But in his 40 years as a pediatrician in Southern California serving those too poor to afford care, including many immigrant families, Sweidan said he's never seen a drop-off in patient visits like this.
"They are scared to come to the offices. They're getting sicker and sicker," said Sweidan, who specializes in neonatology and runs five clinics in Los Angeles and Orange counties. "And when they are near collapsing, they go to the ER because they have no choice."
In the last two months, he has sent young children to the emergency room because their parents worked up the courage to call his office only after several days of high fever. He said he attended to a 14-year-old boy in the ER who was on the verge of a diabetic coma because he'd run out of insulin, his parents too frightened to venture out for a refill.
Sweidan had stopped offering telehealth visits after the covid-19 pandemic, but he and other health care providers have brought them back as ramped-up immigration enforcement drives patients without legal status — and even their U.S. citizen children — deeper into the shadows.
Patients in need of care are increasingly scared to seek it after Trump rescinded a Biden-era policy that barred immigration officials from conducting operations in "sensitive" areas such as schools, hospitals, and churches. Clinics and health plans have taken a page out of their covid playbooks, revamping tested strategies to care for patients scared to leave the house.
Sara Rosenbaum, professor emerita of health law and policy at George Washington University, said she's heard from clinic administrators and industry colleagues who have experienced a substantial drop in in-person visits among immigrant patients.
"I don't think there's a community health center in the country that is not feeling this," Rosenbaum said.
At St. John's Community Health clinics in the Los Angeles area, which serve an estimated 30,000 patients without legal status annually, virtual visits have skyrocketed from roughly 8% of appointments to about 25%, said Jim Mangia, president and chief executive officer. The organization is also registering some patients for in-home health visits, a service funded by private donors, and has trained employees how to read a warrant.
"People are not picking up their medicine," Mangia said. "They're not seeing the doctor."
Mangia said that, in the past eight weeks, federal agents have attempted to gain access to patients at a St. John's mobile clinic in Downey and pointed a gun at an employee during a raid at MacArthur Park. Last month, Immigration and Customs Enforcement contractors sat in a Southern California hospital waiting for a patient and federal prosecutors charged two health center workers they say interfered with immigration officers' attempts to arrest someone at an Ontario facility.
C.S., an immigrant from Huntington Park without legal status, said she signed up for St. John's home visit services in July because she fears going outside. The 71-year-old woman, who asked to be identified only by her initials for fear of deportation, said she has missed blood work and other lab tests this year. Too afraid to take the bus, she skipped a recent appointment with a specialist for her arthritic hands. She is also prediabetic and struggles with leg pain after a car hit her a few years ago.
"I feel so worried because if I don't get the care I need, it can get much worse," she said in Spanish, speaking about her health issues through an interpreter. A doctor at the clinic gave her a number to call in case she wants to schedule an appointment by phone.
Officials at the federal Department of Health and Human Services did not respond to questions from KFF Health News seeking comment about the impact of the raids on patients.
There's no indication the Trump administration intends to shift its strategy. Federal officials have sought to pause a judge's order temporarily restricting how they conduct raids in Southern California after immigrant advocates filed a lawsuit accusing ICE of deploying unconstitutional tactics. The 9th U.S. Circuit Court of Appeals on Aug. 1 denied the request, leaving the restraining order in place.
In July, Los Angeles County supervisors directed county agencies to explore expanding virtual appointment options after the county's director of health services noted a "huge increase" in phone and video visits. Meanwhile, state lawmakers in California are considering legislation that would restrict immigration agents' access to places such as schools and health care facilities — Colorado's governor, Democrat Jared Polis, signed a similar bill into law in May.
Immigrants and their families will likely end up using more costly care in emergency rooms as a last resort. And recently passed cuts to Medicaid are expected to further stress ERs and hospitals, said Nicole Lamoureux, president of the National Association of Free & Charitable Clinics.
"Not only are clinics trying to reach people who are retreating from care before they end up with more severe conditions, but the health care safety net is going to be strained due to an influx in patient demand," Lamoureux said.
Mitesh Popat, CEO of Venice Family Clinic, nearly 90% of whose patients are at or below the federal poverty line, said staff call patients before appointments to ask if they plan to come in person and to offer telehealth as an option if they are nervous. They also call if a patient doesn't show five minutes into their appointment and offer immediate telehealth service as an alternative. The clinic has seen a roughly 5% rise in telehealth visits over the past month, Popat said.
In the Salinas Valley, an area with a large concentration of Spanish-speaking farmworkers, Clinica de Salud del Valle de Salinas began promoting telehealth services with Spanish radio ads in January. The clinics also trained people how to use Zoom and other digital platforms at health fairs and community meetings.
CalOptima Health, which covers nearly 1 in 3 residents of Orange County and is the biggest Medi-Cal benefits administrator in the area, sent more than a quarter-million text messages to patients in July encouraging them to use telehealth rather than forgo care, said Chief Executive Officer Michael Hunn. The insurer has also set up a webpage of resources for patients seeking care by phone or home delivery of medication.
"The Latino community is facing a fear pandemic. They're quarantining just the way we all had to during the covid-19 pandemic," said Seciah Aquino, executive director of the Latino Coalition for a Healthy California, an advocacy group that promotes health access for immigrants and Latinos.
But substituting telehealth isn't a long-term solution, said Isabel Becerra, chief executive officer of the Coalition of Orange County Community Health Centers, whose members reported increases in telehealth visits as high as 40% in the past month.
"As a stopgap, it's very effective," said Becerra, whose group represents 20 clinics in Southern California. "Telehealth can only take you so far. What about when you need lab work? You can't look at a cavity through a screen."
Telehealth also brings a host of other challenges, including technical hiccups with translation services and limited computer proficiency or internet access among patients, she said.
And it's not just immigrants living in the country unlawfully who are scared to seek out care. In southeast Los Angeles County, V.M., a 59-year-old naturalized citizen, relies on her roommate to pick up her groceries and prescriptions. She asked that only her initials be used to share her story and those of her family and friends out of fear they could be targeted.
When she does venture out — to church or for her monthly appointment at a rheumatology clinic — she carries her passport and looks askance at any cars with tinted windows.
"I feel paranoid," said V.M., who came to the U.S. more than 40 years ago and is a patient of Venice Family Clinic. "Sometimes I feel scared. Sometimes I feel angry. Sometimes I feel sad."
She now sees her therapist virtually for her depression, which began 10 years ago when rheumatoid arthritis forced her to stop working. She worries about her older brother, who has high blood pressure and has stopped going to the doctor, and about a friend from the rheumatology clinic, who ices swollen hands and feet because she's missed four months of appointments in a row.
"Somebody has to wake up or people are going to start falling apart outside on the streets and they're going to die," she said.
Telemarketer scam signs victims up for fake 'jobs.'
This webcast was launched on Wednesday, August 13, 2025 in KFF Health News.
With Dan Weissmann
When a New York couple purchased a health insurance plan from a telemarketer, they thought it covered everything they wanted: doctor visits, tests, and medicine. But then came the unexpected bills for thousands of dollars, forcing them to skip crucial medical care.
In their series "Health Care Hustlers," Bloomberg reporters Zachary Mider and Zeke Faux revealed how this couple and thousands of other people signed up for health plans by unknowingly agreeing to work fake "jobs."
Mider and Faux join "An Arm and a Leg" host Dan Weissmann to peel back the surprising layers of this story, from a TV-sitcom-writer-turned-investor who masterminded the idea to the legal gray area that allows these plans to proliferate.
EKALAKA, Mont. — There was no doctor on-site when a patient arrived in early June at the emergency room in the small hospital at the intersection of two dirt roads in this town of 400 residents.
There never is.
Dahl Memorial's three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.
Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana's most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.
Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.
A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.
The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn't proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.
Placing ERs in the hands of nondoctors isn't without controversy. Some doctors and their professional associations say physicians' extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.
The American Medical Association, open to all medical students and physicians, and the American College of Emergency Physicians both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.
Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.
"It's important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible," Haddock said.
Other healthcare providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can't afford or recruit enough — or any — doctors.
"In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well," said Paul Amiott, a board member of the Society of Emergency Medicine PAs.
"I'm not practicing independently" despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.
Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn't unique to PAs — ER doctors seek similar consultations and backup.
The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.
But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.
None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.
But Sanford Health, which bills itself as "the largest rural health system in the United States," is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in a news release.
Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state's northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.
Adelman said he supports such laws only where it's feasible, like in Virginia. He said the state's emergency physicians' organization pushed for the law only after doing research that made it confident that the requirement wouldn't shutter any rural hospitals.
Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.
Adelman said when instituting staffing requirements isn't possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren't refraining just to save money.
He pointed to Vermont, where a report recommended that several of the state's hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state's troubled healthcare system.
Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.
Some doctors have pointed to a case in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, an analysis found.
The Society of Emergency Medicine PAs outlines training and experience PAs should have before practicing in rural areas or without on-site doctors.
Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.
Haddock said ACEP wouldn't want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.
Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.
She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.
She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn't enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.
Dowdy said Dahl Memorial hasn't had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there's a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.
People eating at Ekalaka's sole breakfast spot and attending appointments at the hospital's clinic all told KFF Health News that they've been happy with the care they have received from Dowdy and her co-workers.
Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who've been treated for more serious problems.
"We've got to have this facility here because this facility saves a lot of lives," Bruski said.
Amid the challenges of adulthood, one rite of passage is unique to the United States: the need to find your own health insurance by the time you turn 26.
That is the age at which the Affordable Care Act declares that young adults generally must get off their family's plan and figure out their coverage themselves.
When the ACA was voted into law in 2010, what's known as its dependent coverage expansion was immediately effective, guaranteeing health insurance to millions of young Americans up to age 26 who would otherwise not have had coverage.
But for years, Republicans have whittled away at the infrastructure of the original ACA. Long gone is the requirement to buy insurance. Plans sold in the ACA's online insurance marketplaces have no stringent quality standards. Costs keep rising, and eligibility requirements and subsidies are moving targets.
The erosion of the law has now created an "insurance cliff" for Americans who are turning 26 and don't have a job that provides medical coverage.
Some, scared off by the complexity of picking a policy and by the price tags, tumble over the edge and go without insurance in a health system where the rate for an emergency room visit can be thousands, if not tens of thousands, of dollars.
Today, an estimated 15% of 26-year-olds go uninsured, which, according to a KFF analysis, is the highest rate among Americans of any age.
If they qualify, young adults can sign up for Medicaid, the federal-state program for Americans with low incomes or disabilities, in most but not all states.
Otherwise, many buy cheap subpar insurance that leaves them with insurmountable debt following a medical crisis. Others choose plans with extremely limited networks, losing access to longtime doctors and medicines.
They often find those policies online, in what has become a dizzyingly complicated system of government-regulated insurance marketplaces created by the ACA.
The marketplaces vary in quality from state to state; some are far better than others. But they generally offer few easily identifiable, affordable, and workable choices.
"The good news is that the ACA gave young people more options," said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration.
"The bad news is the good stuff is hidden in a minefield of really bad options that'll leave you broke if you get sick."
Publicly funded counselors called "navigators" or "assisters" can help insurance seekers choose a plan. But those programs vary by state, and often customers don't realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.
In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees lose their insurance, according to the Congressional Budget Office.
Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.
In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.
Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he "didn't make enough to justify having health insurance" and has reluctantly gone without it.
Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents' plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.
Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother's plan until he turned 26, he said.
Now 28, he is insured through his federal job.
"The ACA was groundbreaking legislation, including the idea that every American needs health care," he said. "But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss."
Why 26?
Back in 2010, the decision to make 26 the cutoff age for staying on a parent's insurance was "kind of arbitrary," recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.
"My kids were young , and I was trying to imagine when my child would be an adult."
Before that time, children were often kicked off family plans at much younger ages, typically 18.
The Obama administration's idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn't have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.
But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.
Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.
"You're scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?'" he recalled. "It feels like it's nearly impossible to make a good choice in this scenario."
Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.
More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a KFF Health News data investigation found. Few have the reserves to pay it off.
The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.
Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, "drowning" in texts and phone calls offering plans of uncertain and unregulated quality. "It never ends," said Herne, 27.
Young Invincibles, an advocacy group representing young adults, runs its own "navigator" program to help young people choose health insurance plans.
"We hear the frustration," said Martha Sanchez, the group's former director of health policy and advocacy. "Twenty-six-year-olds have had negative experiences in a process that's become really complex. Many throw up their hands."
Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a "really scary" year after he turned 26.
"Every time he got in the car, I thought, ‘What if?'" Mathis said.
The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It's a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.
But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.
"Technically, we gambled in the right direction," Mathis said. "But I don't feel like we've won."
The Affordability Problem
The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.
But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, without insurance.
Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.
Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university's insurance premiums were more than $5,000 annually.
But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.
"People tell you to think ahead, but I didn't think that meant six months," she said.
When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.
She looked for a health care plan but found it hard to understand the marketplace. (She didn't know there were navigators who could help.) Now she can't afford her medicine or see her endocrinologist.
"I'm tired all the time," Hughes said. "My cycles are not regular anymore at all. When I do get one, it's debilitating." She is hoping a new job will provide insurance later this year.
Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.
Over 30% of people ages 18 to 29 said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.
The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.
Many companies, which say they can't afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.
Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.
In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.
As she left the first of those jobs, her husband's endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.
After a few months, they bought a marketplace plan, but it was expensive and "didn't cover a lot," she said.
When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn't start until the end of her first month of employment. The couple would be uninsured for a few weeks.
A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.
"I think I've done everything right," Creager said. "So why am I in a position where the health insurance available to me doesn't cover what I need, or I can barely afford my premiums, or worse, at times I don't even have it?"
Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn't schedule until after she would be off her family's insurance plan.
Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. "There's this impending terror of, ‘What am I going to do?'" she recalled.
(One day before she turned 26, her father's company agreed to keep her on his plan for six more months, if he paid higher premiums.)
The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation's authors had hoped. The "job lock" tying insurance to employment has long plagued the United States workforce.
Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.
Experts agree that the marketplaces need stronger regulation.
In 2023, the federal government defined clearer standards for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.
Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an "easy pricing" option or a "standard plan."
Most plans on the marketplaces don't meet these criteria. Federal and state regulators had long planned to cull such "noncompliant" plans, gradually — fearing that doing so too quickly would scare insurers away from participating.
But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it's far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.
There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.
If the subsidies expire, premiums are likely to rise sharply for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.
MIAMI — GOP lawmakers in the 10 states that refused the Affordable Care Act's Medicaid expansion for over a decade have argued their conservative approach to growing government programs would pay off in the long run.
Instead, the Republican-passed budget law that includes many of President Donald Trump's priorities will pose at least as big a burden on patients and hospitals in the expansion holdout states as in the 40 states that have extended Medicaid coverage to more low-income adults, hospital executives and other officials warn.
For instance, Georgia, with a population of just over 11 million, will see as many people lose insurance coverage sold through ACA marketplaces as will California, with more than triple the population, according to estimates by KFF, a health information nonprofit that includes KFF Health News.
The new law imposes additional paperwork requirements on Obamacare enrollees, slashes the time they have each year to sign up, and cuts funding for navigators who help them shop for plans. Those changes, all of which will erode enrollment, are expected to have far more impact in states like Florida and Texas than in California because a higher proportion of residents in non-expansion states are enrolled in ACA plans.
The budget law, which Republicans called the "One Big Beautiful Bill," will cause sweeping changes to healthcare across the country as it trims federal spending on Medicaid by more than $1 trillion over the next decade. The program covers more than 71 million people with low incomes and disabilities. Ten million people will lose coverage over the next decade due to the law, according to the nonpartisan Congressional Budget Office.
Many of its provisions are focused on the 40 states that expanded Medicaid under the ACA, which added millions more low-income adults to the rolls. But the consequences are not confined to those states. A proposal from conservatives to cut more generous federal payments for people added to Medicaid by the ACA expansion didn't make it into the law.
"Politicians in non-expansion states should be furious about that," said Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank.
The number of people losing coverage could accelerate in non-expansion states if enhanced federal subsidies for Obamacare plans expire at the end of the year, driving up premiums as early as January and adding to the rolls of uninsured. KFF estimates as many as 2.2 million people could become uninsured just in Florida, a state where lawmakers refused to expand Medicaid and, partly as a result, now leads the nation in ACA enrollment.
For people like Francoise Cham of Miami, who has Obamacare coverage, the Republican policy changes could be life-altering.
Before she had insurance, the 62-year-old single mom said she would donate blood just to get her cholesterol checked. Once a year, she'd splurge for a wellness exam at Planned Parenthood. She expects to make about $28,000 this year and currently pays about $100 a month for an ACA plan to cover herself and her daughter, and even that strains her budget.
Cham choked up describing the "safety net" that health insurance has afforded her — and at the prospect of being unable to afford coverage if premiums spike at the end of the year.
"Obamacare has been my lifesaver," she said.
If the enhanced ACA subsidies aren't extended, "everyone will be hit hard," said Cindy Mann, a health policy expert with Manatt Health, a consulting and legal firm, and a former deputy administrator for CMS.
"But a state that hasn't expanded Medicaid will have marketplace people enrolling at lower income levels," she said. "So, a greater share of residents are reliant on the marketplace."
Though GOP lawmakers may try to cut Medicaid even more this year, for now the states that expanded Medicaid largely appear to have made a smart decision, while states that haven't are facing similar financial pressures without any upside, said health policy experts and hospital industry observers.
KFF Health News reached out to the governors of the 10 states that have not fully expanded Medicaid to see if the budget legislation made them regret that decision or made them more open to expansion. Spokespeople for Republican Gov. Henry McMaster of South Carolina and Republican Gov. Brian Kemp of Georgia did not indicate whether their states are considering Medicaid expansion.
Brandon Charochak, a spokesperson for McMaster's office, said South Carolina's Medicaid program focuses on "low-income children and families and disabled individuals," adding, "The state's Medicaid program does not anticipate a large impact on the agency's Medicaid population."
Enrollment in ACA marketplace plans nationwide has more than doubled since 2020 to 24.3 million. If enhanced subsidies expire, premiums for Obamacare coverage would rise by more than 75% on average, according to an analysis by KFF. Some insurers are already signaling they plan to charge more.
The CBO estimates that allowing enhanced subsidies to expire will increase the number of people without health insurance by 4.2 million by 2034, compared with a permanent extension. That would come on top of the coverage losses caused by Trump's budget law.
"That is problematic and scary for us," said Eric Boley, president of the Wyoming Hospital Association.
He said his state, which did not expand Medicaid, has a relatively small population and hasn't been the most attractive for insurance providers — few companies currently offer plans on the ACA exchange — and he worried any increase in the uninsured rate would "collapse the insurance market."
As the uninsured rate rises in non-expansion states and the budget law's Medicaid cuts loom, lawmakers say state funds will not backfill the loss of federal dollars, including in states that have refused to expand Medicaid.
Those states got slightly favorable treatment under the law, but it's not enough, said Grace Hoge, press secretary for Kansas Gov. Laura Kelly, a Democrat who favors Medicaid expansion but who has been rebuffed by GOP state legislators.
"Kansans' ability to access affordable healthcare will be harmed," Hoge said in an email. "Kansas, nor our rural hospitals, will not be able to make up for these cuts."
For hospital leaders in other states that have refused full Medicaid expansion, the budget law poses another test by limiting financing arrangements states leveraged to make higher Medicaid payments to doctors and hospitals.
Beginning in 2028, the law will reduce those payments by 10 percentage points each year until they are closer to what Medicare pays.
Richard Roberson, president of the Mississippi Hospital Association, said the state's use of what's called directed payments in 2023 helped raise its Medicaid reimbursements to hospitals and other health institutions from $500 million a year to $1.5 billion a year. He said higher rates helped Mississippi's rural hospitals stay open.
"That payment program has just been a lifeline," Roberson said.
The budget law includes a $50 billion fund intended to insulate rural hospitals and clinics from its changes to Medicaid and the ACA. But a KFF analysis found it would offset only about one-third of the cuts to Medicaid in rural areas.
Trump encouraged Florida, Tennessee, and Texas to continue refusing Medicaid expansion in his first term, when his administration gave them an unusual 10-year extension for financing programs known as uncompensated care pools, which generate billions of dollars to pay hospitals for treating the uninsured, said Allison Orris, director of Medicaid policy for the left-leaning think tank Center on Budget and Policy Priorities.
"Those were very clearly a decision from the first Trump administration to say, ‘You get a lot of money for an uncompensated care pool instead of expanding Medicaid,'" she said.
Those funds are not affected by Trump's new tax-and-spending law. But they do not help patients the way insurance coverage would, Orris said. "This is paying hospitals, but it's not giving people health care," she said. "It's not giving people prevention."
States such as Florida, Georgia, and Mississippi have not only turned down the additional federal funding that Medicaid expansion brings, but most of the remaining non-expansion states spend less than the national average per Medicaid enrollee, provide fewer or less generous benefits, and cover fewer categories of low-income Americans.
Mary Mayhew, president of the Florida Hospital Association, said the state's Medicaid program does not adequately cover children, older people, and people with disabilities because reimbursement rates are too low.
"Children don't have timely access to dentists," she said. "Expectant moms don't have access nearby to an OB-GYN. We've had labor and delivery units close in Florida."
She said the law will cost states more in the long run.
"The health care outcomes for the individuals we serve will deteriorate," Mayhew said. "That's going to lead to higher cost, more spending, more dependency on the emergency department."
WATERLOO, Iowa — John-Paul Sager appreciates the care he has received at Department of Veterans Affairs hospitals and clinics, but he thinks it should be easier for veterans like him to use their benefits elsewhere.
Sager, a Marine Corps and Army veteran, uses his VA coverage for non-VA treatment of back injuries stemming from his military service. But he said he sometimes must make several phone calls to obtain approval to see a local chiropractor. "It seems like it takes entirely too long," he said.
Many veterans live hours from VA facilities, or they need health services that aren't readily available from the VA. In such cases, the department is supposed to provide a referral and pay for private care. Critics say it often hesitates to do so.
Republicans controlling Congress aim to streamline the process of obtaining what is known as community care.
Two Republican senators have introduced legislation that would make it easier for rural veterans to seek care at local hospitals and clinics. The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump's first term.
The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump's first term.
Critics worry that steering veterans to private care facilities drains federal money from the VA hospital and clinic system. But supporters say veterans shouldn't be forced to travel long distances or wait months for the treatment they could obtain at local hospitals and clinics.
"My main concern is for veterans, not for the VA," Sen. Kevin Cramer (R-N.D.) told KFF Health News. "I don't believe we have an obligation to sustain the bureaucracy."
About 9 million veterans are enrolled in the VA health system. Last year, about 3 million of them — including 1.2 million rural veterans — used their benefits to cover care at non-VA facilities, according to data provided by the department.
Cramer co-sponsored a bill that would allow veterans who live within 35 miles of a rural, "critical access" hospital to use VA benefits to cover care there or at affiliated clinics without referrals from VA staff.
Cramer, who serves on the Senate Veterans' Affairs Committee, noted his state has just one VA hospital. It's in Fargo, on the state's eastern border, which is more than 400 miles by car from parts of western North Dakota.
Many North Dakota veterans drive past multiple community hospitals to get to the VA hospital for treatment, he said. Meanwhile, many rural hospitals are desperate for more patients and income. "I kept thinking to myself, ‘This doesn't make any sense at all,'" Cramer said.
Cramer said previous laws, including the VA Mission Act, made it easier for veterans to use their benefits to cover care at community hospitals and clinics.
But he said veterans still must fill out too much paperwork and obtain approval from VA staffers to use non-VA facilities.
"We can't let the VA itself determine whether a veteran is qualified to receive local care," he said.
U.S. Rep. Mark Takano of California, who is the top Democrat on the House Veterans' Affairs Committee, said he sees the need for outside care for some veterans. But he contends Republicans are going overboard in shifting the department's money to support private health care facilities.
The VA provides specialized care that responds to veterans' needs and experiences, he argues.
"We must prevent funds from being siphoned away from veterans' hospitals and clinics, or VA will crumble," Takano said in a statement released by his office. "Veterans cannot afford for us to dismantle VA direct care in favor of shifting more care to the community."
Some veterans' advocacy groups have also expressed concerns.
Jon Retzer, deputy national legislative director for the Disabled American Veterans, said the group wants to make it easier for veterans to find care. Rural and female veterans can have a particularly tough time finding appropriate, timely services at VA hospitals and clinics, he said. But the Disabled American Veterans doesn't want to see VA facilities weakened by having too much federal money diverted to private hospitals and clinics.
Retzer said it's true that patients sometimes wait for VA care, but so do patients at many private hospitals and clinics. Most delays stem from staff shortages, he said, which afflict many health facilities. "This is a national crisis."
Retzer said the Disabled American Veterans favors continuing to require referrals from VA physicians before veterans can seek VA-financed care elsewhere. "We want to ensure that the VA is the primary provider of that care," he said.
Veterans Affairs Secretary Doug Collins has pledged to improve the community care program while maintaining the strength of the department's hospitals and clinics. The department declined a KFF Health News request to interview Collins.
Marcus Lewis, CEO of First Care Health Center, which includes a hospital in Park River, North Dakota, supports Cramer's bill. Lewis is a Navy veteran who uses the VA's community care option to pay for treatment of a back injury stemming from his military service.
Overall, Lewis said, the community care program has become easier to use. But the application process remains complicated, and participants must repeatedly obtain VA referrals for treatment of chronic issues, he said. "It's frustrating."
Park River is a 1,400-person town about 50 miles south of the Canadian border. Its 14-bed hospital offers an array of services, including surgery, cancer care, and mental health treatment. But Lewis regularly sees a VA van picking up local veterans, some of whom travel 140 miles to Fargo for care they're entitled to receive locally.
"I think a lot of folks just don't want to fight the system," he said. "They don't want to go through the extra hoops, and so they'll jump in the van, and they'll ride along."
Rep. Mike Bost (R-Ill.), chairman of the House Veterans' Affairs Committee, said veterans in some areas of the country have had more trouble than others in getting VA approval for care from private clinics and hospitals.
Bost helped gain the House's approval for Trump's request for $34.7 billion for the community care program in 2026. Although spending on the program has gone up and down in recent years, the appropriation represents an increase of about 50% from what it was in 2025 and 2022. The Senate included similar figures for next year in its version of a military spending budget that passed Aug. 1.
Bost also co-sponsored a House bill that would spell out requirements for the VA to pay for community care.
Sager hopes the new proposals make life easier for veterans. The Gulf War veteran lives in the northeastern Iowa town of Denver. He travels about 15 miles to Waterloo to see a chiropractor, who treats him for back and shoulder pain from injuries he suffered while training Saudi troops in hand-to-hand combat.
Sager, who remains active in the Army Reserve, also visits a Waterloo outpatient clinic run by the VA, where his primary care doctor practices. He appreciates the agency's mission, including its employment of many veterans. "You just feel like you're being taken care of by your own," he said.
He believes the VA can run a strong hospital and clinic system while offering alternatives for veterans who live far from those facilities or who need care the VA can't promptly provide.
The local VA doesn't offer chiropractic care, so it pays for Sager to visit the private clinic. But every few months, he needs to obtain fresh approval from the VA. That often requires several phone calls, he said.
Sager is one of about a dozen veterans who use the community care program to pay for visits at Vanderloo Chiropractic Clinic, office manager Linda Gill said.
Gill said the VA program pays about $34 for a typical visit, which is comparable to private insurance, but the paperwork is more burdensome. She said leaders of the chiropractic practice considered pulling out of the VA program but decided to put up with the hassles for a good cause. She wishes veterans didn't have to jump through so many hoops to obtain convenient care.
"After what they've done for us? Please," she said.
Now that the Republicans' big tax-and-spending bill has become law, new bureaucratic hurdles have emerged for millions of Americans who rely on Medicaid for health coverage. A provision in the new law dictates that, in most states, for the first time, low-income adults must start meeting work requirements to keep their coverage.
Some states have already tried doing this, but Georgia is the only state that has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.
When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn't opposed to work requirements — in principle.
But when she left her job at a faith-based nonprofit to start her own project, the Be Well Black Girl Initiative, she needed health coverage. She soon came face-to-face with how daunting it can be to prove you are meeting the state's work requirements.
"I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I'm like, I know the process," Corporal said. "I've been in human services."
Corporal has been a social worker for more than two decades in Georgia and was familiar with the state's social service programs. For years, it had been her job to help others access benefit programs.
But her challenges with paperwork and the process had only begun.
Health advocates point to Georgia's system as a sign that the new law will lead to excessive red tape, improper denials, and lost health coverage.
Beginning in 2027, the law will require adults on Medicaid who are under 65 to report how they engaged in at least 80 hours per month of work, education, or volunteer activities. Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.
Most states will have to set up verification systems similar to Georgia's, which can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data. More than $50 million of that was spent on building and operating the eligibility reporting system. Right now, just under 7,500 people are enrolled in Georgia.
For Corporal, 48, forgoing coverage wasn't an option. She had been diagnosed with pre-diabetes and had other medical concerns.
"I have breast cancer in my family history," she said. "So it was like, I gotta get my mammograms."
It offers Medicaid to adults — who otherwise wouldn't qualify for traditional Medicaid in Georgia — with incomes up to the federal poverty level ($15,650 per year for an individual, or $26,650 per year for a family of three), as long as they can show that for at least 80 hours a month they're working, attending school, training for a job, or volunteering.
Corporal was eager to apply. She was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.
She gathered up the various documents and forms needed to verify her duties and volunteer hours, then submitted them through Georgia's online portal.
"And we were denied. I was like, this makes no sense," said Corporal, who has a master's degree in social work. "I did everything right."
In the end, it took eight months fighting to prove that she and her son, a full-time college student in Georgia, qualified for Medicaid. She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.
Corporal recently pulled up one of the denial notices on her cellphone to read aloud: "Your case was denied because you didn't submit the correct documents. And you didn't meet the qualifying activity requirement," she read from the email.
When she tried to call the state Medicaid agency for answers, it was difficult reaching anyone who could explain what was wrong with her application paperwork, she said.
"Or, they'll say they called you, and we look at our call log. Nobody called me," she said. "And the letter will say, you missed your appointment, and it'll come on the same day" as it was scheduled.
Corporal's Pathways to Coverage application was finally approved in March after she spoke about her experience at a public hearing covered by Atlanta news outlets.
When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia's Department of Human Services, emailed this statement: "Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case."
Brown added that Georgia is implementing tech fixes to streamline the uploading and processing of participants' documents. They include "rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents."
Now that Corporal has coverage, she is having to recertify her volunteer hours every month using the same glitchy reporting system. It's stressful, she said.
"It's still a nightmare, even once I got through the red tape and got approved," Corporal said. "Now maintaining it is bringing another level of anxiety."
But she wonders how anyone without her professional background manages to get into the program at all.
"I think the system has to be simplified," she said.
Because Georgia set up its work requirement before the recently passed law, it needed permission from the federal government through a special waiver.
It is now seeking an extension of that waiver to continue the Pathways program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to reverify their hours from once a month to once per year.
But for now, Corporal's experience remains typical. And many health advocates fear it will be replicated under Trump's budget law with its new national Medicaid work mandate.
"In Georgia, we have seen that people just can't get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn't file their paperwork or there's been some other glitch," said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.
Another state, Arkansas, tried work requirements in 2018.
But it didn't go any better there, said Joan Alker, who leads the Center for Children and Families at Georgetown University.
"A lot of the problems were similar to Georgia," she said, "in terms of the website closed at night, people couldn't get a hold of people."
Some Republicans who backed the spending and tax legislation said the idea behind the national Medicaid work mandate was to ensure that as many people as possible who can work, do work. And to eliminate what the Trump administration deems waste, fraud, and abuse.
"What we're doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it," U.S. House Speaker Mike Johnson said during a June appearance on "The Megyn Kelly Show." "You're talking about the elderly, disabled, you know, young single pregnant moms who are down on their luck, right? But it's not being used for those purposes because it's been expanded under the last two Democrat presidents and to cover everybody. So, you've got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we're doing is restoring work requirements to Medicaid. OK, this is common sense."
National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients ages 19-64 already have jobs. The remainder includes students, or those who are too sick or disabled to work.
"Work requirements don't work, except to cut people off of health insurance," she said.
The logistical steps required to report one's activities assume that a recipient has reliable internet or transportation to travel to an agency — things that low-income Georgians may not have.
The paperwork requirements to gain coverage are time-consuming, said one Medicaid recipient, Paul Mikell.
Mikell is a licensed truck driver but does not have coverage through that job. He's also an electrician who currently does property maintenance in exchange for free housing.
Mikell has had Medicaid through Pathways for nearly two years and has had problems navigating the Pathways web portal.
"And I know it wasn't my device because I would go to the library and use the computer, I would try different devices, and I've had the same issues," he said. "Regardless of the device, it's something with the website."
Another time, he said, his attempt to recertify his work hours was delayed because of paperwork issues.
"They said I was ineligible for everything because of a typo in the system or something, I don't know what it was. I eventually was able to speak to someone and she fixed it," he said.
This article is from a partnership with WABE and NPR.
A long list of Lynda Hollander's paternal relatives had heart disease, and several had undergone major surgeries. So when she hit her mid-50s and saw her cholesterol levels creeping up after menopause, she said, "I didn't want to take a chance."
A cardiologist told Hollander that based on factors like age, sex, cholesterol, and blood pressure, she faced a moderate risk of a major cardiac event, like a heart attack, within the next 10 years.
Doctors typically counsel such patients about the importance of diet and exercise, but Hollander, now 64, a social worker in West Orange, New Jersey, didn't have much room for improvement. She was already a serious runner, and although "I fall off the wagon once in a while," her diet was basically healthy. Attempts to lose weight didn't lower her cholesterol.
Her doctor explained that a coronary artery calcium test, something Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. Her doctor explained that a coronary artery calcium test, something Ms. Hollander had never heard of, could provide a more precise estimate of her risk of atherosclerotic heart disease. A brief and painless CT scan, it would indicate whether the fatty deposits called plaque were developing in the arteries leading to her heart.
When plaque ruptures, it can cause clots that block blood flow and trigger heart attacks. The scan would help determine whether Hollander would benefit from taking a statin, which could reduce plaque and prevent more from forming.
"The test is used by more people every year," said Michael Blaha, co-director of the preventive cardiology program at Johns Hopkins University. Calcium scans quadrupled from 2006 to 2017, his research team reported, and Google searches for related terms have risen even more sharply.
Yet "it's still being underused compared to its value," he said.
One reason is that although the test is comparatively inexpensive — sometimes up to $300, but often $100 or less — patients usually must pay for it out-of-pocket. Medicare rarely covers it, though some doctors argue that it should.
Patients with a CAC score of zero — no calcification — have lower risk than their initial assessments indicate and aren't candidates for cholesterol-lowering drugs. But Hollander's score was in the 50s — not high but not negligible.
"It was the first indication of what was going on inside my arteries," she said.
Though guidelines vary, cardiologists generally offer statins to patients with calcium scores over zero, and suggest higher intensity statins when scores exceed 100. At over 300, patients' risks approach those of people who've already had heart attacks; they may need still more aggressive treatment.
Hollander has taken a low dose of rosuvastatin (brand name: Crestor) ever since, supplemented by a non-statin drug, a shot called evolocumab (Repatha).
This is the way calcium testing is supposed to work. It's not a screening test for everyone. It's intended only for selected asymptomatic patients, ages 40 to 75, who have never had a heart attack or a stroke and are not already on cholesterol drugs.
If a doctor calculates the 10-year risk of atherosclerotic cardiovascular disease at 5% or lower, drugs are unnecessary for now. Over 20%, "there's no doubt the risk is sufficiently high to justify medication," said Philip Greenland, a preventive cardiologist at Northwestern University and co-author of a recent review in JAMA.
"It's the in-between range where it's more uncertain," he said, including "borderline" risk of 5% to 7.5% and "intermediate" risk of 7.5% to 20%.
Why add another measurement to these assessments, which already incorporate risk factors like smoking and diabetes?
"A risk score is derived from a large population, with mathematical modeling," Blaha explained. "We can say that this score describes the risk of heart disease among thousands of people. But there are lots of limitations in applying them to one individual."
A calcium scan, however, produces an image of one individual's arteries. Alexander Zheutlin, a cardiology fellow and researcher at Northwestern University, shows patients their images, so that they can see the lighter-colored calcifications.
Cardiologists tend to be fans of calcium testing, because they so regularly encounter patients who are reluctant to take statins. People who feel fine may hesitate to start drugs they'll take for the rest of their lives, despite statins' proven history of reducing heart attacks, strokes and cardiac deaths.
In 2019, a survey of almost 5,700 adults for whom statin therapy was recommended found that a quarter were not in treatment. Of those, 10% had declined a statin and 30% had started and then discontinued, primarily citing fear of side effects.
An American College of Cardiology expert consensus report recently put the rate of muscle pain, statin users' most common complaint, at 5% to 20%. Researchers consider the fear of side effects overblown, citing studies showing that reports of muscle pain were comparable whether patients took statins or placebos.
"The actual risk is much, much lower than the perceived risk," Zheutlin said.
That may be little comfort to people who are in pain, but cardiologists argue that reducing doses or switching to different statins usually solves the problem. Some patients will do better on a non-statin cholesterol drug.
Hollander, for example, suffered "muscle cramps that would wake me up at night." Her doctor advised fewer doses, so Hollander now takes Crestor three days a week and self-injects Repatha twice monthly.
(Statins also carry a very low risk of a dangerous condition, rhabdomyolysis, that causes muscle breakdown, and they slightly increase the chance of diabetes.)
Some caveats: No one has undertaken a randomized clinical trial to show whether calcium testing eventually reduces heart attacks and cardiac deaths. That's why, although several professional associations endorse calcium scans to help determine treatment, the independent U.S. Preventive Services Task Force has called the current evidence "insufficient" to recommend widespread use.
Such a trial would be expensive and difficult to mount, with many confounding variables. And pharmaceutical companies aren't eager to underwrite one, since a successful result could mean that patients with zero scores avoid cholesterol drugs altogether.
But a recent Australian study of asymptomatic patients with family histories of coronary artery disease found that, after three years, those who had undergone calcium scans had sustained a reduction in cholesterol and a significantly lower risk of heart disease than those who had not been tested.
The test "leads to more statin prescriptions, better adherence to statins, less progression of atherosclerosis, and less plaque growth," Greenland said of the study, in which he was not involved. "It tips the scale."
Another concern: people age 75 and older. Most will have arterial plaque, making a scan's benefit "less clear-cut," said Zheutlin, lead author of a recent JAMA Cardiology article pointing out that CAC testing can be both overused and underused.
Because older adults face more chronic diseases and medical issues, cholesterol-lowering may become a lower priority. A study now enrolling participants over 75 should answer some questions about statins, calcium scans, and dementia in a few years.
Meanwhile, cardiologists see calcium scans as a persuasive tool.
"It's incredibly frustrating," Zheutlin said. With statins, "we have cheap, safe, effective drugs available at any pharmacy" that help prevent heart attacks. If CAC test results prove more influential than traditional risk assessments alone, he said, more patients might agree to take them.
A calcium scan helped Stephen Patrick, 70, a retired tech executive in San Francisco, reach that point. "For years, I was borderline on cholesterol, and I managed to beat it back with less cheese toast" and lots of exercise, he said. "I was on no meds, and I took pride in that."
Last fall, with both his total and his LDL cholesterol higher than recommended, his doctor suggested a calcium scan. His score: 176.
He's taking atorvastatin (Lipitor) daily, and his cholesterol levels have dropped dramatically. "I might have tried it anyway," he said. "But the calcium score meant I had to pay more attention."
The New Old Age is produced through a partnership with The New York Times.
Cosmetic surgery chains have been the target of scores of medical malpractice and negligence lawsuits alleging disfiguring injuries — including 12 wrongful death cases filed over the past seven years.
This article was published on Tuesday, July 29, 2025 in KFF Health News.
A few days after a harrowing cosmetic surgery procedure, Erin Schaeffer said, she woke up with fluid leaking from an open wound in her stomach.
Schaeffer went on to spend a week in a Florida hospital battling a severe infection after a type of tummy tuck and liposuction at the Jacksonville branch of Sono Bello, a national cosmetic surgery chain.
More than a year later, scars remain on her lower body — and in a lawsuit she is accusing Sono Bello of using an obstetrician-gynecologist who was inadequately trained to remove her excess skin and fat, a procedure she says caused excruciating pain.
"I literally felt like I was skinned alive," said the 37-year-old, who works as a training manager for United Parcel Service.
Schaeffer and her husband, Jonathan, are suing Sono Bello and Manuel Herrera in Duval County Circuit Court. The suit accuses Herrera, a board-certified OB-GYN, of "performing procedures that he was not trained or qualified to perform."
Sono Bello and Herrera denied the allegations in a joint court filing. And in an interview with KFF Health News and NBC News, Robert Centeno, Sono Bello's medical director for the East region, said its surgeons undergo "very rigorous training."
Backed by private-equity financing, Sono Bello is the largest of a breed of cosmetic surgery chains vying for a slice of the growing body-contouring market in the U.S. One research firm estimated that the market, which includes procedures ranging from wrinkle removal to liposuction, topped $22 billion in 2024.
The chains sell an array of body-reshaping operations, such as "Mommy Makeovers" and liposuction, targeting customers willing to pay up to $20,000 out-of-pocket for a new figure, often on credit with steep interest rates from companies specializing in credit for elective medical procedures. Sono Bello boasts it is "America's top cosmetic surgery specialist."
But a joint investigation by KFF Health News and NBC News found that Sono Bello and other cosmetic surgery chains have been the target of scores of medical malpractice and negligence lawsuits alleging disfiguring injuries — including 12 wrongful death cases filed over the past seven years.
Injured patients have accused the chains of hiring doctors with minimal cosmetic surgery training, of failing to recognize and treat life-threatening infections and other dangerous surgical complications, and of high-pressure sales tactics that minimized safety risks, court records show. Sono Bello and the other companies have denied the allegations in court.
"These people promise to turn you into the fairest person in the land, and the risks aren't often worth the reality," said Sean Domnick, a Florida attorney who heads the American Association for Justice, a trial lawyers' group.
Sono Bello's Centeno disagrees. He said the company's mission is to "help each and every one of our patients live their best lives now." Sono Bello offers "life-changing transformations" that enhance a person's "appearance as well as their quality of life," said Centeno, a surgeon himself at the company's Troy, Michigan, office.
The doctors who perform such surgeries, court records show, are sometimes paid more for taking on patients with a high body mass, as obesity raises the risk of devastating complications.
And as the chains grow, there's little regulatory oversight. While the FDA maintains a database of complaints about drugs or medical devices, there's nothing similar for cosmetic surgeries.
Schaeffer had liposuction at Sono Bello in January 2024 and was satisfied with the results. On the morning of March 29, 2024, she went in for more liposuction and a mini-tummy tuck that Sono Bello calls AbEX. The medical staff gave her Xanax, a tranquilizer, and the painkiller oxycodone in pill form, according to medical records Sono Bello turned over to Schaeffer's attorney. During the procedure, she received an infusion of lidocaine to numb the area but remained awake. Sono Bello says the local anesthesia is safer and promotes faster healing with "minimal discomfort," so patients may return to work or other normal activities within a week.
That didn't happen for Schaeffer, who said she felt so much pain during the operation that she began to cry and "begged" the doctor to stop near the end.
"I said, ‘I don't care what I look like,'" she said in an interview. "‘I can't handle the pain.'"
Two days later, she spiked a fever, and a day after that her pubic area swelled up "severely," she said. Sono Bello medical staff told her that was normal and that she was fine, she said. Two days later, however, blood and fluid spilled out of her stomach when she got up.
On one visit to the office, Herrera told her she required surgery at a hospital to treat her wounds. But, Schaeffer recounted, Herrera said he couldn't arrange that because he was an obstetrician, not a plastic surgeon, and didn't have hospital privileges locally. Herrera has hospital privileges in the Orlando area, about 140 miles southwest of Jacksonville.
"I was just in utter shock," Schaeffer said.
Sono Bello spokesperson Mark Firmani said the company does not require its doctors to have local hospital privileges, though many do have them.
Centeno said Schaeffer's painful experience is not common.
"The reality is that over 90% of our patients who have our procedures completed are extremely comfortable during the procedure and they do quite well," he said. Patients of Sono Bello and some other clinics also have complained to the Better Business Bureau of unexpectedly painful procedures.
Centeno said that Herrera still works for the company, but the doctor's name does not appear on the company's Jacksonville website. Herrera runs an OB-GYN and aesthetics practice, which includes skin care treatments, in Winter Garden, Florida, near Orlando, and is board-certified by the American Board of Obstetrics & Gynecology.
Sono Bello has considered him a rising star; Herrera's work in 2023 won Sono Bello's annual "New Talent Award," given to a company doctor who exhibits "exceptional technical skills, productivity, and off-the-charts brand loyalty."
Herrera completed a Sono Bello fellowship program that teaches a "suite of aesthetic procedures" in a six- to eight-week course under the direction of a company surgeon. The company says the fellowship offers "patient-focused training in awake total body contouring and skin excision procedures." Sono Bello allows physicians who have completed formal residencies in more than half a dozen types of surgery to apply for its fellowship.
In a post on a Sono Bello website, Herrera said that before taking the fellowship course, he "had been a skilled surgeon for over 13 years with extensive experience in other areas but limited knowledge on body sculpting." Herrera did not respond to calls and emails requesting comment and directed Sono Bello to respond on his behalf. Company spokesperson Firmani said Herrera is still a member of the Sono Bello team.
Many established plastic surgeons who spoke with KFF Health News and NBC News worry that chain surgery groups may be inclined to spend more effort on marketing and sales than on making sure their doctors are properly credentialed and capable of handling any complications that arise.
Medical practices owned by private equity or investment firms have more money to spend drawing in patients and "the ability to operate and provide quality patient care is now less important," said Mark Domanski, a plastic surgeon in Northern Virginia.
Doctor Entrepreneurs
Formed in 2008 by entrepreneurial physician Tom Garrison, Sono Bello now runs more than 100 centers nationwide. Private equity investors have pumped $816 million into the company, most of it since 2023, according to PitchBook, which tracks the industry. Sono Bello advertises widely on television and online, aimed at what one major investor termed the "everyday woman and man." It has advertised having "150+ board-certified surgeons who have performed over 300,000 laser lipo & body contouring procedures."
Sono Bello limits its offerings to services such as liposuction and its version of tummy tucks, which it believes its surgeons have mastered. It does not perform Brazilian butt lifts, or fat transfers, though many other cosmetic surgery chains do.
While Sono Bello boasts that the vast majority of its patients are satisfied, court records show that allegations of substandard medical care have trailed its rapid growth.
Sono Bello and its corporate affiliates and surgeons have defended more than 60 medical malpractice cases, including four suits involving patient deaths, since April 2013, court records show. Sono Bello has settled three of four wrongful death cases filed since May 2018, while one is pending, court records show.
Schaeffer's suit in Jacksonville is among at least 19 filed since the start of March 2023. Many are pending in the courts, and the company has denied the allegations.
Other physicians who have extended their brands to multiple cities and relied heavily on social media and splashy websites to bring in patients have also faced lawsuits.
Mia Aesthetics, formed in 2017 by Texas surgeon Sergio Alvarez, runs a dozen cosmetic surgery clinics from Miami to Las Vegas. Mia Aesthetics provides "the highest quality plastic surgery at affordable prices proving that being beautiful and saving money are two realities that can exist simultaneously," its website says. Alvarez is a board-certified plastic surgeon.
Patients filed at least 30 medical negligence cases against Mia Aesthetics and its affiliates from November 2020 through March of this year, court records show. A dozen suits target its Miami surgery center. The company has sought, and often won, dismissal of malpractice suits because patients signed contracts agreeing to arbitration of any disputes, court dockets show. Alvarez did not respond to requests for comment.
Owned by New York physician Sergey Voskin since 2016, Goals Aesthetics and Plastic Surgery has branched out from a small cosmetic surgery office in the Brooklyn borough of New York City to a network of a dozen surgery centers it manages in eight states.
Goals clinics and affiliated surgeons have been named as defendants in at least 40 malpractice suits filed from October 2018 through March, court records show. The Atlanta branch accounted for more than 20 such cases in Georgia courts from September 2022 through June 2024. Most are pending. Goals defended two lawsuits brought by the families of New York patients who died shortly after having liposuction procedures, court records show. Goals denied the allegations and won dismissal of some cases by invoking arbitration agreements, according to court dockets. The company says these agreements are commonly used throughout the medical industry.
Voskin declined to be interviewed. In a statement, Goals lawyer Joshua Lurie said the medical offices it manages have performed more than 10,000 procedures and have "one of, if not the highest track records of safety among similar types of medical practices."
Lurie said the "vast majority" of malpractice claims are "meritless." These "bad faith filings create an implication of risk when none exist and when, again, there is a very negligible negative outcome from surgery compared to the total procedures performed," he wrote.
No Guarantees
Malpractice suits by themselves are not proof of wrongdoing. Nobody tracks the outcome of these lawsuits, which often are settled under confidential terms that keep key details out of public view and prohibit patients from discussing their experiences. Surgeons often argue that complications are a risk of surgery and that a poor outcome doesn't mean the doctor was negligent. To prove negligence, injured patients generally must show their care fell below what a reasonably prudent doctor with similar training would have done.
That can be a challenge. Typically, the surgery chains fight back by arguing that complications are a risk of any surgical procedure and that they never guarantee results.
Before their procedures, patients must sign consent forms acknowledging that their expectations must be "realistic" and that complications or dissatisfaction with the result does not necessarily mean the surgeon botched the job. The American Society of Plastic Surgeons investigates ethics complaints against its members, but not allegations of competence or malpractice.
Some pre-surgery contracts allow for low-cost "revisions" for disgruntled patients. Sono Bello has offered a "satisfaction commitment," which states: "If your surgeon's evaluation determines your results to be deficient, we will touch up the area at no cost to you."
Other contracts contain disclaimers, such as reminding patients that dramatic "before and after" photos widely shown in online advertisements and other solicitations may not reflect typical results.
Demonstrating the influence of social media in driving sales, Goals once required patients to sign a non-disparagement clause. The contract stated that patients who bad-mouth the company on social media without first giving the company "an opportunity to remedy any alleged issues" agree to pay damages of $10,000 for each violation.
In a civil investigation of Goals' marketing tactics, Georgia Attorney General Chris Carr alleged that policy, and others, violated state consumer protection laws. In September 2022, Goals agreed to stop using the non-disparagement clause and to pay the state $119,480 to settle the matter, without admitting any wrongdoing.
Both Goals and Mia Aesthetics have clauses in their service contracts that require arbitration of any disputes in lieu of court action, a process many consumer advocates believe favors the industry. These agreements are becoming more common among plastic surgeons. The arbitration clauses have prevented some aggrieved patients from getting their day in a courtroom.
That happened in a wrongful death case filed by the family of Angela Mendez, 57, who was found dead in her apartment a day after liposuction at a Goals office in New York City in March 2021. She died from a pulmonary thromboembolism, a blood clot in her lung, as a complication of cosmetic surgery, according to an autopsy report.
Her family sued the company alleging negligence. But, in June 2024, a judge ruled that Mendez had signed a form requiring the case to be heard in arbitration and the lawsuit was dismissed.
Attorney Gary Zucker, who represents the family, is appealing. "It's been a one-two punch for the family," Zucker said.
Goals attorney Lurie called arbitration "a common practice throughout the industry and many industries" that is "intended to speed the process to come to resolutions in a more expedited fashion." In a 2023 deposition, Lurie said patients can opt out of the arbitration agreement, which "has happened multiple times."
‘A Hard Sell'
When Erin Schaeffer first visited Sono Bello, a sales agent told her she was a "perfect candidate" for a tummy tuck procedure, she said in an interview with KFF Health News and NBC News.
Though she wanted to think about it and talk it over with her family, she said, the salesperson persuaded her to go ahead. Because cosmetic surgery is elective, insurance doesn't cover it. Schaeffer made a down payment and signed up for a credit plan through outside companies to repay most of the $19,838 bill over a five-year period, according to her medical records. She said she's now paying $420 a month.
"I definitely felt like it was a hard sell," Schaeffer said. "She didn't want me to leave out of there without putting money down on it."
Schaeffer said she didn't meet the doctor until about a week before the procedure, and only briefly. Some patients suing other companies have argued in court filings that they didn't meet the surgeon until the day of their operations, a practice that draws sharp criticism from more traditional surgeons.
Scott Hollenbeck, president of the American Society of Plastic Surgeons, said patients need time with their doctor to fully understand the pros and cons of surgery and shouldn't be pressured into quick decisions.
"It is not possible to do that when you see the doctor an hour before surgery for the first time," he said. "You should have time to process what they told you, think about it, and make a decision."
"That is best done with a surgeon, not a marketer," Hollenbeck said.
Good Candidates
Many plastic surgeons discourage people with obesity from undergoing liposuction and other cosmetic procedures because of an elevated risk of infections and other serious medical complications. Candidates are considered obese at a body mass index of 30 or above. Sono Bello patients have an average BMI of 31, according to Centeno. At the time of her surgery, Schaeffer had a BMI of 36.
But there's no consensus over who should be turned away because of their size — and policies vary.
Sono Bello says its AbEX tummy tuck can be done safely with a body mass index as high as 42, well beyond the body mass limits for a traditional abdominoplasty done using general anesthesia. The AbEX removes loose and sagging skin around the stomach "to achieve a more toned and sculpted look," according to the company.
Centeno said that high BMI "does confer additional risk, which can be managed." But he said it would be "discriminatory, unethical, and inappropriate for Sono Bello or any other medical practice to deny care to a patient based solely on their BMI."
Yet high BMI patients have alleged they suffered devastating complications, according to KFF Health News' review of the court cases filed against Sono Bello and other companies.
One patient is Marissa Edwards, then 45, a California medical receptionist with three children. At 5 feet 3 inches tall, she weighed 237 pounds, with a body mass index of 41.
She had AbEX and liposuction at a Sono Bello clinic in San Diego on Oct. 11, 2022, according to court filings. During an office visit eight days later, she complained of swelling and pain in her abdomen, but a nurse "dismissed her complaints," according to the suit. On Nov. 4, Edwards noticed the incision was opening, while a rash formed around her belly button. In a text to Sono Bello, she attached a photo of her wound which, the suit alleges, should have alerted the staff that it needed "immediate evaluation by a qualified medical professional."
On Nov. 5, she woke up "feeling extremely hot," and "nearly fainted," according to her complaint. Her husband drove her to an urgent care center, which diagnosed her with sepsis and rushed her to a hospital by ambulance.
When she awoke the next morning, her bedsheets were soaked with body fluid. As she stood up, "fluid began to pour out of her stomach and hit the floor," according to the complaint. She spent six days in the hospital.
Edwards alleges in her lawsuit that Sono Bello's medical staff failed to recognize and respond to early signs of trouble.
"I have sepsis and could have died," she texted to Sono Bello's office line, according to court documents. "I am very upset."
In one text that was included in her lawsuit, she wrote: "So I would appreciate some type of empathy from you!! If you only knew what I have been through and you went through this I'm sure you wouldn't be giving me this snotty attitude."
Sono Bello denies any negligence. In a court filing, the company noted that infections are a risk of surgery, and that Edwards had signed a consent form that stated in part: "The practice of medicine and surgery is not an exact science and results are not guaranteed." Sono Bello filed a motion for summary judgment that argued her care was not negligent and "not a substantial factor" in causing her alleged injuries. The case was settled earlier this month under confidential terms.
Value Units
While patients with high BMI are riskier, they also are more lucrative for Sono Bello surgeons, court records show.
The company pays its surgeons for procedures based in part on the patient's BMI, using a formula it calls a "surgical value unit."
The compensation plan surfaced in a lawsuit filed in December 2023 by Shirley Webb, then a 79-year-old Nevada woman. Hoping to slim down for a dream cruise, she paid $14,703 for an AbEX tummy tuck and liposuction of her stomach at the Sono Bello branch in Las Vegas.
Eighteen days after her operation, she was "oozing and bleeding" from her surgical wounds, and her son rushed her to a hospital, where doctors diagnosed "severe sepsis with shock," according to the complaint. She spent several months in hospitals and rehabilitation care, running up medical bills of more than $2.6 million, her lawyer stated during a deposition.
Lloyd Krieger, a California plastic surgeon who served as a medical expert for Webb's legal team, said the operations never should have happened because she was at "very high risk for multiple procedures given her advanced age and high BMI," according to the suit.
In a court deposition, Sono Bello surgeon Charles Kim testified that operating on Webb earned him "surgical value units" that boosted his pay to about $2,000 for the procedure.
Sono Bello and Kim denied Webb's negligence claims and the parties settled the case in early 2025 under confidential terms, court records show.
Centeno said Sono Bello surgeons are paid more for higher BMI patients because they "require additional work and additional complexity in terms of decision-making." He added that "our high BMI patients routinely undergo our procedures safely with an extremely high patient satisfaction rate."
Schaeffer said people hoping to reshape their bodies need to do a lot of research before plunging ahead with plastic surgery. She said she was hoping to get rid of excess skin and fat after dropping 100 pounds.
Instead, she missed seven weeks of work recovering from her tummy tuck in Jacksonville. "I went into this procedure to try to make myself feel better after losing the weight, and I came out with something even worse," she said.
"I trusted. I believed in what they told me, which I think most people do," Schaeffer said.
If you want to create a perfect storm at Covered California and other Affordable Care Act marketplaces, all you have to do is make enrollment more time-consuming, ratchet up the toll on consumers' pocketbooks, and terminate financial aid for some of the youngest and healthiest enrollees.
And presto: You've got people dropping coverage; rising costs; and a smaller, sicker group of enrollees, which translates to higher premiums.
The Trump administration and congressional Republicans have just checked that achievement off their list.
They have done it with the sprawling tax and spending law President Donald Trump signed on July 4 and a related set of new regulations released by the Centers for Medicare & Medicaid Services that will govern how the ACA marketplaces are run.
Among the many provisions, there's this: Large numbers of lawfully present immigrants currently enrolled in Obamacare health plans will lose their subsidies and be forced to pay full fare or drop their coverage.
Wait. What?
I understand that proponents of the new policies think the government spends too much on taxpayer subsidies, especially those who believe the ACA marketplaces are rife with fraud. It makes sense that they would support toughening enrollment and eligibility procedures and even slashing subsidies. But taking coverage away from people who live here legally is not health care policy. It's an echo of the federal immigration raids in Los Angeles and elsewhere.
"It's creating a very hostile environment for them, especially after having to leave their countries because of some very traumatic experiences," says Arturo Vargas Bustamante, a professor of health policy and management at UCLA's Fielding School of Public Health. "For those who believe health care is a human right, this is like excluding that population from something that should be a given."
In Covered California, 112,600 immigrants, or nearly 6% of total enrollees, stand to lose their federal tax subsidies when the policy takes effect in 2027, according to data provided by the exchange. In the Massachusetts and Maryland marketplaces, the figure is closer to 14%, according to their directors, Audrey Morse Gasteier and Michele Eberle, respectively.
It's not clear exactly how much financial aid those immigrants currently receive in ACA marketplaces. But in Covered California, for example, the average for all subsidized enrollees is $561 per month, which covers 80% of the $698 average monthly premium per person. And immigrants, who tend to have lower-than-average incomes, are likely to get more of a subsidy.
The immigrants who will lose their subsidies include victims of human trafficking and domestic violence, as well as refugees with asylum or with some temporary protected status. And "Dreamers" will no longer be eligible for ACA marketplace health plans because they will not be considered lawfully present. Immigrants who are not in the country legally cannot get coverage through Covered California or most other ACA marketplaces.
The nearly 540,000 Dreamers in the United States arrived in the U.S. as kids without immigration papers and were granted temporary legal status by President Barack Obama in 2012. Of those, an estimated 11,000 have ACA health plans and would lose them, including 2,300 in Covered California.
Supporters of the policy changes enshrined in the CMS rule and budget law think it's high time to rein in what they say are abuses in the system that started under the Biden administration with expanded tax credits and overly flexible enrollment policies.
"It's about making Obamacare lawful and implementing it as drafted rather than what Biden turned it into, which was a fraud and a waste-infused program," says Brian Blase, president of Arlington, Virginia-based Paragon Health Institute, which produces policy papers with a free-market bent and influenced the Republican-driven policies.
But Blase doesn't have much to say about the termination of Obamacare subsidies for lawfully present immigrants. He says Paragon has not focused much on that subject.
Jessica Altman, executive director of Covered California, expects most immigrants who lose subsidies will discontinue their enrollment. "If you look at where those populations fall on the income scale, the vast majority are not going to be able to afford the full cost of the premium to stay covered," she says.
Apart from the human hardship cited by Bustamante, the exodus of immigrants could compromise the financial stability of coverage for the rest of Covered California's 1.9 million enrollees. That's because immigrants tend to be younger than the average enrollee and use fewer medical resources, thus helping offset the costs of older and sicker people who are more expensive to cover.
Covered California data shows that immigrant enrollees targeted by the new federal policies pose significantly lower medical risk than U.S. citizens. And a significantly higher percentage of immigrants in the exchange are ages 26 to 44, while 55- to 64-year-olds make up a smaller percentage.
Still, it would be manageable if immigrants were the only younger people to leave the exchange. But that is unlikely to be the case. More red tape and higher out-of-pocket costs — especially if enhanced tax credits disappear — could lead a lot of young people to think twice about health insurance.
The covid-era enhanced tax credits, which have more than doubled ACA marketplace enrollment since their advent in 2021, are set to expire at the end of December without congressional action. And, so far, Republicans in Congress do not seem inclined to renew them. Ending them would reverse much of that enrollment gain by jacking up the amount consumers would have to spend on premiums out of their own pockets by an average of 66% at Covered California and more than 75% nationally.
And an analysis by the Congressional Budget Office shows that a consequent exodus of younger, healthier people from the marketplaces would lead to even greater costs over time.
Enhanced tax credits aside, consumers face additional hurdles: The annual enrollment period for Covered California and other marketplaces will be shorter than it is now. Special enrollment periods for people with the lowest incomes will be effectively eliminated. So will automatic renewals, which have greatly simplified the process for a majority of enrollees at Covered California and some other marketplaces. Enrollees will no longer be able to start subsidized coverage, as they can now, before all their information is fully verified.
"Who are the people who are going to decide to go through hours and hours of onerous paperwork?" says Morse Gasteier. "They're people who have chronic conditions. They have health care issues they need to manage. The folks we would expect not to wade through all that red tape would be the younger, healthier folks."
California and 20 other states this month challenged some of that red tape in a federal lawsuit to stop provisions of the CMS rule that erect "unreasonable barriers to coverage." California Attorney General Rob Bonta said he and his fellow attorneys general hoped for a court ruling before the rule takes effect on Aug. 25.
"The Trump administration claims that their final rule will prevent fraud," Bonta said. "It's obvious what this is really about. It's yet another political move to punish vulnerable communities by removing access to vital care and gutting the Affordable Care Act."
