For more than a decade, Kaiser Permanente has been under the microscope for shortcomings in mental health care, even as it is held in high esteem on the medical side.
In 2013, California regulators fined the insurer $4 million for failing to reduce wait times, giving patients inaccurate information, and improperly tracking appointment data. And in 2023, KP agreed to pay $50 million, the largest penalty ever levied by the state's Department of Managed Health Care, for failing to provide timely care, maintain a sufficient number of mental health providers, and oversee its providers effectively.
Now, Kaiser Permanente is back in the hot seat as mental health workers in Southern California wage a strike that's in its fourth month. KP therapists and union representatives accuse the HMO giant of saddling workers with excessive caseloads and often forcing patients to wait twice as long as the state allows for follow-up appointments. They say that the staff is burned out and that this work environment makes it hard to recruit clinicians, exacerbating the staffing problem.
KP rebuffs these claims, saying the union is parading out old problems, seeking to create "an inaccurate and outdated perception" of KP's care. They say the union's pay demands are "in direct contrast to our commitment to providing quality, affordable care."
Kaiser Permanente — the largest commercial health plan in California, with about 9 million members — is far from alone in struggling to provide adequate mental health care. A pandemic-induced shortage of health care workers has created obstacles for all health plans in recent years, on top of a preexisting scarcity. Moreover, many therapists decline to contract with insurers. And lingering bias in the health care system against mental health services — and patients — may also be at play.
Federal and state laws require health plans to provide mental health care on par with medical care. But many people who have sought therapy can vouch that those measures, known as mental health parity laws, do not seem to be followed consistently. You can spend hours or even days calling every therapist allegedly in your insurance company's network and come away empty-handed.
Secret-shopper surveys of 4,300 randomly selected outpatient providers listed as accepting new patients showed that "an alarming proportion" of them were unresponsive or unreachable, according to a federal government report issued last month. And while that was true for medical providers, it was consistently worse for mental health and substance abuse care, according to the report.
In California, state regulators have been conducting behavioral health care investigations of the insurance companies they regulate to help identify the extent and causes of delays in care.
So far, the DMHC has investigated nine health plans (not including KP) and found dozens of violations related to appointment availability, timely access, quality of care, and patient appeals, department spokesperson Rachel Arrezola says. The agency also has identified numerous "barriers" that do not necessarily break the law but may make it more difficult for patients to get care, she says.
Mark Peterson, a professor at UCLA's Luskin School of Public Affairs, notes that the open-ended nature of therapy can conflict with health plans' focus on their bottom lines. "It may be once a week, it may be more than once a week and go on for years," Peterson says.
For insurers, he says, the question is, "How do you put an appropriate limit on that?"
And the unwillingness of many therapists to accept insurance companies' payment rates, or to abide by their restrictions, often leads them to decline participation in health plan networks and charge higher rates. That, Peterson says, makes therapy financially inaccessible for a lot of people seeking it.
Even if you have some coverage for therapy outside your health plan network, your insurer will pay only a percentage of the rate that it recognizes as legitimate. "If your therapist is charging $300 an hour, and your insurance company only recognizes $150 an hour, and they only pay 50% of what they recognize, now you've got a quarter coverage of your therapy," Peterson says.
Since Kaiser Permanente is a closed system and patients don't get reimbursed for care outside the network, access problems for its patients can be "highly pronounced," Peterson adds.
In California, KP has accounted for over $54 million of the $55.7 million in mental-health-related fines the DMHC has levied on insurers in the past two decades. That includes the $50 million fine imposed in 2023, which was part of a settlement in which KP agreed to fix deficiencies the department found and to invest an additional $150 million in projects intended to enhance access to mental health care, not just for KP members, around California.
Officials at the National Union of Healthcare Workers, which represents some 2,400 KP mental health workers in the ongoing Southern California contract talks, say the HMO could easily invest enough to become a paragon of high-quality mental health care if it wanted to.
Greg Tegenkamp, the lead union negotiator, says KP could "lead the way to do the right thing."
Kaiser Permanente says it already is doing the right thing, even as it acknowledges past shortcomings. In a recent statement, it said it has invested over $1 billion in new treatment spaces and more mental health providers since 2020.
"We've grown our workforce and increased our network of skilled therapists so that any Kaiser Permanente member who needs an appointment is able to get timely, high-quality, clinically appropriate care," the company says.
In addition to higher wages and lower patient loads, workers want more time to complete follow-up tasks outside sessions and the reinstatement of a pension that was eliminated for those hired in Southern California after 2014.
Kaiser Permanente says that it already pays its mental health workers in Southern California about 18% above the market rate and that the current proposal would raise pay even more. KP recently raised its proposed wage increase by a modest amount, according to union officials.
KP refutes reports from workers about long wait times for patients seeking mental health appointments. It says the average wait time is 48 hours for urgent appointments and six business days for nonurgent ones, "which is better than the state's requirement" of no more than 10 days.
But workers say KP patients still face long delays for follow-up appointments.
"It's really hard for our patients to get regular, frequent appointments," says Kassaundra Gutierrez-Thompson, a KP therapist in Southern California who is on strike. Gutierrez-Thompson says she's seen it from both sides, since she is also a patient who sees a KP psychiatrist for depression and recently faced a big rescheduling delay after one of her appointments was canceled without notice.
As a provider, Gutierrez-Thompson says, she and her colleagues are expected to see patients "back-to-back-to-back." She says some of her colleagues developed urinary tract infections when they couldn't get to the bathroom. One even started wearing adult diapers, she says.
"The working conditions are like a factory," Gutierrez-Thompson says. "We do such human work, but they would love for us to be robots with no needs and just see patients all day."
Valentino Valdez was given his birth certificate, his Social Security card, a T-shirt, and khaki pants when he was released from a Texas prison in 2019 at age 21. But he didn't have health insurance, mental health medications, or access to a doctor, he said.
Three years later, he landed in an inpatient hospital after expressing suicidal thoughts.
After more than a decade cycling through juvenile detention, foster care placements, and state prisons, Valdez realizes now that treatment for his mental health conditions would have made life on his own much easier.
"It's not until you're put in, like, everyday situations and you respond adversely and maladaptive," he said, "you kind of realize that what you went through had an effect on you."
"I was struggling with a lot of mental stuff," said Valdez, now 27.
For years, people like Valdez have often been left to fend for themselves when seeking health care services after their release from jail, prison, or other carceral facilities. Despite this population's high rate of mental health problems and substance use disorders, they often return to their communities with no coverage, which increases their chances of dying or suffering a lapse that sends them back behind bars.
A new federal law aims to better connect incarcerated children and young adults who are eligible for Medicaid or the Children's Health Insurance Program to services before their release. The goal is to help prevent them from developing a health crisis or reoffending as they work to reestablish themselves.
"This could change the trajectory of their lives," said Alycia Castillo, associate director of policy for the Texas Civil Rights Project. Without that treatment, she said, many young people leaving custody struggle to reintegrate into schools or jobs, become dysregulated, and end up cycling in and out of detention facilities.
Medicaid has historically been prohibited from paying for health services for incarcerated people. So jails, prisons, and detention centers across the country have their own systems for providing health care, often funded by state and local budgets and not integrated with a public or private health system.
The new law is the first change to that prohibition since the Medicare and Medicaid Act's inception in 1965, and it came in a spending bill signed by President Joe Biden in 2022. It took effect Jan. 1 this year, and requires all states to provide medical and dental screenings to Medicaid- and CHIP-eligible youths 30 days before or immediately after they leave a correctional facility. Youths must continue to receive case management services for 30 days after their release.
More than 60% of young people who are incarcerated are eligible for Medicaid or CHIP, according to a September 2024 report from the Center for Health Care Strategies. The new law applies to children and young adults up to age 21, or 26 for those who, like Valdez, were in foster care.
Putting the law into practice, however, will require significant changes to how the country's thousands of correctional facilities provide health care to people returning to communities, and it could take months or even years for the facilities to be fully in compliance.
"It's not going to be flipping a switch," said Vikki Wachino, founder and executive director of the Health and Reentry Project, which has been helping states implement the law. "These connection points have never been made before," said Wachino, a former deputy administrator of the Centers for Medicare & Medicaid Services.
The federal CMS under the Biden administration did not respond to a question about how the agency planned to enforce the law.
It's also unclear whether the Trump administration will force states to comply. In 2018, President Donald Trump signed legislation requiring states to enroll eligible youths in Medicaid when they leave incarceration, so they don't experience a gap in health coverage. The law Biden signed built on that change by requiring facilities to provide health screenings and services to those youths, as well as ones eligible for CHIP.
Even though the number of juveniles incarcerated in the U.S. has dropped significantly over the past two decades, more than 64,000 children and young adults 20 and younger are incarcerated in state prisons, local and tribal jails, and juvenile facilities, according to estimates provided to KFF Health News by the Prison Policy Initiative, a nonprofit research organization that studies the harm of mass incarceration.
A 'Neglected Part of the Health System'
The federal Bureau of Justice Statistics estimates that about a fifth of the country's prison population spent time in foster care. Black youths are nearly five times as likely as white youths to be placed in juvenile facilities, according to the Sentencing Project, a nonprofit that advocates for reducing prison and jail populations.
Studies show that children who receive treatment for their health needs after release are less likely to reenter the juvenile justice system.
"Oftentimes what pulls kids and families into these systems is unmet needs," said Joseph Ribsam, director of child welfare and juvenile justice policy at the Annie E. Casey Foundation and a former state youth services official. "It makes more sense for kids to have their health care tied to a health care system, not a carceral system."
Yet many state and local facilities and state health agencies nationwide will have to make a lot of changes before incarcerated people can receive the services required in the law. The facilities and agencies must first create systems to identify eligible youths, find health care providers who accept Medicaid, bill the federal government, and share records and data, according to state Medicaid and corrections officials, as well as researchers following the changes.
In January, the federal government began handing out around $100 million in grants to help states implement the law, including to update technology.
Some state officials are flagging potential complications.
In Georgia, for example, the state juvenile justice system doesn't have a way to bill Medicaid, said Michelle Staples-Horne, medical director for the Georgia Department of Juvenile Justice.
In South Dakota, suspending someone's Medicaid or CHIP coverage while they are incarcerated instead of just ending it is a challenge, Kellie Wasko, the state's secretary of corrections, said in a November webinar on the new law. That's a technical change that's difficult to operationalize, she said.
State Medicaid officials also acknowledged that they can't force local officials to comply.
"We can build a ball field, but we can't make people come and play ball," said Patrick Beatty, deputy director and chief policy officer for the Ohio Department of Medicaid.
States should see the law as a way to address a "neglected part of the health system," said Wachino, the former CMS official. By improving care for people transitioning out of incarceration, states may spend less money on emergency care and on corrections, she said.
"Any state that is dragging its feet is missing an opportunity here," she said.
'Our System Is Making People Worse'
The Texas Department of Family Services took custody of Valdez when he was 8 because his mother's history of seizures made her unable to care for him, according to records. Valdez said he ran away from foster care placements because of abuse or neglect.
A few years later, he entered the Texas juvenile justice system for the first time. Officials there would not comment on his case. But Valdez said that while he was shuffled between facilities, his antidepressant and antipsychotic medications would be abruptly stopped and his records rarely transferred. He never received therapy or other support to cope with his childhood experiences, which included sexual abuse, according to his medical records.
Valdez said his mental health deteriorated while he was in custody, from being put in isolation for long periods of time, the rough treatment of officials, fears of violence from other children, and the lack of adequate health care.
"I felt like an animal," Valdez said.
In August, the U.S. Department of Justice released a report that claims the state exposes children in custody to excessive force and prolonged isolation, fails to protect them from sexual abuse, and fails to provide adequate mental health services. The Texas Juvenile Justice Department has said it is taking steps to improve safety at its facilities.
In 2024, 100% of children in Texas Juvenile Justice Department facilities needed specialized treatment, including for problems with mental health, substance use, or violent behavior, according to the department.
Too often, "our system is making people worse and failing to provide them with the continuity of care they need," said Elizabeth Henneke, founder and CEO of the Lone Star Justice Alliance, a nonprofit law firm in Texas.
Valdez said trauma from state custody shadowed his life after release. He was quick to anger and violence and often felt hopeless. He was incarcerated again before he had a breakdown that led to his hospitalization in 2022. He was diagnosed with post-traumatic stress disorder and put on medication, according to his medical records.
"It helped me understand that I wasn't going crazy and that there was a reason," he said. "Ever since then, I'm not going to say it's been easy, but it's definitely been a bit more manageable."
Of the more than 11,000 EMS agencies in the U.S. that provide ground transport to acute care hospitals, only about 1% carry blood.
This article was published on Monday, February 10, 1015 in KFF Health News.
One August afternoon in 2023, Angela Martin's cousin called with alarming news. Martin's 74-year-old aunt had been mauled by four dogs while out for a walk near her home in rural Purlear, North Carolina. She was bleeding heavily from bites on both legs and her right arm, where she'd tried to protect her face and neck. An ambulance was on its way.
"Tell them she's on Eliquis!" said Martin, a nurse who lived an hour's drive away in Winston-Salem. She knew the blood thinner could lead to life-threatening blood loss.
When the ambulance arrived, the medics evaluated Martin's aunt and then did something few emergency medical services crews do: They gave her a blood transfusion to replace what she'd lost, stabilizing her sinking blood pressure.
The ambulance took her to the local high school, and from there a medical helicopter flew her to the nearest trauma center, in Winston-Salem. She needed more units of blood in the helicopter and at the hospital but eventually recovered fully.
"The whole situation would have been different if they hadn't given her blood right away," Martin said. "She very well might have died."
More than 60,000 people in the U.S. bleed to death every year from traumatic events like car crashes or gunshot wounds, or other emergencies, including those related to pregnancy or gastrointestinal hemorrhaging. It's a leading cause of preventable death after a traumatic event.
But many of those people likely wouldn't have died if they had received a blood transfusion promptly, trauma specialists say. At a news conference last fall, members of the American College of Surgeons estimated that 10,000 lives could be saved annually if more patients received blood before they arrived at the hospital.
"I don't think that people understand that ambulances don't carry blood," said Jeffrey Kerby, who is chair of the ACS Committee on Trauma and directs trauma and acute care surgery at the University of Alabama-Birmingham Heersink School of Medicine. "They just assume they have it."
Of the more than 11,000 EMS agencies in the U.S. that provide ground transport to acute care hospitals, only about 1% carry blood, according to a 2024 study.
The term "blood deserts" generally refers to a problem in rural areas where the nearest trauma center is dozens of miles away. But heavy traffic and other factors in suburban and urban areas can turn those areas into blood deserts, too. In recent years, several EMS agencies throughout the country have established "pre-hospital blood programs" aimed at getting blood to injured people who might not survive the ambulance ride to the trauma center.
With blood loss, every minute counts. Blood helps move oxygen and nutrients to cells and keeps organs working. If the volume gets too low, it can no longer perform those essential functions.
If someone is catastrophically injured, sometimes nothing can save them. But in many serious bleeding situations, if emergency personnel can provide blood within 30 minutes, "it's the best chance of survival for those patients," said Leo Reardon, the Field Transfusion Paramedic Program director for the Canton, Massachusetts, fire department. "They're in the early stages of shock where the blood will make the most difference."
There are several roadblocks that prevent EMS agencies from providing blood. Several states don't allow emergency services personnel to administer blood before they arrive at the hospital, said John Holcomb, a professor in the division of trauma and acute care surgery at UAB's Heersink School.
"It's mostly tradition," Holcomb said. "They say: ‘It's dangerous. You're not qualified.' But both of those things are not true."
On the battlefields in the Middle East, operators of military medical facilities would maintain that only nurses and doctors could do blood transfusions, said Randall Schaefer, a U.S. Army trauma nurse who was deployed there and now consults with states on implementing pre-hospital blood programs.
But in combat situations, "we didn't have that luxury," Schaefer said. Medical staff sometimes relied on medics who carried units of blood in their backpacks. "Medics can absolutely make the right decisions about doing blood transfusions," she said.
A quick response made a difference: Soldiers who received blood within minutes of being injured were four times as likely to survive, according to military research.
Civilian emergency services are now incorporating lessons learned by the military into their own operations.
But they face another significant hurdle: compensation. Ambulance service payments are based on how far vehicles travel and the level of services they provide, with some adjustments. But the fee schedule doesn't cover blood products. If EMS responders carry blood on calls, it's usually low-titer O whole blood, which is generally safe for anyone to receive, or blood components — liquid plasma and packed red blood cells. These products can cost from $80 to $600 on average, according to Schaefer's study. And payments don't cover the blood coolers, fluid warming equipment, and other gear needed to provide blood at the scene.
On Jan. 1, the Centers for Medicare & Medicaid Services began counting any administration of blood during ambulance pre-hospital transport as an "advanced life support, level 2" (ALS2) service, which will boost payment in some cases.
The higher reimbursement is welcome, but it's not enough to cover the cost of providing blood to a patient, which can run to more than $1,000, Schaefer said. Agencies that run these programs are paying for them out of their own operating budgets or using grants or other sources.
Blood deserts exist in rural and urban areas. Last August, Herby Joseph was walking down the stairs at his cousin's house in Brockton, Massachusetts, when he slipped and fell. The glass plate he was carrying shattered and sliced through the blood vessels in his right hand.
"I saw a flood of blood and called my cousin to call 911," Joseph, 37, remembered.
The ambulance team arrived in just a few minutes, evaluated him, and called in the Canton-based Field Transfusion Paramedic Program team, which began administering a blood transfusion shortly thereafter. The program serves 30 towns in the Boston area. Since the transfusion program began last March, the team has responded to more than 40 calls, many of them related to car accidents along the ring of interstate highways surrounding the area, Reardon said.
Brockton has a Level 3 trauma center, but Joseph's injuries required more intensive care. Boston Medical Center, the Level 1 trauma center where the EMS team was taking Joseph, is about 23 miles from Brockton, and depending on traffic it can take more than a half hour to get there.
Joseph was given more blood at the medical center, where he remained for nearly a week. He eventually underwent three surgeries to repair his hand and has now returned to his warehouse job.
Although Boston has several Level 1 trauma centers, the region south of the city is pretty much a trauma desert, said Crisanto Torres, one of the trauma surgeons who cared for Joseph.
Boston Medical Center partners with the Canton Fire Department to operate the field transfusion program. It's an important service, Torres said.
"You can't just put up a new Level 1 trauma center," he said. "This is one way to blunt the inequity in access to care. It buys patients time."
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.
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.
"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."
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.
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."
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.
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, 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."
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."
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."