For California Farmworkers, Telehealth Visits With Mexican Doctors Fill a Gap

KFF Health News, February 5, 2025

MiSalud connects Spanish-speaking farm workers in California to physicians and mental health therapists in Mexico.

This article was published on Tuesday, February 4, 2025 in KFF Health News.

By Victoria Clayton

SALINAS, Calif. — This coastal valley made famous by the novelist John Steinbeck is sometimes known affectionately as "America's salad bowl," though the planting and harvesting is done mostly by immigrants from Mexico.

For Taylor Farms, a major global purveyor of packaged salads and cut vegetables, that's made it a logical place to pioneer a novel type of health care for its workforce, one that could have broad utility in the smartphone era: cross-border medical consultations through an app.

The company is among the first customers of a startup called MiSalud, which connects Spanish-speaking Taylor Farms employees to physicians and mental health therapists in Mexico. Providers aren't licensed in the U.S. and can't prescribe medications but instead serve as health coaches who can dispense advice and work with a U.S.-based doctor if needed.

Amy Taylor, who has led the company's wellness initiative since 2014 and is the daughter-in-law of company founder Bruce Taylor, said about 5,600 of Taylor Farms' 6,400 employees who work where MiSalud is currently available have signed up for the app, and 2,300 have used the app at least once. The service is free for employees and up to three family members.

Amy Taylor said the company hopes the app, which is part of a broader wellness program, can help employees stay healthier while keeping health care and other labor costs in check. She plans a full evaluation once the program has been in place for two years.

The health of farmworkers is a major concern for the state's agricultural economy. A 2022 study led by researchers from the University of California-Merced evaluated the health of more than 1,200 farmworkers and found that 37% of men and 47% of women reported having at least one chronic condition, including common conditions such as diabetes, high blood pressure, and anxiety.

Taylor said her company's employees, ranging from fieldworkers and drivers to retail packaging and office staff, mirror the study's findings. She said predominant health concerns among workers include obesity, high blood pressure, diabetes, and mental health.

"These are the people who are feeding America healthy food," Taylor said of the company's employees. "They should also be healthy."

MiSalud — or "My Health" — was the inspiration of Bismarck Lepe, a serial entrepreneur and Stanford graduate, who hails from a migrant farmworker family. Until age 6, when his family settled in Oxnard, California, they would travel between Mexico, California, and Washington state to harvest fruit. He saw that family and friends often delayed health care until they could return to Mexico because the U.S. system was too difficult to navigate, and insurance coverage too expensive or hard to find.

"My mother still prefers to get her health care in Mexico," Lepe said. "It's easier for her."

Lepe and co-founders Wendy Johansson and Cindy Blanco Ochoa launched MiSalud Health in 2021 with $5 million from a venture capital fund backed by Melinda French Gates' Pivotal Ventures, which focuses on social-impact investing. It has since added Samsung Next and Ulu Ventures as investors.

MiSalud started out by offering consultations with Mexican physicians for individuals who downloaded the app, Johansson said. But people keen enough to find the app, download it, and sign up for the program themselves weren't ultimately those who needed it most, and in 2023 the company pivoted to offering its service to companies as an employee benefit. (Individuals can still use it too.)

Besides Taylor Farms, the company counts the California city of Lynwood among about a dozen other clients, according to Johansson. MiSalud touted that nearly 40% of employees served by its platform say that without the app they would either have ignored their health concerns or waited until they could travel to Mexico to see a doctor.

Paul Brown, a UC-Merced professor of health economics who contributed to the university's farmworker health study, warned that telehealth consultations aren't adequate substitutes for in-person care by a primary care physician or a specialist. However, "to the extent that these types of programs can kind of link people into more standard care, that's good," he added.

Brown said MiSalud's approach could be more effective if policies changed to allow Mexican doctors to more easily treat patients in the U.S. A California program begun in 2002 allows Mexican doctors to travel to the Salinas Valley and other heavily Latino communities and treat patients, but cross-border telemedicine, even between states, remains limited.

Even so, Taylor Farms employees say the app has been helpful. Rosa "Rosita" Flores, a line supervisor with the company's retail operations, said she decided to give MiSalud a try after co-workers raved about it.

A recent company wellness fair, partly sponsored by MiSalud, had alerted her to the importance of monitoring her blood sugar and blood pressure levels, so she booked an appointment on the app to discuss it. "The app is very easy to use," she said in Spanish. When she had to cancel a video chat after her daughter got sick, the health coaches followed up by text.

Proponents of cross-border medicine say the approach helps bridge linguistic and cultural barriers in health care. Almost half of all U.S. immigrants — about two-thirds of whom are native Spanish speakers — have limited proficiency in English, and research has repeatedly shown that language barriers often discourage people from seeking care.

For example, Alfredo Alvarez, a MiSalud health coach who is a licensed physician in Mexico, pointed to belief in el mal de ojo, or the "evil eye" — the idea that a jealous or envious glance by someone can cause harm, especially to children. An American doctor might be dismissive of the notion, but he understands.

"This isn't uncommon here," he said of Mexico. "It's a belief in traditional medicine."

It's not that Alvarez encourages his socios, or members, to pass an egg over the child or make the child wear a special bracelet — traditional ways of diagnosing and treating el mal de ojo. Rather, he acknowledges their traditions and steers them to evidence-based medicine.

MiSalud's coaches can try to break stereotypes as well. For example, Alvarez said, a Mexican reverence for machismo can translate to the idea that "men don't do doctor visits." Meanwhile, he said, women may overlook their health in prioritizing other family members' needs.

Coaches also try to remove the stigma around seeking mental health treatment. "A lot of our socios have been extremely uncomfortable with or wary of mental health professionals," said Rubén Benavides Crespo, a MiSalud mental health coach who is a licensed psychologist in Mexico.

The app tries to break through by making it easy to book counseling appointments and asking questions such as whether someone has trouble sleeping, rather than invoking more worrisome or potentially stigmatizing terms like anxiety or depression.

MiSalud representatives say the app saw a 50% increase in requests for mental health support following the November presidential election. A more common request, however, is grief counseling, often following the loss of a loved one.

"Loss requires adaptation," Benavides said.

For Sam Chaidez, director of operations for a Taylor Farms location in Gonzales, MiSalud is a welcome addition for weight management. The son of fieldworkers, Chaidez graduated from UC-Davis and returned to the Salinas Valley to work for the company in 2007.

In 2019, Chaidez, a new parent at the time, began to understand his risk for diabetes and other health problems because of Taylor Farms' wellness program. Through diet and exercise and, more recently, coaching by MiSalud, Chaidez has shed 150 pounds.

Chaidez encourages co-workers to walk with him at lunch, and he credits MiSalud coaches for helping him keep the weight off and stay healthy. "It's been a great help," he said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Indiana Governor Appoints Business Leader To Shake Up Healthcare

KFF Health News, February 4, 2025

Gloria Sachdev says the free-market approach of limited government intervention doesn't work with healthcare.

This article was published on Tuesday, February 4, 2025 in KFF Health News.

By Samantha Liss

Gloria Sachdev has spent years challenging the healthcare industry, trying to bring down the high cost of care.

It's working, even in an unlikely place: Indiana, which has had some of the nation's highest hospital prices. Over the past few years, Indiana lawmakers have passed bills pushed by Sachdev that target complex and sometimes wonky health policy issues.

Sachdev, 55, trained as a pharmacist and for years led a coalition of Indiana businesses. In her quest to shake up the status quo, she sparked the creation of a national report on hospital pricing. She won over powerful Republican donor Al Hubbard, who has championed her proposals. She's convened healthcare experts from across the country to tackle cost transparency. In turn, all this has elevated her profile in Indiana and beyond.

Now, this disruptor has ascended to a position of power in the Hoosier State. Indiana's new Republican governor, Mike Braun, appointed her to a newly created Cabinet position overseeing the state's healthcare agencies.

Republican leaders in Indiana have been receptive to Sachdev's work, persuaded by her argument that the free-market approach of limited government intervention, long favored by the GOP, doesn't work with healthcare.

"I believe in a free market, too," she said.

But healthcare isn't like a grocery store where shoppers have lots of options in the cereal aisle and can see the prices. Too often, Indiana patients are left with few choices and no price transparency, Sachdev said. That messaging has resonated with Indiana Republicans, she said, because they see it in their own communities.

A decade ago, when she began representing frustrated employers as chief executive of the Employers' Forum of Indiana, she asked the businesses within that coalition to identify their biggest pain point: "They unanimously said healthcare affordability."

Sachdev had spent years training as a pharmacist, pursuing a career in healthcare like her father. He was a researcher at the University of Oklahoma who made advances in decoding cystic fibrosis, a life-threatening genetic disorder that damages the lungs.

In her own career, Sachdev said, she has always sought answers to seemingly simple questions, driven by data and her belief that sound policy stems from rigorous analysis of the available evidence. So to examine the employers' concerns, she sought to find out how healthcare prices in Indiana compared with those in other states. No such data existed at the time.

She cold-called Chapin White, then an economist at the Rand Corp. research organization, and persuaded him to help her find the answer. After some initial studies of Indiana, Rand published a study in 2019 that analyzed the prices paid by private health plans to more than 1,500 hospitals across the nation.

The results shocked her: Indiana landed at the top of the list, with the highest hospital prices among the 25 states initially studied. Sachdev was incredulous that her adopted state had earned such a dubious distinction. "We're not New York City," she said.

The results emboldened her — and state lawmakers — to take action. "When we're highlighted like that, it certainly requires our attention," said Chris Garten, the majority floor leader in the Indiana Senate and a former chair of the General Assembly's oversight task force on healthcare costs.

The push for transparency also gained momentum nationally, leading President Donald Trump to issue an executive order in his first term that required hospitals to publicly disclose prices.

"Gloria was the catalyst for getting this started," said Brown University economist Christopher Whaley, one of the other authors of the price transparency report while at Rand.

Consolidation has fueled higher prices in medical care. But Indiana is an outlier in how it chose to respond to consolidation, at least among red states, said Katie Gudiksen, executive editor of The Source on Healthcare Price and Competition, an online resource from the University of California Law-San Francisco.

Over the past few years, Indiana legislators have enacted laws to combat consolidation, banning large hospital systems from tacking on extra fees, restricting employers from imposing non-compete contracts on primary care physicians, and requiring healthcare companies to report pending mergers to the state's attorney general.

Sachdev called the move to ban extra fees in some hospitals a major victory. Across the U.S., hospitals may add an extra charge to a bill, known as a facility fee, even when the visit happens outside the hospital at an affiliated doctor's office. Indiana's law not only lowers prices, she said, but also removes an incentive for hospitals to buy up physician practices for the purpose of tacking on a facility fee.

"All of our efforts are really in this space of increasing competition," she said.

Last spring, Sachdev drew national medical pricing experts to Indianapolis for a conference on healthcare transparency. Celebrity entrepreneur Mark Cuban, a critic of high prices in the industry, was a keynote speaker.

At the conference, the latest installment of the Rand report was unveiled. Indiana had fallen from the top spot to the state with the ninth-highest prices.

Last fall, however, a hospital merger threatened to undo some of Sachdev's wins in Indiana. Rival hospitals in Terre Haute were seeking to merge. The deal would have left the city and those in the surrounding rural areas with a hospital monopoly, and such consolidations elsewhere have been shown to raise medical prices.

Under the state's Certificate of Public Advantage law, the deal would have been shielded from federal anti-monopoly restrictions. Two dozen states have had COPA laws on their books at some point, despite warnings from the Federal Trade Commission that such hospital mergers can become difficult to control and may decrease the overall quality of care.

The deal faced immense pushback. Doctors, health economists, and the FTC called on the Indiana Department of Health to deny Union Health's application to merge with HCA Healthcare-owned Terre Haute Regional Hospital.

In an opinion piece in The Indianapolis Star, Sachdev urged regulators to consider the harm that came after similar mergers elsewhere.

"The evidence shows how deals, like the one in Terre Haute, can crush communities," Sachdev wrote with Zack Cooper, a health economist and associate professor at Yale University.

In November, just days before the state was due to rule on the deal, Union Health withdrew its merger application.

"I was thrilled," Sachdev said. "The writing was on the wall that it would have been denied."

Now, Indiana state Sen. Ed Charbonneau, a Republican and chair of the Senate health committee, has introduced a bill to repeal the state's COPA law. Indiana would become the sixth state to roll back such a law.

Describing Sachdev as aggressive and analytical, Charbonneau said she regularly shares her thoughts about the COPA law and other healthcare issues. "Gloria is not at all reluctant to come and talk to me or call me or text me," he said.

When Braun appointed her as secretary of health and family services, he said in a statement that her "proven track record of transforming healthcare delivery and costs makes her the ideal choice to lead Indiana's health initiatives."

Braun's healthcare agenda targets prices that "are robbing Hoosiers' paychecks," according to his campaign platform, which adds, "Without intervention, the strain will only get worse."

In his second week as governor, Braun signed multiple executive orders seeking to increase transparency, directing state agencies to review the practices of pharmacy benefit managers and evaluate pricing. He also has said he plans to build on the legislature's "ambitious work" of tackling affordability. With Republicans in control of the legislature, Braun is unlikely to encounter political gridlock, a reality that excites Sachdev.

"I've been working from the ground up, and we've made progress," she said. "If I'm helping Gov. Braun from the top down, we can make faster, greater progress."

Samantha Liss: sliss@kff.org, @samanthann

Across the South, Rural Healthcare Has Become 'Trendy.' Medicaid Expansion Has Not.

KFF Health News, February 3, 2025

Clemson Rural Health is one of several programs attempting to meet this need in the state.

This article was published on Monday, February 3, 2025 in KFF Health News.

By Lauren Sausser

WALHALLA, S.C. — Nestled in the foothills of the Blue Ridge Mountains, a small primary care clinic run by Clemson University draws patients from across the region. Many are Hispanic and uninsured, and some are willing to travel from other counties, bypassing closer healthcare providers, just to be seen by Michelle Deem, the clinic's bilingual nurse practitioner.

"Patients who speak Spanish really prefer a Spanish-speaking provider," Deem said. "I've gotten to know this community pretty well."

Clemson doesn't operate an academic medical center, nor does it run a medical school. Arguably, the public university is best known for its football program. Yet, with millions of dollars earmarked from the state legislature, it has expanded into delivering healthcare, with clinics in Walhalla and beyond. School leaders are attempting to address gaps in rural and underserved parts of a state where health outcomes routinely rank among the worst in the country.

"Some of these communities have such high need," said Ron Gimbel, director of Clemson Rural Health, which operates four clinics and a fleet of mobile health units as part of the university's College of Behavioral, Social and Health Sciences. "They have so many barriers that impact their ability to be healthy."

Clemson Rural Health is one of several programs attempting to meet this need in the state.

"Rural health is trendy," said Graham Adams, CEO of the South Carolina Office of Rural Health.

State lawmakers nationwide are spending millions of dollars to address a rural healthcare crisis long in the making. For more than a decade, though, Republican-controlled legislatures in most Southern states have refused billions in federal funds that would provide public health insurance coverage to more low-income adults. These are the same states where racial health disparities and health outcomes are often worse than in other regions.

Nearly every state has extended Medicaid coverage for women in the months after they give birth. But 10 states haven't fully expanded Medicaid coverage with federal money made available under the 2010 Affordable Care Act. Seven of these states — Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee, and Texas — are in the South. With few exceptions, adults without children in these states don't qualify for Medicaid coverage, regardless of their income level.

Georgia Gov. Brian Kemp and South Carolina Gov. Henry McMaster, both Republicans, recently announced plans to expand Medicaid in limited ways to include some parents. The South Carolina plan would impose work requirements on some of these newly eligible Medicaid beneficiaries, while the Georgia plan would allow some parents of young children to skirt the state's existing Medicaid work rules. Both plans require federal approval.

Jonathan Oberlander, a professor and health policy scholar at the University of North Carolina, said he doesn't expect to see any of the remaining states rushing to fully expand Medicaid. Before Donald Trump took office on Jan. 20, Republicans in Washington had already expressed their intention to dramatically cut spending for Medicaid, which covers 72 million people at a cost of nearly $900 billion.

"There's a large gray cloud hanging over Medicaid expansion right now, and that's because there's so much uncertainty about what the Trump administration and congressional Republicans are going to do," Oberlander said.

Even so, in South Carolina this year the advocacy group CoverSC plans to lobby the General Assembly to pass a bill to adopt Medicaid expansion, said Beth Johnson, regional government relations director for the American Cancer Society Cancer Action Network and a CoverSC board member. The state's legislative session began Jan. 14.

If such a measure were approved, the federal government would cover 90% of the state's Medicaid expansion costs and South Carolina would be expected to pay 10%, or an estimated $270 million during the first year, according to a 2024 report by the Milken Institute School of Public Health at George Washington University.

Across all 10 non-expansion states — which, outside the South, also include Kansas, Wisconsin, and Wyoming — about 1.5 million people fall into a coverage gap, according to 2024 estimates from KFF, the health information nonprofit that includes KFF Health News. That means they do not qualify for Medicaid coverage or financial assistance to buy insurance through the federal marketplace.

Many of the people who would qualify for Medicaid if these states were to expand eligibility are gig workers, Johnson said. They play music, drive for Uber, or deliver pizza, and they typically don't qualify for health insurance through their jobs.

"They are providing services that we all appreciate," she said. "And they simply can't afford health insurance."

In some South Carolina communities, Clemson Rural Health attempts to fill this gap by providing primary care, cancer screenings, nutrition education, and diabetes management for uninsured patients free of charge or at reduced rates. Only about half of the patients seen by Clemson Rural Health have health insurance, Gimbel said, compared with 92% of the U.S. population.

During the current state fiscal year, Clemson Rural Health has been underwritten by a $2.5 million contract, its largest source of funding, from the state Department of Health and Human Services, which administers Medicaid in South Carolina and operates with a budget approved by state lawmakers.

That's a relatively small amount of money compared with the $47.5 million the state legislature has given to the Medical University of South Carolina in recent years to move into rural communities. MUSC has served Charleston for most of its 200-year history, but since 2019 it has expanded across the state by purchasing, building, or partnering with seven rural hospitals — some on the brink of closure — and one freestanding emergency department. MUSC is set to open an additional rural hospital this year.

Other states have made similar investments. The University of Georgia, for example, has established a new medical school, partly to send more physicians into underserved and rural areas. The Georgia General Assembly kicked in half the cost of a new $100 million building for medical education and research in Athens.

Meanwhile, the Tennessee General Assembly passed a budget last year that included $81 million for a variety of rural health initiatives.

Outside the South, state legislatures in Colorado, Nevada, West Virginia, and elsewhere have made recent investments in rural health, in addition to expanding Medicaid eligibility.

Some of this spending has been prompted by a wave of rural hospital closures — more than 100 since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

It's not yet clear what long-term impact some of these initiatives will have — for instance, whether the Clemson program will "reduce premature mortality, decrease preventable hospitalizations, and improve overall quality of life," as it aims to do, according to its website. Some public health experts point out that bolstering the number of rural clinics, hospitals, and doctors in the South won't matter much if patients can't afford to make an appointment.

"Lack of ability to pay is one of the greatest barriers," said Adams, the Office of Rural Health chief.

Oberlander said conservative lawmakers often consider projects such as building new rural clinics more politically palatable than expanding Medicaid coverage.

"The further away you get from the ACA, the less polarized the politics of healthcare," he said.

South Carolina Senate President Thomas Alexander, a Republican who lives in Walhalla, said the General Assembly is willing to invest in some rural health initiatives to improve healthcare access.

"Just because you expand Medicaid doesn't mean you've expanded access to the services," Alexander said. "I want to focus on expanding access to the services."

Gimbel would not comment on Medicaid expansion in South Carolina, and he said it's too soon to know how federal Medicaid changes under the Trump administration might affect funding for Clemson Rural Health, which currently receives money from the state's Medicaid agency. But making the Clemson program financially solvent might take several more years, he said.

"If rural health was profitable," he said, "we wouldn't have a rural health problem."

Lauren Sausser: lsausser@kff.org, @laurenmsausser

Trump’s Order on Gender-Affirming Care Escalates Reversal of Trans Rights

KFF Health News, January 31, 2025

President Donald Trump ratcheted up his administration’s reversal of transgender rights on Tuesday with an executive order that seeks to intervene in parents’ medical decisions by prohibiting government-funded insurance coverage of puberty blockers or surgery for people under 19.

This article was published on Friday, January 31, 2025 in KFF Health News.

By Julie Appleby

President Donald Trump ratcheted up his administration’s reversal of transgender rights on Tuesday with an executive order that seeks to intervene in parents’ medical decisions by prohibiting government-funded insurance coverage of puberty blockers or surgery for people under 19.

Trump’s order, titled “Protecting Children From Chemical and Surgical Mutilation,” is certain to face legal challenges and would require congressional or regulatory actions to be fully enacted. But transgender people and their advocates are concerned it will nonetheless discourage prescriptions and medical procedures they consider to be lifesaving in some cases, while complicating insurance coverage for gender-affirming care.

“It can’t be understated how harmful this executive order is, even though it doesn’t do anything on its own,” said Andrew Ortiz, a senior policy attorney at the Transgender Law Center. “It shows where the administration wants to go, where it wants the agencies to put their efforts and energies.”

The order is one of several Trump has issued, less than two weeks since taking office, that target the trans community. He has directed his administration to recognize only the male and female sex — and to abandon the term “gender” altogether. He ordered the State Department to issue passports identifying Americans only by their genders assigned at birth. He has encouraged the Justice Department to prosecute teachers and other school officials who help trans children transition, including by using their preferred names. And he signed an order that’s expected to lead to transgender people being banned from military service.

“We’re terrified. We cry every day. Hurting my family and my kid is winning politics for Republicans right now,” said the parent of a transgender child who lives in Missouri and asked not to be identified for fear of being targeted. “Every bone in my body is telling me I can’t keep my child safe from my government anymore, I can’t keep my family safe.”

About 300,000 American children ages 13-17 identify as transgender, according to the Williams Institute at the UCLA School of Law, which researches sexual orientation and gender identity law and public policy. But the number who seek gender-affirming care is believed to be far fewer. An examination by Reuters and Komodo Health of about 330 million health insurance claims filed from 2017 to 2021 found that fewer than 15,000 patients ages 6 to 17 with a diagnosis of gender dysphoria had received gender-affirming hormone therapy and fewer than 5,000 had started puberty-blocking medications — though the annual number of such patients more than doubled over the five-year span.

Trump’s order seeking to disrupt insurance coverage for young people, the Williams Institute said in a brief, “will likely at least limit the availability of gender-affirming care or make it more difficult to access in the short term and could increase risk for both providers and recipients of the care.”

Much of what the order calls for would require rule changes or other federal guidance, which can take weeks to months. Though it is mostly directed toward government health insurance programs, the order could have private-sector implications, too, and is likely to face litigation from states or advocacy organizations.

Specifically, the directive intends to limit insurance coverage for hormonal or surgical treatments that help young people transition.

It directs the secretary of the Department of Health and Human Services to “take all appropriate steps” to end insurance coverage of such treatments. It specifically names several government programs such as Tricare, which serves the military and its dependents; Medicare and Medicaid; federal and postal health benefit programs; and the Foreign Service Benefit Plan.

“The aim here is clearly targeted at federally funded plans, such as Medicare and Medicaid, but there’s a lack of clarity as to whether it would impact other plans, such as exchange plans, where essential health benefits are required,” said Lindsey Dawson, director of LGBTQ Health Policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

State Medicaid programs vary widely in their rules around transgender care, with a variety of limits or restrictions on what types of care can be covered for minors in just over half the states, according to a map provided by the Colorado-based Movement Advancement Project, a nonprofit think tank.

While little is likely to happen immediately from the order — one of more than 100 issued by the president since his inauguration last week — it could, nonetheless, have a chilling effect on medical professionals.

The order directs the Department of Justice to work with Congress to promote legislation that would allow children and parents a “private right of action” — the ability to file a lawsuit — against medical professionals who provide transgender care.

And the Justice Department was also directed to consider the application of existing laws to those who provide or promote access to gender care.

In addition, one section of the order directs agencies to “take appropriate steps to ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children,” a move that could affect hospitals or medical schools.

Julian Polaris, a partner at the consulting firm Manatt, said the order “displays the federal government’s willingness to use federal programs to restrict access to disfavored services even to providers and patients outside those federal programs.”

The move drew immediate criticism from groups supporting LBGTQ+ people’s rights.

“It is unconscionable that less than 24 hours after trying to take away Head Start programs and school meals for kids, President Trump issued an order demonizing transgender youth and spreading dangerous lies about gender-affirming care,” Alexis McGill Johnson, president and CEO of Planned Parenthood Federation of America, wrote in a press release.

Because it defines “youths” as those under age 19, the order would apply the directives to medical treatments provided to 18-year-olds, who otherwise are considered adults in making legal choices, voting, or serving in the military.

“There’s also just a problem with not seeing young people as capable in making decisions around their health and their futures, and so blurring that line and trying to move it up and taking more control over more people is obviously concerning,” Ortiz said. “But having the line hard at 18 also doesn’t make it any better.”

Ortiz noted that the order contains misinformation about medical care for young people who are transitioning and targets a small subset of U.S. residents: transgender youths in families that can access and afford gender-affirming care.

“That should be concerning to everybody,” he said, “that they are pulling out populations to target, to say that, ‘We don’t think that you deserve access to best-practice medical care.’”

Trump’s order explained that the action was necessary because such medical treatment could cause young people to regret the move later, once they “grasp the horrifying tragedy that they will never be able to conceive children of their own or nurture their children through breastfeeding.”

KFF Health News Midwest correspondent Bram Sable-Smith contributed to this report.

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

Covered California Hits Record Enrollment, but Key Subsidies in Jeopardy

KFF Health News, January 24, 2025

Republicans have criticized the cost of the subsidies, and it's not clear they'll renew them.

This article was published on Thursday, January 23, 2025 in KFF Health News.

By Claudia Boyd-Barrett

Covered California, the state's health insurance marketplace, has hit a record 1.8 million enrollees and the number could climb higher ahead of a Jan. 31 open enrollment deadline, due in large part to enhanced subsidies that have made plans more affordable.

But the state's progress in extending health coverage to all residents could come to an abrupt halt as the second Trump administration takes power alongside a Republican Congress whose leadership has long been hostile to the Affordable Care Act, the 2010 federal law also known as Obamacare.

Top of mind for Covered California officials is the looming expiration of the additional federal subsidies for health insurance approved by Congress in 2021 as part of a covid pandemic relief package. That resulted in lower premiums for people around the country — especially middle-class households — who buy health insurance through the exchanges established by the Affordable Care Act.

"Whether there will be action to extend the enhanced subsidies — that's a big impact that we are closely tracking," said Covered California Executive Director Jessica Altman, who noted the program had about 1.5 million enrollees prior to enhanced subsidies.

Republicans have criticized the cost of the subsidies, and it's not clear they'll renew them.

Without an extension, researchers at the University of California-Berkeley Labor Center estimate, Covered California premiums for subsidized enrollees would soar by an average of $967 a year beginning in 2026, and an estimated 69,000 Californians would lose their insurance.

California took its own steps last year to make coverage more affordable, eliminating deductibles and reducing other out-of-pocket costs on all mid-tier policies known as "silver" plans.

However, the state's health care spending is likely to face fresh pressure if Republicans in Washington follow through on long-standing designs to cut funding for Medicaid, the health insurance program for low-income Americans, known in California as Medi-Cal. In addition to bolstering Covered California, the state has also aggressively pushed to expand Medi-Cal, including to immigrants living in the U.S. without authorization, and now spends $161 billion a year on that program, about half paid by the federal government.

About 144,000 of Covered California's 1.8 million enrollees as of Dec. 14 are first-time buyers, and nearly 90% of all enrollees qualify for financial help. Covered California has extended the enrollment period to March 8 for residents in Los Angeles and Ventura counties due to wildfires, and has also issued extensions related to the bird flu and an earthquake in Northern California.

Low-income residents pay little or nothing for monthly premiums, while for those earning more, premiums are capped at a percentage of household income. With the enhanced federal subsidies, no one is required to spend more than 8.5% of their income on premiums, provided they stick to a silver plan. Such plans, however, can have smaller provider networks and significant out-of-pocket costs.

According to Covered California, the average monthly premium is $136 for those who receive subsidies, two-thirds of whom pay $10 or less a month. But people with higher incomes can end up paying significantly more. For example, a family of four making $200,000 in the Los Angeles area would pay well over $1,000 a month for a silver plan, according to a calculator for estimating costs.

While federal and state subsidies have significantly boosted the amount of assistance available, the underlying cost of insurance has continued to go up. Covered California premiums are up by 7.9% on average for 2025, but the extra subsidies shield most enrollees from the increase.

"You end up with people's out-of-pocket spending probably being lower than we've seen," said Dylan Roby, a professor of health, society, and behavior at the University of California-Irvine. "That doesn't necessarily mean that premiums are going down. It just means that the state or federal government is paying a larger share of premiums on behalf of enrollees than before."

Neither Trump nor incoming congressional leaders have given clear signals about how they view the future of the subsidies, but both have a history of seeking to repeal and weaken the Affordable Care Act. House Speaker Mike Johnson has vowed "massive reform" of the health care law, though without offering specifics.

Experts including Roby say Republicans could extend the subsidies to avoid an outcry from consumers, health insurers, hospitals, and others who have benefited from them. Enrollment in marketplace plans is especially high in Republican-controlled states that have not expanded Medicaid, because it offers low-income people a way to access affordable health insurance.

"I don't think Republican House members are that inclined to make all of their constituents' health insurance premiums go up," Roby said. "I'm kind of optimistic that [the subsidies] will be renewed."

But uncertainty over the future of the subsidies, even if they eventually get renewed, could affect the cost of marketplace plans, said Rachel Linn Gish, communications director for Health Access California, a consumer advocacy coalition. That's because insurers are already starting to plan their rates for next year and will likely price in the risk of nonrenewal, she said.

"We are going to be fighting for the next year to try to save those enhanced subsidies and subsequently all of the other frameworks and financing of the Affordable Care Act," Linn Gish said. "Because if any of that gets rolled back, people will lose health care coverage."

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Trump's Early Health Moves Signal Intent to Erase Biden's Legacy. What's Next Is Unclear.

KFF Health News, January 23, 2025

However, Trump's initial orders will have little immediate impact.

This article was published on Thursday, January 23, 2025 in KFF Health News.

By Julie Appleby and Stephanie Armour

President Donald Trump's early actions on health care signal his likely intention to wipe away some Biden-era programs to lower drug costs and expand coverage under public insurance programs.

The orders he issued soon after reentering the White House have policymakers, health care executives, and patient advocates trying to read the tea leaves to determine what's to come. The directives, while less expansive than orders he issued at the beginning of his first term, provide a possible road map that health researchers say could increase the number of uninsured Americans and weaken safety net protections for low-income people.

However, Trump's initial orders will have little immediate impact. His administration will have to take further regulatory steps to fully reverse Biden's policies, and the actions left unclear the direction the new president aims to steer the U.S. health care system.

"Everyone is looking for signals on what Trump might do on a host of health issues. On the early EOs, Trump doesn't show his cards," said Larry Levitt, executive vice president for health policy at KFF, the health policy research, polling, and news organization that includes KFF Health News.

A flurry of executive orders and other actions Trump issued on his first day back in office included rescinding directives by his predecessor, former President Joe Biden, that had promoted lowering drug costs and expanding coverage under the Affordable Care Act and Medicaid.

Executive orders "as a general matter are nothing more than gussied up internal memoranda saying, ‘Hey, agency, could you do something?'" said Nicholas Bagley, a law professor at the University of Michigan. "There may be reason to be concerned, but it's down the line."

That's because making changes to established law like the ACA or programs like Medicaid generally requires new rulemaking or congressional action, either of which could take months. Trump has yet to win Senate confirmation for any of his picks to lead federal health agencies, including Robert F. Kennedy Jr., the anti-vaccine activist and former Democratic presidential candidate he has nominated the lead the Department of Health and Human Services. On Monday, he appointed Dorothy Fink, a physician who directs the HHS Office on Women's Health, as acting secretary for the department.

During Biden's term, his administration did implement changes consistent with his health orders, including lengthening the enrollment period for the ACA, increasing funding for groups that help people enroll, and supporting the Inflation Reduction Act, which boosted subsidies to help people buy coverage. After falling during the Trump administration, enrollment in ACA plans soared under Biden, hitting record highs each year. More than 24 million people are enrolled in ACA plans for 2025.

The drug order Trump rescinded called on the Centers for Medicare & Medicaid Services to test ways to lower drug costs, such as setting a flat $2 copay for some generic drugs in Medicare, the health program for people 65 and older, and having states try to get better prices by banding together to buy certain expensive cell and gene therapies.

That might indicate Trump expects to do less on drug pricing this term or even roll back drug price negotiation in Medicare.

The White House did not respond to a request for comment.

Biden's experiments in lowering drug prices didn't fully get off the ground, said Joseph Antos of the American Enterprise Institute, a right-leaning research group. Antos said he's a bit puzzled by Trump's executive order ending the pilot programs, given that he has backed the idea of tying drug costs in the U.S. to lower prices paid by other nations.

"As you know, Trump is a big fan of that," Antos said. "Lowering drug prices is an easy thing for people to identify with."

In other moves, Trump also rescinded Biden orders on racial and gender equity and issued an order asserting that there are only two sexes, male and female. HHS under the Biden administration supported gender-affirming health care for transgender people and provided guidance on civil rights protections for transgender youths. Trump's missive on gender has intensified concerns within the LGBTQ+ community that he will seek to restrict such care.

"The administration has forecast that it will fail to protect and will seek to discriminate against transgender people and anyone else it considers an ‘other,'" said Omar Gonzalez-Pagan, senior counsel and health care strategist at Lambda Legal, a civil rights advocacy group. "We stand ready to respond to the administration's discriminatory acts, as we have previously done to much success, and to defend the ability of transgender people to access the care that they need, including through Medicaid and Medicare."

Trump also halted new regulations that were under development until they are reviewed by the new administration. He could abandon some proposals that were yet to be finalized by the Biden administration, including expanded coverage of anti-obesity medications through Medicare and Medicaid and a rule that would limit nicotine levels in tobacco products, Katie Keith, a Georgetown University professor who was deputy director of the White House Gender Policy Council under Biden, wrote in an article for Health Affairs Forefront.

"Interestingly, he did not disturb President Biden's three executive orders and a presidential memorandum on reproductive health care," she wrote.

However, Trump instructed top brass in his administration to look for additional orders or memorandums to rescind. (He revoked the Biden order that created the Gender Policy Council.)

Democrats criticized Trump's health actions. A spokesman for the Democratic National Committee, Alex Floyd, said in a statement that "Trump is again proving that he lied to the American people and doesn't care about lowering costs — only what's best for himself and his ultra-rich friends."

Trump's decision to end a Biden-era executive order aimed at improving the ACA and Medicaid probably portends coming cuts and changes to both programs, some policy experts say. His administration previously opened the door to work requirements in Medicaid — the federal-state program for low-income adults, children, and the disabled — and previously issued guidance enabling states to cap federal Medicaid funding. Medicaid and the related Children's Health Insurance Program cover more than 79 million people.

"Medicaid will be a focus because it's become so sprawling," said Chris Pope, a senior fellow at the Manhattan Institute, a conservative policy group. "It's grown after the pandemic. Provisions have expanded, such as using social determinants of health."

The administration may reevaluate steps taken by the Biden administration to allow Medicaid to pay for everyday expenses some states have argued affect its beneficiaries' health, including air conditioners, meals, and housing.

One of Trump's directives orders agencies to deliver emergency price relief and "eliminate unnecessary administrative expenses and rent-seeking practices that increase healthcare costs." (Rent-seeking is an economic concept describing efforts to exploit the political system for financial gain without creating other benefits for society.)

"It is not clear what this refers to, and it will be interesting to see how agencies respond," Keith wrote in her Health Affairs article.

Policy experts like Edwin Park at Georgetown University have also noted that, separately, Republicans are working on budget proposals that could lead to large cuts in Medicaid funding, in part to pay for tax cuts.

Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning research group, also pointed to Congress: "On one hand, what we see coming from the executive orders by Trump is important because it shows us the direction they are going with policy changes. But the other track is that on the Hill, there are active conversations about what goes into budget legislation. They are considering some pretty huge cuts to Medicaid."

Julie Appleby: jappleby@kff.org, @Julie_appleby

Stephanie Armour: sarmour@kff.org, @StephArmour1

As States Diverge on Immigration, Hospitals Say They Won't Turn Patients Away

KFF Health News, January 23, 2025

Donald Trump returned to the White House declaring a national emergency at the U.S.-Mexico border.

This article was published on Thursday, January 23, 2025 in KFF Health News.

By Vanessa G. Sánchez and Daniel Chang

California is advising health care providers not to write down patients' immigration status on bills and medical records and telling them they don't have to assist federal agents in arrests. Some Massachusetts hospitals and clinics are posting privacy rights in emergency and waiting rooms in Spanish and other languages.

Meanwhile, Florida and Texas are requiring health care facilities to ask the immigration status of patients and tally the cost to taxpayers of providing care to immigrants living in the U.S. without authorization.

Donald Trump returned to the White House declaring a national emergency at the U.S.-Mexico border, suspending refugee admissions, and challenging birthright citizenship, or the policy of giving U.S. citizenship to anyone born in the U.S. As he begins carrying out the "largest deportation operation" in the nation's history, states have offered starkly different guidelines to hospitals, community clinics, and other health facilities for immigrant patients.

Trump has also rescinded a long-standing policy not to arrest people without legal status at or near sensitive locations, including schools, churches, and hospitals. A proposal to formalize such protections died in Congress in 2023.

But no matter the guidelines that states issue, hospitals around the U.S. say patients won't be turned away for care because of their immigration status. "None of this changes the care patients receive," said Carrie Williams, a spokesperson for the Texas Hospital Association, which represents hospitals and health care systems in the state. "We don't want people to avoid care and worsen because they are concerned about immigration questions."

During Trump's first term, immigration agents arrested people receiving emergency care in hospitals and a child during an ambulance transfer. Immigration officers in Texas arrested a woman awaiting brain surgery in a hospital in Fort Worth. In Portland, Oregon, officers arrested a young man leaving a hospital, and in San Bernardino, California, a woman drove herself to the hospital to give birth after her husband was arrested at a gas station.

An estimated 11 million immigrants live in the United States without authorization, with the largest numbers in California, Texas, Florida, New York, New Jersey, and Illinois, according to Pew Research Center.

Half of immigrant adults likely without authorization are uninsured, compared with fewer than 1 in 10 citizens, according to the 2023 KFF-Los Angeles Times Survey of Immigrants, the largest nongovernmental survey of immigrants in the U.S. to date. While some states are highlighting health care expenses incurred by immigrants, a KFF brief noted that immigrants contribute more to the system through health insurance premiums and taxes than they use. Immigrants also have lower health care costs than citizens.

Some health care providers fear Immigration and Customs Enforcement agents will disrupt their work at health facilities and cause patients, particularly children, to skip medical care. On Trump's first day, the Republican president issued an executive order aimed at ending birthright citizenship for children born to a parent without legal authorization or on a visa, which could leave them ineligible for federal health and social programs. The order was immediately challenged by states and a civil rights group.

"You are instilling fear into folks who may defer care, who may go without care, whose children may not get the vaccines they need, who may not be able to get treatment for an ear infection or surgery," said Minal Giri, a pediatrician and the chair of the Refugee/Immigrant Child Health Initiative at the Illinois chapter of the American Academy of Pediatrics.

A recent survey conducted by the Im/migrant Well-Being Research Center at the University of South Florida found that 66% of noncitizens reported increased hesitation in seeking care after Florida Gov. Ron DeSantis signed a law in 2023 requiring hospitals that accept Medicaid to ask about a patient's legal status. That's compared with just 27% for citizens.

"That really was alarming to me to see how this law made people hesitant to go to the doctor, even in an emergency," said Liz Ventura Molina, a co-author of the survey and report.

In signing the law, DeSantis touted it as "the most ambitious anti-illegal immigration" legislation in the nation. This month, the Republican governor called for a special session of the state legislature to help support Trump's immigration agenda.

Jackson Health System, a public safety net provider in Miami, said in a statement that quarterly reports to the state don't contain individual patient information. "We do adhere to all required cooperation with law enforcement agencies, including ICE, as part of any criminal investigations, understanding that privacy laws mandate we only release private patient information through a court-ordered warrant."

In August, Texas Gov. Greg Abbott, a Republican, issued an executive order similar to Florida's law to record health care costs incurred by immigrants without legal authorization. All hospitals that receive funding from Medicaid or the Children's Health Insurance Program are expected to begin reporting the data to Texas Health and Human Services in March.

Even cities controlled by Democrats are walking a fine line. New York City Mayor Eric Adams met in December with Trump's incoming "border czar," Tom Homan, and pledged to remove immigrants who have been convicted of a major felony and lack legal status to remain in the country.

At the same time, Adams proposed an awareness campaign to let immigrants and asylum-seekers know they are safe to use the city's hospital systems.

Some states are going further by advising health facilities to do all they can to protect immigrant patients.

In December, California Attorney General Rob Bonta released a 42-page document recommending providers avoid including patients' immigration status in bills and medical records. The guidance also emphasized that while providers should not physically obstruct immigration agents, they are under no obligation to assist with an arrest.

According to the document, health care facilities should post information about patients' right to remain silent and are encouraged to provide patients with contact information for legal-aid groups "in the event that a parent is taken into immigration custody." If feasible, it says, the facility should designate an immigrant-affairs liaison to help train staff and provide nonlegal advice to families.

"We cannot let the Trump deportation machine create a culture of fear and mistrust that prevents immigrants from accessing vital public services," said Bonta, a Democrat.

On Tuesday, the Trump administration directed the Department of Justice to investigate state and local officials who don't cooperate with immigration enforcement. During Trump's first term, California limited cooperation with federal authorities, citing public safety and community trust concerns. The department, then under Jeff Sessions, sued to block the law but the state won in federal court, arguing that states have the authority to decide whether local resources are used to enforce federal law. The Trump administration appealed, but the Supreme Court turned down the petition.

Under California law, state-run health care facilities are required to adopt policies to limit their participation in immigration enforcement, and private entities are encouraged to follow similar protocols. David Simon, a spokesperson for the California Hospital Association, which represents more than 400 hospitals, said members have incorporated such policies, ensuring patient privacy.

"Hospitals don't call ICE about patients," Simon said.

California is bracing for a new round of clashes with Trump. Gov. Gavin Newsom and fellow Democratic state leaders have agreed to set aside $50 million for litigation and grants to nonprofit immigrant groups.

Lawmakers in New Jersey are considering legislation to limit health care facilities from asking about a patient's immigration status. The bill would also require the state attorney general to establish policies for hospitals and health care facilities for ensuring patient access.

In New York City, hospital administrators are directing staff to seek guidance from an "immigration liaison" if immigration authorities show up, and to take photos and videos of any enforcement actions if they can't reach them first. They are also discouraging staff from actively helping a person hide from ICE. In Massachusetts, some clinics and hospitals are training staff on how to read ICE warrants and plan to require ICE agents to identify themselves and present a warrant if they want to enter a private area.

"You can't be scrambling in the moment," said Altaf Saadi, a neurologist who co-directs a clinic for asylum-seekers at the Massachusetts General Hospital. "We have to prepare for these worst-case scenarios, and we hope that they don't happen, but we do need to be prepared."

Vanessa G. Sánchez: vsanchez@kff.org, @vanesanchez_g

Daniel Chang: dchang@kff.org, @dchangmiami

Dogs Paired with Providers at Hospitals Help Ease Staff and Patient Stress

KFF Health News, January 21, 2025

The interactions provide benefits for conditions including behavioral and mood issues and physical symptoms of stress. 

This article was published in on Tuesday, January 21, 2025 in KFF Health News.

By John Daley, Colorado Public Radio

DENVER — Outside HCA HealthONE Rose medical center, the snow is flying. Inside, on the third floor, there's a flurry of activity within the labor and delivery unit.

"There's a lot of action up here. It can be very stressful at times," said Kristina Fraser, an OB-GYN in blue scrubs.

Nurses wheel a very pregnant mom past.

"We're going to bring a baby into this world safely," Fraser said, "and off we go."

She said she feels ready in part due to a calming moment she had just a few minutes earlier with some canine colleagues.

A pair of dogs, tails wagging, had come by a nearby nursing station, causing about a dozen medical professionals to melt into a collective puddle of affection. A yellow Lab named Peppi showered Fraser in nuzzles and kisses. "I don't know if a human baby smells as good as that puppy breath!" Fraser had said as her colleagues laughed.

The dogs aren't visitors. They work here, too, specifically for the benefit of the staff. "I feel like that dog just walks on and everybody takes a big deep breath and gets down on the ground and has a few moments of just decompressing," Fraser said. "It's great. It's amazing."

Hospital staffers who work with the dogs say there is virtually no bite risk with the carefully trained Labradors, the preferred breed for this work.

The dogs are kept away from allergic patients and washed regularly to prevent germs from spreading, and people must wash their hands before and after petting them.

Doctors and nurses are facing a growing mental health crisis driven by their experiences at work. They and other health care colleagues face high rates of depression, anxiety, stress, suicidal ideation, and burnout. Nearly half of health workers reported often feeling burned out in 2022, an increase from 2018, according to the Centers for Disease Control and Prevention. And the percentage of health care workers who reported harassment at work more than doubled over that four-year period. Advocates for the presence of dogs in hospitals see the animals as one thing that can help.

That includes Peppi's handler, Susan Ryan, an emergency medicine physician at Rose.

Ryan said years working as an emergency room doctor left her with symptoms of PTSD. "I just was messed up and I knew it," said Ryan, who isolated more at home and didn't want to engage with friends. "I shoved it all in. I think we all do."

She said doctors and other providers can be good at hiding their struggles, because they have to compartmentalize. "How else can I go from a patient who had a cardiac arrest, deal with the family members telling them that, and go to a room where another person is mad that they've had to wait 45 minutes for their ear pain? And I have to flip that switch."

To cope with her symptoms of post-traumatic stress disorder, Ryan started doing therapy with horses. But she couldn't have a horse in her backyard, so she got a Labrador. 

Ryan received training from a national service dog group called Canine Companions, becoming the first doctor trained by the group to have a facility dog in an emergency room. Canine Companions has graduated more than 8,000 service dogs.

The Rose medical center gave Ryan approval to bring a dog to work during her ER shifts. Ryan's colleagues said they are delighted that a dog is part of their work life.

"When I have a bad day at work and I come to Rose and Peppi is here, my day's going to be made better," EMT Jasmine Richardson said. "And if I have a patient who's having a tough day, Peppi just knows how to light up the room."

Nursing supervisor Eric Vaillancourt agreed, calling Peppi "joyful."

Ryan had another dog, Wynn, working with her during the height of the pandemic. She said she thinks Wynn made a huge difference. "It saved people," she said. "We had new nurses that had never seen death before, and now they're seeing a covid death. And we were worried sick we were dying."

She said her hospital system has lost a couple of physicians to suicide in the past two years, which HCA confirmed to KFF Health News and NPR. Ryan hopes the canine connection can help with trauma. "Anything that brings you back to the present time helps ground you again. A dog can be that calming influence," she said. "You can get down on the ground, pet them, and you just get calm."

Ryan said research has shown the advantages. For example, one review of dozens of original studies on human-animal interactions found benefits for a variety of conditions including behavioral and mood issues and physical symptoms of stress. 

Rose's president and CEO, Casey Guber, became such a believer in the canine connection he got his own trained dog to bring to the hospital, a black Lab-retriever mix named Ralphie.

She wears a badge: Chief Dog Officer.

Guber said she's a big morale booster. "Phenomenal," he said. "It is not uncommon to see a surgeon coming down to our administration office and rolling on the ground with Ralphie, or one of our nurses taking Ralphie out for a walk in the park."

This article is from a partnership that includes CPR News, NPR, and KFF Health News.

John Daley, Colorado Public Radio: @CODaleyNews

Trump's Return Puts Medicaid on the Chopping Block

KFF Health News, January 13, 2025

Republicans plan to use funding cuts and regulatory changes to dramatically shrink Medicaid.

This article was published on Monday, January 13, 2024 in KFF Health News.

By Phil Galewitz

Under President Joe Biden, enrollment in Medicaid hit a record high and the uninsured rate reached a record low.

Donald Trump's return to the White House — along with a GOP-controlled Senate and House of Representatives — is expected to change that.

Republicans in Washington say they plan to use funding cuts and regulatory changes to dramatically shrink Medicaid, the nearly $900-billion-a-year government health insurance program that, along with the related Children's Health Insurance Program, serves about 79 million mostly low-income or disabled Americans.

The proposals include rolling back the Affordable Care Act's expansion of Medicaid, which over the last 11 years added about 20 million low-income adults to its rolls. Trump has said he wants to drastically cut government spending, which may be necessary for Republicans to extend 2017 tax cuts that expire at the end of this year.

Trump made little mention of Medicaid during the 2024 campaign. The first Trump administration approved work requirements in several states, though only Arkansas implemented theirs before a federal judge said it violated the law. The first Trump administration also sought to block-grant funding to states.

House Budget Committee Chair Jodey Arrington (R-Texas) told KFF Health News that Medicaid and other federal entitlement programs need major changes to help cut the federal debt. "Without them, we will watch this country sadly enter into fiscal collapse."

Rep. Chip Roy (R-Texas), a member of the Budget Committee, said Congress needs to explore cutting federal spending on Medicaid.

"You need wholesale reform on the healthcare front, which can include undoing a lot of the damage being done by the ACA and Obamacare," Roy said. "Frankly, we could end up providing better service if we do it the right way."

Advocates for poor people fear GOP funding cuts will leave more Americans without insurance, making it harder for them to get care.

"Medicaid is an obvious target for huge cuts," said Joan Alker, executive director of Georgetown University's Center for Children and Families. "An existential fight about Medicaid's future likely lies ahead."

Medicaid, which turns 60 in July, is nearing the end of a disruptive period, after covid pandemic-era coverage protections expired in 2023 and all enrollees had to prove they still qualified. More than 25 million people lost coverage over the 18 months after the "unwinding" began, though it has not notably increased the number of people without insurance, according to the latest census data.

The unwinding's disruptions could pale in comparison to what happens in the next four years, said Matt Salo, former executive director and founder of the National Association of Medicaid Directors. "What we are going to see is an even bigger seismic shift in who Medicaid covers and how it operates," he said.

But Salo said any efforts to shrink the program will face pushback.

"A lot of powerful entities — state governments, managed-care organizations, long-term care providers, and everyone under the sun who wants to do well by doing good — wants to see Medicaid work efficiently and be adequately funded," he said. "And they will be highly motivated to push back on something they see as draconian cuts, because it could affect their business model."

The GOP is looking at several tactics to reduce the size of Medicaid:

  • Shifting to block grants. Switching to annual block grants could lower federal funding for states to operate the program while giving states more discretion over how to spend the money. Currently, the government matches a certain percentage of state spending each year with no cap. Republican presidents since Ronald Reagan have sought to block-grant Medicaid with no success. Arrington said he favors ending the open-ended federal funding to states and replacing it with a set annual amount based on how many people each state has in the program.
  • Cutting ACA Medicaid funding. The ACA provided financing to cover, through Medicaid, Americans with incomes up to 138% of the federal poverty level, or $20,783 for an individual last year. The federal government pays 90% of the cost for adults covered through the law's Medicaid expansion, which 40 states and Washington, D.C., have adopted. The GOP may try to lower that funding to the same match rate the feds pay states for everyone else in the program, which averages about 60%. "We should absolutely note that we are subsidizing the healthy, able-bodied Medicaid expansion population at a higher rate than we do the poorest and sickest among us, which was the original intent of the program," Arrington said. "That's not right."
  • Lowering federal matching funds. Since Medicaid began, the federal match rate has been based on the relative wealth of a state's population, with poorer states receiving a higher rate and no state receiving less than a 50% match. Ten states get the base rate — all but two are Democratic-run states, including New York and California. The GOP may seek to cut the base rate to 40% or less.
  • Adding work requirements. During the first Trump term, federal courts ruled that Medicaid law doesn't allow coverage to be conditioned on enrollees' working or seeking jobs. But the GOP may try again. "If we can get strict work requirements on able-bodied adults, that can be a huge cost savings by itself," Rep. Tom McClintock (R-Calif.) told KFF Health News. Because most Medicaid enrollees already work, go to school, or serve as caregivers, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
  • Placing enrollment hurdles. About 10 states offer some populations what's called continuous eligibility, whereby people stay enrolled for years without having to renew their coverage. That policy's been shown to prevent enrollees from falling out of the program for short periods because of hardships or paperwork problems, which can lead to surprise medical bills and debt. The Trump administration could seek to repeal waivers that allow states to grant multiyear continuous eligibility, which would require people in those states to reapply for coverage annually.

If the GOP's plans to shrink Medicaid are realized, Democrats and health experts say, low-income people forced to buy private insurance would face challenges paying monthly premiums and the large copayments and deductibles common to commercial plans that typically don't exist in Medicaid.

The Paragon Health Institute, a leading conservative think tank run by former Trump adviser Brian Blase, has issued reports saying the billions in extra money states took to expand Medicaid under the ACA has been a boon to private insurers that manage the program and relatively wealthier people it says shouldn't be enrolled.

Josh Archambault, a senior fellow with the conservative Cicero Institute, said he hopes the Trump administration holds states accountable for overpaying providers and enrolling people in Medicaid who are not eligible. Conservatives have cited CMS reports saying states improperly pay Medicaid providers billions of dollars a year, though the federal government notes that is mostly due to lack of documentation.

He said the GOP will look to scale back Medicaid to its "traditional" populations of children, pregnant women, and people with disabilities. "We need to rebalance the program that most people think is underperforming," he said. Most Americans, including large majorities of both Republicans and Democrats, view the program favorably, according to polls.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Can Medical Schools Funnel More Doctors Into the Primary Care Pipeline?

KFF Health News, January 13, 2025

The driving force is often money.

 

This article was published on Monday, January 13, 2025 in KFF Health News.

Throughout her childhood, Julia Lo Cascio dreamed of becoming a pediatrician. So, when applying to medical school, she was thrilled to discover a new, small school founded specifically to train primary care doctors: NYU Grossman Long Island School of Medicine.

Now in her final year at the Mineola, New York, school, Lo Cascio remains committed to primary care pediatrics. But many young doctors choose otherwise as they leave medical school for their residencies. In 2024, 252 of the nation's 3,139 pediatric residency slots went unfilled and family medicine programs faced 636 vacant residencies out of 5,231 as students chased higher-paying specialties.

Lo Cascio, 24, said her three-year accelerated program nurtured her goal of becoming a pediatrician. Could other medical schools do more to promote primary care? The question could not be more urgent. The Association of American Medical Colleges projects a shortage of 20,200 to 40,400 primary care doctors by 2036. This means many Americans will lose out on the benefits of primary care, which research shows improves health, leading to fewer hospital visits and less chronic illness.

Many medical students start out expressing interest in primary care. Then they end up at schools based in academic medical centers, where students become enthralled by complex cases in hospitals, while witnessing little primary care.

The driving force is often money, said Andrew Bazemore, a physician and a senior vice president at the American Board of Family Medicine. "Subspecialties tend to generate a lot of wealth, not only for the individual specialists, but for the whole system in the hospital," he said.

A department's cache of federal and pharmaceutical-company grants often determines its size and prestige, he said. And at least 12 medical schools, including Harvard, Yale, and Johns Hopkins, don't even have full-fledged family medicine departments. Students at these schools can study internal medicine, but many of those graduates end up choosing subspecialties like gastroenterology or cardiology.

One potential solution: eliminate tuition, in the hope that debt-free students will base their career choice on passion rather than paycheck. In 2024, two elite medical schools — the Albert Einstein College of Medicine and the Johns Hopkins University School of Medicine — announced that charitable donations are enabling them to waive tuition, joining a handful of other tuition-free schools.

But the contrast between the school Lo Cascio attends and the institution that founded it starkly illustrates the limitations of this approach. Neither charges tuition.

In 2024, two-thirds of students graduating from her Long Island school chose residencies in primary care. Lo Cascio said the tuition waiver wasn't a deciding factor in choosing pediatrics, among the lowest-paid specialties, with an average annual income of $260,000, according to Medscape.

At the sister school, the Manhattan-based NYU Grossman School of Medicine, the majority of its 2024 graduates chose specialties like orthopedics (averaging $558,000 a year) or dermatology ($479,000).

Primary care typically gets little respect. Professors and peers alike admonish students: If you're so smart, why would you choose primary care? Anand Chukka, 27, said he has heard that refrain regularly throughout his years as a student at Harvard Medical School. Even his parents, both PhD scientists, wondered if he was wasting his education by pursuing primary care.

Seemingly minor issues can influence students' decisions, Chukka said. He recalls envying the students on hospital rotations who routinely were served lunch, while those in primary care settings had to fetch their own.

Despite such headwinds, Chukka, now in his final year, remains enthusiastic about primary care. He has long wanted to care for poor and other underserved people, and a one-year clerkship at a community practice serving low-income patients reinforced that plan.

When students look to the future, especially if they haven't had such exposure, primary care can seem grim, burdened with time-consuming administrative tasks, such as seeking prior authorizations from insurers and grappling with electronic medical records.

While specialists may also face bureaucracy, primary care practices have it much worse: They have more patients and less money to hire help amid burgeoning paperwork requirements, said Caroline Richardson, chair of family medicine at Brown University's Warren Alpert Medical School.

"It's not the medical schools that are the problem; it's the job," Richardson said. "The job is too toxic."

Kevin Grumbach, a professor of family and community medicine at the University of California-San Francisco, spent decades trying to boost the share of students choosing primary care, only to conclude: "There's really very little that we can do in medical school to change people's career trajectories."

Instead, he said, the U.S. health care system must address the low pay and lack of support.

And yet, some schools find a way to produce significant proportions of primary care doctors — through recruitment and programs that provide positive experiences and mentors.

U.S. News & World Report recently ranked 168 medical schools by the percentage of graduates who were practicing primary care six to eight years after graduation.

The top 10 schools are all osteopathic medical schools, with 41% to 47% of their students still practicing primary care. Unlike allopathic medical schools, which award MD degrees, osteopathic schools, which award DO degrees, have a history of focusing on primary care and are graduating a growing share of the nation's primary care physicians.

At the bottom of the U.S. News list is Yale, with 10.7% of its graduates finding lasting careers in primary care. Other elite schools have similar rates: Johns Hopkins, 13.1%; Harvard, 13.7%.

In contrast, public universities that have made it a mission to promote primary care have much higher numbers.

The University of Washington — No. 18 in the ranking, with 36.9% of graduates working in primary care — has a decades-old program placing students in remote parts of Washington, Wyoming, Alaska, Montana, and Idaho. UW recruits students from those areas, and many go back to practice there, with more than 20% of graduates settling in rural communities, according to Joshua Jauregui, assistant dean for clinical curriculum.

Likewise, the University of California-Davis (No. 22, with 36.3% of graduates in primary care) increased the percentage of students choosing family medicine from 12% in 2009 to 18% in 2023, even as it ranks high in specialty training. Programs such as an accelerated three-year primary care "pathway," which enrolls primarily first-generation college students, help sustain interest in non-specialty medical fields.

The effort starts with recruitment, looking beyond test scores to the life experiences that forge the compassionate, humanistic doctors most needed in primary care, said Mark Henderson, associate dean for admissions and outreach. Most of the students have families who struggle to get primary care, he said. "So they care a lot about it, and it's not just an intellectual, abstract sense."

Establishing schools dedicated to primary care, like the one on Long Island, is not a solution in the eyes of some advocates, who consider primary care the backbone of medicine and not a separate discipline. Toyese Oyeyemi Jr., executive director of the Social Mission Alliance at the Fitzhugh Mullan Institute of Health Workforce Equity, worries that establishing such schools might let others "off the hook."

Still, attending a medical school created to produce primary care doctors worked out well for Lo Cascio. Although she underwent the usual specialty rotations, her passion for pediatrics never flagged — owing to her 23 classmates, two mentors, and her first-year clerkship shadowing a community pediatrician. Now, she's applying for pediatric residencies.

Lo Cascio also has deep personal reasons: Throughout her experience with a congenital heart condition, her pediatrician was a "guiding light."

"No matter what else has happened in school, in life, in the world, and medically, your pediatrician is the person that you can come back to," she said. "What a beautiful opportunity it would be to be that for someone else."

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