in unlikely states who seem to have at least a chance of getting elected because of the frustration, mostly with the economy — whether that will bring along some of these other issues in a way that it might not have. Because, as we say all the time, midterms are about turnout, and it looks like the motivated voters this time are bluer than redder. But I guess that’s another thing that we will have to wait and see. 

All right, that is this week’s news. Now we’ll play my interview with Aaron Carroll of AcademyHealth, and then we will come back and do our extra credits.  

I am pleased to welcome back to the podcast Dr. Aaron Carroll, president and CEO of AcademyHealth, which supports the health services research community. Aaron Carroll, thank you so much for being here. 

Aaron Carroll: Always a pleasure. 

Rovner: So I’ve asked you here to talk about the Trump administration’s effective dismantling of the Agency for Healthcare Quality and Research, which even many of our very nerdy listeners might not have heard of. But first, tell us what health services research is and how it differs from the biomedical research that most people are more familiar with. 

Carroll: I think everybody really gets what we might call discovery research, which is about learning new things at a cellular, molecular, you know, body level — the creation of drugs, the creation of new procedures. You know, everybody sort of understands why we need to do that. But that’s only part of the problem. The bigger problem is how do we actually get that to where people are? So health services research focuses on: How do we improve the access, the quality, and the cost of a healthcare system? Another way I like to think about it is that everything that people hate about healthcare is what health services research focuses on. It costs too much? Yeah, that’s health services research. You can’t get in to see the clinician you want? Wait times are too long? That’s health services research. You feel like you’re not getting the quality that you should, or you’re worried that you know chronic diseases on …? That’s health services research. We spend very little time and very little money, unfortunately, on that type of research. But it’s just as important as discovery research, and I think that one of the reasons why we continue to be so dissatisfied with the healthcare system is because we’re not committed to studying and improving those things in the same way we are discovery. 

Rovner: So how does AHRQ facilitate that, or how has AHRQ facilitated that? 

Carroll: Sure. So, I mean, some of it is by creating and maintaining some of the big databases that people use to study the healthcare system, things like MEPS or other related databases. 

Rovner: MEPS is the Medical Expenditures … 

Carroll: Medical Expenditure Panel Survey. Yes, but I think the bigger way is that they give out independent investigator grants the same way that the NIH does. It just focuses more on health services research, and sometimes they have, you know, different areas that they choose to focus on, depending on the administration, because every administration should get to set priorities or, you know, decide what they think are most important. But they usually give out lots of grants, and I’ve had some over my career, that allow you to do all kinds of research to try to examine how you might improve the way that people receive care or pay for care or get care. 

Rovner: And some of that research has actually created improvements in the healthcare system, is that fair to say?  

Carroll: Absolutely. Yeah, I mean, the reason that, like, we landed on, say, $35 for insulin is because of health services research. It’s because of research that was done that found that that was sort of the inflection point. That when out-of-pocket costs got above that amount, people stopped taking their insulin as they should. And I understand the need for some copays — and obviously, we have a healthcare system. … But it’s, like, finding that kind of stuff out is health services research. And, you know, even some of the grants that were canceled this year would make sense to any, everyday Americans. Like, how do we improve the way that hospitals use antibiotics so we get less resistance, or how do we improve care using telehealth so that kids can get better asthma care or autism diagnoses? These are not discoveries in the sense of new medications, but they are things that we need to learn how to do to make the healthcare system work for everyone. 

Rovner: So I actually covered the creation of not just AHRQ, but of its predecessor agency, the Agency for Health Care Policy and Research, way back in 1989, when I was a baby healthcare reporter. It was not just a bipartisan agency. Its creation was spearheaded by Republicans who wanted to know, basically, which medical interventions worked and whether the U.S. was getting its money’s worth on medical procedures. The reinvention of the agency 10 years later was led by Sen. Bill Frist, a Republican former transplant surgeon who later served as the Senate’s majority leader. So, how did the Trump administration come to view this agency as so “woke” that it basically needed to be disassembled? 

Carroll: I don’t know. And again, if you don’t like the research priorities, it is perfectly reasonable for an administration to say, Let’s change them. And if they decided they wanted to focus on cost, OK. If they decided they wanted to focus on access, OK. There’s so many different ways to do this, but what they’ve done instead is apparently cancel a ton of grants that were already ongoing — and I’d be happy to talk about more specifics about that — but also they just are not spending the money. In fiscal year 2025, there was a significant amount of money that wasn’t spent. Many believe that’s an illegal impoundment, and there’s a case working its way through the courts right now, led by the Society for General Internal Medicine and Public Citizen, and they actually folded in some of the cancellation grants. But in fiscal year 2026, almost no money has been given out for new grants. Today, as we’re taping this, it is the last day of the fiscal year. I have no idea how possibly they’re going to spend the $345 million that was appropriated in 2026. A lot of that is not going to go out the door. In answer to that, they have said that 97% is being on track to be spent. I don’t know how that’s possible. And it’s very, very likely, again, we’re going to see a ton of money unspent, and I imagine lawsuits and more yelling will follow. 

Rovner: So, Congress appropriated this money. The president signed the appropriations bill. What can Congress do, and why isn’t Congress doing something? 

Carroll: So I ask those same questions every day. I don’t understand how Congress is not out of its mind. I mean, this is not something, again, from the “woke” Biden administration. This is this Congress, this House, this Senate passed a budget in a bipartisan manner, that was then signed by the president of the United States — this president — into law. The money’s been appropriated. … In fact, there was specific language in the budget that required HHS to staff up to make sure that they could spend this money. They have not staffed up. They have not spent the money. I don’t know how Congress is not losing their minds. It is an absolute ignoring the law. It is absolutely ignoring Congress’ will. I know there’s a GAO investigation. I know questions have been asked, and I don’t think answers have been given. It makes no sense whatsoever. I don’t know, again, why Congress isn’t screaming and yelling and taking action. Now, what action should they take? Hearings, oversight, make sure that all of this happens. Haul people in to session and find out why are they not following the law, and force the executive branch, as the legislative branch should do, as an equal part of our government, to follow the law. 

Rovner: And it’s not just the grants. I mean, most of the staff has now been basically terminated. 

Carroll: Yeah. Well, that’s what I mean. And there are now minimum staffing requirements in the law, and those are not being followed. I mean, depending upon whose estimates you believe, somewhere between 75% and 90% of AHRQ staff have either been let go or have left the organization. We can’t get exact numbers because they won’t release them. But there aren’t enough people even to process or put the money out the door. Even if they decided today we’ve got to get all the money, it’s not possible. There just aren’t people there to fill out the forms, check the budgets, do all the due diligence, administer the grants, oversee it. There’s no one there, and it’s an absolute abdication of their responsibility to enact the budget and the law as Congress has appropriated and put forth. 

Rovner: Last question: What would it mean — I mean, what would the loss, basically, of what AHRQ has been doing for these last 26 years mean — to the healthcare system and how it runs? 

Carroll: I mean, we spend $40-some billion a year on the NIH — I think about $47 billion. AHRQ, again, is $345 million. So we have been massively underspending on sort of what I would call “delivery” research on how the healthcare system works. And it’s one of the reasons why Americans are getting angrier and angrier every year because they’re, like, Why won’t things get better? Well, we’re not funding it enough. We’re not doing enough. And then, what little we were doing, they canceled in July and refused to spend now. So, what’ll happen? We will remain just as angry, if not angrier, about how much we’re paying for healthcare. We will remain just as angry, if not angrier, about how we can’t get what we need, and we’ll remain just as angry, if not angrier, about the fact that we can spend all this money that we do, $5 trillion-plus, and still feel like we’re not getting the quality, and continue to complain about how unhealthy we all are. AHRQ is the solution to a lot of these problems, and, for some reason, we just won’t use it. 

Rovner: Aaron Carroll, we will stay on top of this. We will revisit it. I promise. 

Carroll: I’m glad to hear that. 

Rovner: Thank you. 

Carroll: Thank you. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week? 

Roubein: My extra credit is headlined “” It was in Stat by Elaine Chen. I thought it was a really fascinating story because we’ve all seen the cultural shift toward GLP-1s, and we’ve all heard the drugs praised as a way to address obesity as a medical issue. But Elaine reports that the drugs are now being increasingly marketed as a way to look and feel better. I thought there were some notable examples. The story explored how Novo Nordisk, which is one of the drugs’ makers, has particularly leaned into the shift. For instance, the company had advertisements this summer with slogans that include “live lighter” and “a summer glow-up.” And instead of labeling the drug as a drug for weight management, it sometimes is referring to it as a weight loss drug. And Elaine talked to some doctors and patient advocates that think the drug’s being talked about more as a retail product, run against the industry’s sort of initial goals of trying to convince the greater public that obesity is a disease and that the drug should be covered by insurance. For Novo Nordisk’s part, a spokeswoman told Elaine that how people expect to access and experience care has changed in recent years, and the company recognizes that healthcare needs to become more responsive, relevant, and easier to fit into everyday life. 

Rovner: I would just note, and it’s a very good story, that if the drugmakers lowered the price of the drugs, it would be easier to get it covered by insurance. But that’s just an aside. Shefali. 

Luthra: My story is from The Atlantic by Caitlin Dickerson. The headline is “.” It’s a great story. It is about when parents are deported without their children, what happens to those children? This is the kind of reporting that is really hard to do because you have to spend time with children who have lost their parents. But I think it’s really important, especially as we see this uptick in detaining and deporting, in particular, people with children. I’ve spoken to a lot of mothers who have been deported when they had children here, and the consequences will last probably people’s whole lives. There are health consequences, especially when you have young children. There is PTSD, and I think Caitlin Dickerson has done some of the best reporting on immigration in the past decade, maybe longer. And this is absolutely an essential addition to that canon. 

Rovner: It is indeed. Rachana. 

Pradhan: My story is a trifecta from my colleagues Phil Galewitz, Andrew Jones, and Claudia Boyd-Barrett, who wrote a story about, as of today, hundreds of thousands likely of immigrants who are lawfully present in the United States but who have low incomes are now no longer eligible for Medicaid. This is part of President Trump’s signature One Big Beautiful Bill Act, which will enact greater coverage reductions next year, starting in 2027. But this group of people is now no longer eligible for Medicaid. It includes refugees, some people who have been granted asylum, and also, you know, victims of domestic violence and/or human trafficking. So the story gets into how we have our beloved Congressional Budget Office here in Washington that sort of estimates the impacts of tons of legislation. And they estimated previously that about 100,000 immigrants would be uninsured by 2034 because of this provision. But based on figures that my three colleagues got from state governments or state Medicaid agencies, the figure is likely to be higher of the numbers of immigrants with legal status who are going to now not be able to receive Medicaid. So yeah. So it’s a great read, and I know Julie will put the link in the podcast and in the comments. 

Rovner: I will indeed. Yes, there’s the continuing, you know, “immigration is a health issue, too” theme that we have this week. All right, my extra credit is actually an update to an extra credit from last month. Like last month’s story, it’s from The New York Times, and it’s called “,” by Madaleine Rubin. And it seems that my alma mater — also, full disclosure, the alma mater of my editor and several of our panelists — has rethought the idea of letting incoming freshmen complete their first semester without letter grades to ease them into college life. According to a statement from interim university president Domenico Grasso, there was concern that students would be, quote, “unfairly portrayed as coddled or unprepared for the demands of a rigorous Michigan education.” Yeah, I would add that a lot of the backlash came from my fellow alums, and that even though I attended Michigan well back in the 20th century, even in the olden days, we had the option to take classes pass/fail if we wanted to. Although I would note that under the original proposal here, the students wouldn’t have failed, but they would either have gotten a pass or a “no credit.” Good job rethinking this, guys, and Go Blue. 

OK, that is this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts — as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X , or on Bluesky . Where are you guys hanging about these days? Shefali. 

Luthra: I guess I’m on Bluesky , but you can also email me. 

Rovner: There you go. Rachana. 

Pradhan: @rachanadpradhan, both on and on , and you can always email me at RachanaP@kff.org. 

Rovner: Rachel. 

Roubein: Yes. X: ; Bluesky: ; and Signal is always good too: RachelRoubein.28. 

Rovner: Great. Thank you all. We will be back in your feed next week. Until then, be healthy. 

Credits

Francis Ying Audio producer
Emmarie Huetteman Editor

Click here to find all our podcasts.

And subscribe to “What the Health? From ³Ô¹Ï²»´òìÈ” on , , , , , or wherever you listen to podcasts.

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2292271 Rural MAHA Followers Say Trump Health Policies Haven’t Reached Their Communities /rural-health/kff-ap-poll-rural-voters-maha-make-america-healthy-again-local-impact-midterms/ Wed, 30 Sep 2026 10:01:00 +0000 /?p=2290225

About half of rural voters identify with , a sprawling political movement championed by the Trump administration, but most said President Donald Trump’s healthcare policies have not benefited their communities, according to a from The Associated Press in partnership with KFF.

About 8 in 10 rural voters — an important voting bloc for Trump and fellow Republicans in recent elections — said the Trump administration’s policies have had a negative effect or no impact on the health of people where they live. Most MAHA supporters, 68%, also feel this way, according to the national survey of more than 2,000 rural registered voters.

The findings signal an apparent disconnect between the Trump administration’s MAHA-branded policy priorities and rural America’s perception of their reach and effectiveness.

Iowa pastor Mike Jager, 58, is a registered Republican and considers himself part of the MAHA movement. The Trump administration’s health policies have had “minimal” impact on the health of his community, Jager said, but he added that Trump’s health secretary, , is moving the needle “in the right direction.”

“It’s a beginning,” Jager said. “It’s a big ship to try and turn around and course-correct.”

Kennedy has used the MAHA label to support various agendas, including , , and investing in regenerative agriculture.

Jager lives in Sumner, Iowa, “less than a quarter mile from where the corn ends and the city begins.” He’s seen family members and neighbors develop diseases that he believes resulted in part from exposure to agricultural chemicals and consumption of unhealthy, processed foods.

In the June Republican primary for governor, Jager voted for Zach Lahn, a businessman and farmer, who ran on a MAHA platform and beat out Trump-backed U.S. Rep. Randy Feenstra. He plans to vote for him again in November.

A photo of Mike Jager standing in front of an altar inside of a church.
Jager said that President Donald Trump’s health secretary, Robert F. Kennedy Jr., is moving the needle “in the right direction.” (Miriam Alarcón Avila for ³Ô¹Ï²»´òìÈ)

Many Rural Voters Are Prioritizing Health Issues

About two-thirds of rural voters who support MAHA said it’s “extremely” or “very” important to them to vote for a candidate who does, too, while only 4 in 10 rural voters overall said the same.

Trump sought to seize on MAHA support during his campaign for another term two years ago. Now, amid tight midterm races, Kennedy has campaigned to galvanize the movement’s support. In May, he attended a MAHA bill signing with Iowa Republican Gov. Kim Reynolds, and in August, he went fishing with Lahn, posting about it on social media.

Yet the survey indicates voters are noticing “this weird split in the Trump administration” between what Kennedy messages and what Trump says and does, said David Peterson, a political science professor at Iowa State University.

“It’s this mix of things coming out of D.C., out of different pieces of the administration, that’s confusing people,” Peterson said.

In Iowa, concerns about what’s causing are “a big deal,” he said. For many people who identify with MAHA, being healthy includes taking on corporate agriculture and pharmaceutical companies that they think cause cancer, he added.

“The sort of populist messaging around that is appealing right now,” Peterson said.

In the poll, views on healthcare access and costs largely diverged along party lines. Most Democratic and independent voters said the Trump administration’s healthcare policies have had a negative impact on their healthcare costs and the health and well-being of people in their communities. Republicans were likelier to say there hasn’t been an impact.

Talking on the phone from her 200-acre farm in Carroll County, Iowa, 71-year-old Donna Klocke said that her husband had died from cancer and that she has neighbors who also have cancer.

“It’s just very prevalent,” Klocke said. “We’re in a farming community. We use chemicals and pesticides and all kinds of things that aren’t necessarily good for us.”

Klocke, a Democrat, said the MAHA movement is a good idea because she cares about being healthy, but she does not consider herself part of it and will not be voting for a candidate who represents the movement.

Kennedy, who was an anti-vaccine activist before entering politics and has sent to Americans about , scares her.

“Measles are coming back and polio,” Klocke said. “It’s the measles that really gets me. It’s like, do you not understand how dangerous it is?”

A photo of Donna Klocke standing in front of a cornfield in Iowa.
Donna Klocke cares about being healthy but does not consider herself part of the Make America Healthy Again movement. Her husband died from cancer after a life spent farming the family’s 200 acres in Carroll County, Iowa. (Kathyrn Gamble for ³Ô¹Ï²»´òìÈ)

Survey Reflects Angst Over Healthcare

About half of rural voters said their communities don’t have enough doctors or other healthcare providers, and even more said there aren’t enough mental health workers specifically. The share of rural voters who said their community does not have enough hospitals increased to 35% from 21% in a similar question asked in a KFF-Washington Post survey in 2017.

And as with the general population, healthcare, gas, and grocery costs are top pain points. More than 6 in 10 rural voters said they were worried about healthcare costs.

The level of worry varied based on coverage, with rural voters enrolled in employer plans or Medicare less likely to be worried. The survey found that 80% of working-age rural voters on Medicaid were very or somewhat worried about healthcare costs. Last year, Republicans passed that cut over $900 billion in projected Medicaid spending over a decade and mandated new eligibility requirements.

Among rural voters who purchase their own insurance, such as the individual coverage plans available on Affordable Care Act marketplaces, 77% said they were worried.

In the tiny community of Lipan, Texas, west of Dallas, Kim Solis and her husband have a handyman-and-home-remodel business and get their insurance on the marketplace. Since Trump was elected again, their premium payment jumped from zero to $166 a month. Their copays went up, and their deductibles each increased by $2,000.

Solis, 62, said she worries what will happen if they get a big medical bill.

“Certainly, we’d be in a world of hurt trying to take money out of savings or getting it out of our 401(k) just to be able to do something about it,” she said.

Most MAHA Voters Are Also MAGA — But Not All

Like the general population, rural voters said they trust their own doctors and healthcare providers for health information over government agencies or officials, according to the poll.

Trust in Kennedy and Trump fell largely along partisan lines. About 10% of rural Democratic voters reported having a “great deal” or “fair amount” of trust in Kennedy, compared with 74% of rural Republican voters. About 5% of rural Democrats and 69% of rural Republicans said they trust Trump a “great deal” or “fair amount” for reliable health information.

While Make America Great Again and MAHA identities are “linked in a lot of ways,” the rising costs of healthcare and groceries pose a challenge for those committed to the MAHA principles that Kennedy promotes, said Peterson, the Iowa State professor.

Buying healthy food “becomes, ‘I can’t afford to do that because of Trump’s policies,’” he said.

In Stamping Ground, Kentucky, Alma Johnson, 65, works as night security at a horse farm. Johnson said gas had gone up but her overall cost of living had decreased since Trump took office.

Johnson voted for Trump in 2016, 2020, and 2024 and said she “pretty much” likes how Trump is running the country. But she said she is not a MAGA devotee, preferring to “think for myself.”

MAHA, however, is an easy sell for Johnson because, she said, she doesn’t think people should be able to buy junk food through the Supplemental Nutrition Assistance Program, or SNAP.

Still, she said she hasn’t seen much impact from the Trump administration’s healthcare policies, including the .

“It takes a long time to change people, their habits, their thoughts, or the things they do,” Johnson said.

About the Poll

The KFF-AP Rural Voters Survey was conducted online and by telephone Aug. 12-24, 2026, among 2,241 registered voters living in rural areas, defined as census tracts that fall within codes 5-10 of the U.S. Department of Agriculture’s 2020 Rural-Urban Commuting Area codes. Voters were reached through a combination of the probability-based SSRS Opinion Panel and a registration-based sample from the L2 voter file. Overall results have a margin of sampling error of plus or minus 3 percentage points, including design effects due to weighting. Error margins are larger for subgroups. In collaboration with the AP, KFF researchers worked to design the survey sample and questionnaire and analyze and report findings.

This report is from a collaboration between ³Ô¹Ï²»´òìÈ and The Associated Press.

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2290225 US Poised To Boot Legal Immigrants From Medicaid, Including Refugees and Sex-Trafficking Victims /medicaid/immigrants-kicked-off-medicaid-refugees-asylum-seekers-trump-big-beautiful-bill-cbo-2/ Wed, 30 Sep 2026 09:00:00 +0000 /?p=2291547 Hundreds of thousands of immigrants with legal status are at risk of losing government health coverage starting Oct. 1, state data shows, signaling that the impact of Medicaid changes in President Donald Trump’s signature legislation from 2025 may be greater than anticipated.

Many lawfully present immigrants will be among the first people to lose Medicaid coverage under congressional Republicans’ One Big Beautiful Bill Act, which is expected to cut spending by more than $900 billion through 2034 for the state-federal health program for people with low incomes or disabilities. The law will strip many more immigrants of their Affordable Care Act plan subsidies and Medicare coverage next year.

Those losing their health benefits who were previously eligible include refugees of war, asylees who fled persecution, victims of sex trafficking, and interpreters who risked their lives assisting U.S. service members in Afghanistan — all of whom are in the country with the federal government’s permission. The law does not affect coverage for a few groups, including those who hold green cards.

The Congressional Budget Office, the nonpartisan budget scorekeeper, estimated the law’s changes eliminating Medicaid eligibility for many noncitizen adults with legal status would lead to about 100,000 more immigrants being .

³Ô¹Ï²»´òìÈ asked several states how many Medicaid enrollees they had identified as being at risk of losing coverage under the provision. More than 281,000 immigrants from nine states and the District of Columbia are expected to lose Medicaid in October.

While some may be able to obtain coverage elsewhere, the state numbers suggest hundreds of thousands of immigrants nationally are at imminent risk of becoming uninsured.

The CBO declined to comment.

Florida alone identified nearly 177,000 immigrants who would no longer qualify for the state’s Medicaid program starting in October, said Anna Holaday, a spokesperson for the Florida Department of Children and Families. The agency verified the enrollees’ immigration status through government databases and sent notices to people to give them an opportunity to provide more information proving they remain eligible, Holaday said.

Arizona predicts nearly 28,000 could lose eligibility. New Jersey expects 15,000 to 25,000 of its noncitizen residents to lose their Medicaid coverage. In North Carolina, it’s about 29,000, and in Washington state it’s 11,000. Final numbers from states on how many Medicaid enrollees have been terminated from the program won’t be available until later this fall.

Lawmakers rely on the CBO to understand the budgetary and economic impacts of proposed legislation. Yet the federal agency did not publish estimates on the One Big Beautiful Bill Act’s impact on noncitizens enrolled in Medicaid until a month after Congress passed the bill and Trump signed it into law.

Much of the attention around Medicaid changes in the law has centered on implementation of work requirements as a new condition of eligibility for many enrollees starting in January. The CBO estimates the requirements will increase the number of uninsured Americans by about 5 million by 2034.

Without health coverage, immigrants are likely to lose access to doctors, prescription drugs, and most other medical services. They still could qualify for coverage of emergency care under a separate program known as Emergency Medicaid.

“I came here to live a better life,” said Ahin, a refugee who left war-torn Syria for Turkey in 2011 and came to the U.S. in October 2024. She spoke with ³Ô¹Ï²»´òìÈ on the condition that she be identified by only her first name, out of concern for her privacy and security.

Soon after arriving in the U.S., she developed severe abdominal pain that required intestinal surgery. Those costs, along with ongoing visits to specialists, were covered by Medicaid.

“I’m really worried about this,” she said. “It’s truly a terrible situation.”

Ahin, 25, said she doesn’t know what she will do if she needs to go to the hospital — she wouldn’t be able to pay the bill. She lives in a small apartment in New Jersey with her mother. Medicaid has also been vital to her mother, who has asthma.

Health Benefits Wane for Immigrants

The federal government required states to notify immigrants who will soon lose coverage, but immigrant rights advocates say some states did not begin sending letters until September. That’s given enrollees little time to react, including to respond if the state was mistakenly ending their coverage.

Cutting off Medicaid coverage is just the first move to drop government health benefits provided to many lawfully present immigrants. Under a change starting in January, the CBO estimates, about 1 million will lose eligibility for government subsidies to buy individual health coverage on Affordable Care Act marketplaces by 2034. And they will also lose access to Medicare, a change expected to affect about 100,000 immigrants, the agency forecasts.

Trump has argued that taxpayer-funded programs should be reserved for American citizens. As Congress debated the legislation in May 2025, the White House with the misleading claim that the One Big Beautiful Bill Act would remove Medicaid coverage for people who are in the country without authorization.

Under long-standing law, people who are in the country without authorization do not qualify for the general Medicaid program that is funded by state and federal dollars.

The health coverage cuts are part of a broader Trump strategy to send a message that immigrants are not welcome in the United States, said Ben D’Avanzo, senior strategist for federal advocacy at the National Immigration Law Center. The Trump administration has also moved to kick people with legal status off the Supplemental Nutrition Assistance Program, or SNAP, and tried to do the same with the children’s program Head Start until a federal judge intervened. 

In addition to green card holders, people under age 19 and immigrants from Cuba, Haiti, or certain Pacific Island countries their Medicaid coverage affected by the law.

A Few States Try To Fill in the Gaps

Some states are staving off the coverage loss using their own money. California expects about 148,000 immigrants to lose Medicaid coverage. But the state is spending $365 million for a separate program to keep them covered until July 2027, according to Tony Cava, a spokesperson for the California Department of Health Care Services.

New York and Pennsylvania also have state-funded health coverage for many of the immigrants who are affected.

Carlos Alarcón, health and public benefits policy manager with the California Immigrant Policy Center, an advocacy group, said taking away health coverage for immigrants will affect the health of the state as a whole. The fewer people who have access to healthcare, the easier it will be for contagious diseases to spread, as happened during the covid pandemic, he said.

Alarcón said he hopes the state-funded coverage will be extended under California’s next governor. Polling released in September showed Democrat Xavier Becerra, secretary of the Department of Health and Human Services under President Joe Biden, leading Republican Steve Hilton in the gubernatorial race. Becerra to issue an executive order to maintain health coverage for every Californian affected by federal cuts.

“I believe there’s folks in the legislature that will really want to fight to make sure that we restore things as much as we can,” Alarcón said.

Refugee assistance groups say they have been trying to educate people in their communities and direct them to health clinics that are government-funded or free.

“We’ve just been scrambling trying to find free medical care,” said , co-founder of the . “To not be a welcoming place is the most un-American thing I’ve ever experienced.”  

Andrea Mendez Perez, director at Interfaith-RISE, a refugee resettlement organization in southern New Jersey, said the Trump administration has elongated the process for people to get green cards and is now taking away coverage from those without them. Before 2025, it typically took about six months to qualify for a green card, documentation that allows a foreign national to live and work permanently in the United States, she said. Today, it’s well over a year.

For many of these immigrants on Medicaid, losing their ability to get their prescribed medications “is a life-or-death situation,” Mendez Perez said.

Ahin, the Syrian refugee, applied for permanent residency soon after arriving in the U.S. two years ago. Mendez Perez said she should have her green card by now, which would have spared her from being dropped under the GOP law. “She is stuck in the middle and has no control.”

Colleen McCauley, policy and advocacy director at the Camden Coalition, a nonprofit that helps connect people to healthcare in southern New Jersey, said the loss of coverage is devastating.

“None of them did anything wrong,” McCauley said, “and they are losing coverage.”

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2291547 Confusion and Angst Follow State’s Early Rollout of Medicaid Work Rules /medicaid/medicaid-work-rules-requirements-worries-dropped-coverage-montana/ Tue, 29 Sep 2026 09:00:00 +0000 /?p=2288566 MISSOULA, Mont. — Bethany Zulick went back to school in January to become a high school English teacher.

Years ago, she taught English as a second language overseas and loved it.

“It’s so exciting to me to watch someone learn a new word or have that spark of understanding,” she said.

Zulick knew she could earn enough money as a substitute teacher to make going back to school financially viable — except for the cost of health insurance. She didn’t want to risk being unable to see her doctor for her allergies, or for preventative care.

The offered through Montana State University was too expensive, Zulick said, almost as much as her tuition. But then she found a solution that allowed her to make the leap: Medicaid. She wouldn’t have to pay any monthly premiums.

It worked well for a few months, as Zulick taught by day and took online classes at night.

But in June, the state sent a letter that she said left her “completely confused.” She knew Montana was rolling out a system for work requirements over the summer, but she thought she wouldn’t have to prove she met the requirements until next year, when her Medicaid enrollment came up for renewal.

Yet the letter from the Montana Department of Public Health and Human Services outlining the new requirements gave conflicting information on when Zulick would have to prove she was meeting them. First it said at her next renewal, which would be sometime next spring. Lower down it told her she would have to submit paperwork to prove compliance much earlier — “within 30 days” of the date on the letter, June 26. She wondered: Was it a boilerplate mass-mailing letter she could ignore, or was her insurance on the line?

the new work requirements by Jan. 1, but three states — Montana, , and — have already gotten started. Medicaid advocates worry that the expedited timeline in those states will lead to thousands of people losing coverage because they’re confused about the new rules, even if they are eligible for the program — and that Montana may offer a troubling preview of what will happen nationwide next year.

State health department officials maintain they are well prepared and told state lawmakers they plan to process roughly 5,000 enrollees monthly.

Growing Confusion, Dwindling Help

Rep. of the Montana House has gotten dozens of calls from confused constituents, specifically about letters like the one Zulick received.

“The notices coming from the department are very, very confusing, and it’s very hard to find help figuring out what’s going on,” said the Democratic legislator, who asked health department leaders about those letters at a hearing in early September. Letters being sent to enrollees have been updated to be clearer, state health officials told lawmakers at the hearing.

In Montana, nearly are subject to the new rules. Medicaid costs are split between the federal and state governments, and states are responsible for administering the program, which provides health insurance for people with low incomes or disabilities.

Under the new work requirements, enrollees must document that they’re working, volunteering, or studying 80 hours per month — or they must show that they qualify for one of a range of exemptions, such as being “medically frail” or being the primary caretaker for a family member.

Montana began with a soft launch of the work requirements in July and gave enrollees until Oct. 1 to comply.

Critics contend that isn’t enough time, because the state hasn’t finished setting up new computer systems or hiring the staff it said it would need. Of the 59 positions, only about 20 were filled, state health department officials told state lawmakers during the Sept. 9 hearing, adding that numbers had fluctuated amid staff turnover.

State health officials have said they’ll eventually be able to automatically verify that students are enrolled in public universities. However, that computer system isn’t expected to be up and running until next year, leaving students like Zulick to track down and submit the correct paperwork to prove their college enrollment.

However, there are fewer outside resources to help residents with these bureaucratic tasks.

For example, , a nonprofit that helps Montanans fill out such paperwork, lost federal funding last year, going from a staff of 18 to two part-time employees working a phone line.

The state does operate a helpline, but that Montanans stay on hold much longer than the national average and that many callers hang up before they connect with a state employee.

“We were worried about chaos that could be generated by the state rushing,” said , CEO of the Montana Healthcare Foundation, a nonprofit aimed at improving health in the state. “Given how little information the state has provided about what they are doing, I’m much more worried about chaos.”

Wernham pointed to a similar upheaval in 2023, when states undertook a massive process to redetermine the eligibility of all Medicaid enrollees, after regular eligibility checks were paused during the pandemic.

Many Montanans who were financially eligible lost Medicaid coverage for technical reasons, such as incorrectly filling out paperwork — roughly 87,000, according to state data from two years ago.

Even vulnerable Montanans who didn’t need to file paperwork, because their coverage should have been automatically renewed, were dropped from the Medicaid rolls, including people who were homeless.

A photo of Rep. Mary Caferro speaking at a podium seen from a different angle. Behind her stand several women holding signs that read, "Keep the care in healthcare," and "Medicaid saves lives. Hands off Medicaid."
Montana House Democrat Mary Caferro addresses protesters in July at the Montana Capitol in Helena. Montana is among three states that have adopted Medicaid work requirements months ahead of the federal deadline. The new rules have confused some Montanans on Medicaid, and critics say that confusion will lead to people unnecessarily losing coverage. (Aaron Bolton/MTPR)

Long-Sought Requirements in State

The Montana Legislature passed a measure expressing its desire to add work requirements to Medicaid, but the state didn’t have permission from the federal government to move forward until now.

Having work requirements creates accountability for people who rely on the social safety net, said Montana Senate President , a Republican.

“In an economy like this, if you’re an able-bodied adult that’s able to work, you really do need to step up,” he said.

Asked about confusion among enrollees about the rules, Regier responded that the Oct. 1 deadline offered more than enough time to work out the kinks in the new system.

In the end, Zulick learned she didn’t need to worry about that deadline, because she got married in July and no longer qualified for Medicaid, although she didn’t know that would be the case when she got the June letter.

But others remain scared about losing coverage, including Heather Reel, who attended a rally at the state capitol in July to push back against Montana’s early rollout.

Reel relies on Medicaid for its mental health coverage. Without it, she said, she would struggle to care for her teenage son, who has autism and is nonverbal. Between her shifts at a fast food restaurant and caring for her son, she’s scared she’ll be too busy to figure out how to report her work hours.

Montana’s Rollout a Potential Preview

The handful of states that are implementing the Medicaid work requirements early are building the plane as they’re taking off, said , who provides Medicaid analysis for The Commonwealth Fund, a nonprofit focused on making healthcare more equitable.

“Montana is going to be an example for what we might see nationally as things roll out,” she said.

Although most other states are sticking to the Jan. 1 deadline to build and test their Medicaid systems, they still might not have all the components in place, she said.

If states can’t automatically renew or deny coverage based on the new rules, state workers will have to do so manually, on a case-by-case basis. That could create backlogs and more disruption, leading more people to lose coverage, Coleman said.

Jon Ebelt, a spokesperson for the state’s health department, said in a statement that Montana’s Medicaid office is ready for the change on Oct. 1.

“We are committed to ensuring eligible Montanans maintain coverage while meeting requirements, and we will continue to monitor implementation closely,” Ebelt said.

Democratic state lawmakers have repeatedly asked state health officials to extend the Oct. 1 deadline for enrollees to comply with the new rules, but they’ve said they have no plans to do so.

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

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2288566 Nursing Home Beds Are Becoming More Scarce /aging/new-old-age-nursing-home-beds-scarce-capacity-baby-boomers-workforce/ Wed, 23 Sep 2026 09:00:00 +0000 /?p=2287906 The San Vicente de Paúl Nursing Home in the South Bronx hasn’t admitted a patient since December 2024. ArchCare, which operates the facility, has reduced its capacity from 120 available beds to 53 and plans to shrink it further.

Another ArchCare nursing home, on Staten Island, has shut down a full floor. North of the city, in Dutchess County, its Ferncliff Nursing Home has contracted from 309 available beds to 196.

The eight nursing homes owned by ArchCare, a nonprofit that provides eldercare through the Archdiocese of New York, have 269 fewer usable beds than they did 18 months ago, a nearly 12% decline, creating waiting lists for patients seeking long-term care.

Across New York state, 24 nursing homes have closed since 2020, resulting in a loss of more than 3,000 licensed beds, according to LeadingAge New York, which represents nonprofit senior living organizations.

That mirrors . In 2015, the Centers for Medicare & Medicaid Services certified 15,648 nursing facilities. A decade later, that number had fallen by more than 900.

With the oldest baby boomers turning 80 this year, an age when the need for long-term care climbs sharply, researchers are sounding alarms. Will there be enough nursing home beds for a rapidly graying nation?

“We’re seeing a serious problem and it’s heading in the wrong direction,” said David Grabowski, a health policy researcher at Harvard Medical School. He is an author of a study in JAMA Internal Medicine that in national nursing home capacity from 2019 to 2024. “As you look at the demographics, this is only going to get worse, maybe a lot worse,” he said, especially given looming Trump administration policies on immigration and Medicaid financing.

The reasons for the shrinkage?

ArchCare blames inadequate state reimbursement for Medicaid, a perennial industry complaint. The primary payer for nursing home care, Medicaid provides less than the daily cost of care, said Clif Porter, chief executive of the American Health Care Association, an industry trade group.

“Before the pandemic and inflation, the losses were sustainable,” said Jason Hutchens, ArchCare’s chief operating officer. More recently, he said, “we were running at an unsustainable loss — we had no choice.”

Nursing homes, , try to compensate by attracting short-stay patients covered by Medicare, which pays higher rates than Medicaid. When they can’t, “unless you’re extremely rapacious or extremely efficient, you’re not going to make it,” said Vincent Mor, a health services researcher at the Brown University School of Public Health who is an author of an article, published in the New England Journal of Medicine, about reduced capacity. “The numbers don’t add up.”

Staff shortages, which have plagued nursing homes for decades, have also caused contractions and closures. Nursing home aides work stressful, low-paying jobs with historically high turnover rates. Their median hourly wage last year was $20.67, according to , a research and advocacy group for direct care workers. Although pay has risen over the past decade, about 40% of nursing home aides rely on some form of public assistance, such as Medicaid or the Supplemental Nutrition Assistance Program, PHI reported.

The number of nursing home aides has rebounded from the covid pandemic, according to PHI, but fewer are working than in 2015. And while hiring and retention have improved, Porter said, “there’s still a significant gap between demand, especially future demand, and where the workforce currently is.”

National occupancy rates, which fell sharply during the pandemic, have returned to a more typical 80%.

That figure can be misleading; it doesn’t mean 1 bed in 5 sit empty, awaiting a patient. Occupancy counts state-licensed beds, but the more meaningful number is operating beds — how many are actually available depending on a facility’s staffing and other factors.

That number is usually lower and, in many cases, sinking. The American Health Care Association reported in 2024 that almost half of nursing homes were and 57% had waiting lists for new residents.

It’s possible, of course, that they also face financial losses because of lower demand. “Nursing homes close because people don’t want to go to nursing homes,” said Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care, an advocacy group. “The quality is so low that people avoid them like the plague.”

Last year, Medicare inspectors found at least one quality violation serious enough to harm or jeopardize residents in 27% of nursing homes, according to an analysis by KFF, a health information nonprofit.

In recent decades alternatives emerged that diverted patients from nursing homes. About a million older adults currently live in assisted living facilities. And among Medicaid recipients, the ongoing policy shift called “rebalancing” has enabled more people to receive services at home () rather than in nursing homes.

In 1988, only 10% of Medicaid expenditures for long-term services went to home- or community-based services; the rest paid for institutional care. By 2020, more than 60% of expenditures funded home and community care, said Priya Chidambaram, a KFF senior policy manager specializing in Medicaid, citing a staff analysis.

How big a problem these trends pose depends partly on geography. The decline in the number of nursing homes in rural locations — about 10% from 2015 to 2025 — than the national drop of about 6%.

“It’s more difficult to staff a rural nursing home,” Chidambaram said. “Labor pools are smaller, and it’s hard to get people to take lower-paid or part-time jobs if they have to travel long distances.”

Bed shortages are also creating bottlenecks at hospitals. Where nursing home capacity declined, Grabowski’s team found, patients stayed in hospitals longer because they couldn’t locate posthospital care. They often had to travel farther to find facilities. “It gums up the entire system,” Grabowski said.

On two fronts, Trump administration policies could make matters worse, experts said. Revoking legal status for certain immigrant groups .

So far, “we’re not seeing significant impact across the country,” Porter said. But the effects are being felt in specific locations, including Florida, New York, and Massachusetts, he confirmed. With further revocations and deportations, “a lot fewer older adults are going to have caregivers,” Grabowski said.

The administration’s more than $900 billion in cuts to Medicaid over a decade are also expected to exact a toll. As states grapple with reduced funding, analysts expect home and community services to take a greater initial hit than institutional care. But that could increase pressure on nursing homes if patients who lose home care turn to institutions instead.

Less of these services “means more nursing home entry,” Grabowski said.

As policy ideas circulate — with calls for better data tracking, special visas for immigrant health workers, and targeted grants for nursing homes serving high-cost populations — researchers, advocates, and families are waiting to see what unfolds.

“So much of this is speculative,” Chidambaram said. “We don’t know what states will decide. We don’t know how the market will react. We’re in new territory here.”

The New Old Age is produced through a partnership with .

³Ô¹Ï²»´òìÈ 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 .

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

]]> 2287906