Most voters approached for this article declined to be interviewed, saying they didn't understand the issue.

This article first appeared November 05, 2018 on Kaiser Health News.

By Samantha Young

MODESTO, Calif. — Betsy Foster and Doug Dillon are devotees of Josh Harder. The Democratic upstart is attempting to topple Republican incumbent Jeff Denham in this conflicted, semi-rural district that is home to conservative agricultural interests, a growing Latino population and liberal San Francisco Bay Area refugees.

To Foster's and Dillon's delight, Harder supports a "Medicare-for-all" health care system that would cover all Americans.

Foster, a 54-year-old campaign volunteer from Berkeley, believes Medicare-for-all is similar to what's offered in Canada, where the government provides health insurance to everybody.

Dillon, a 57-year-old almond farmer from Modesto, says Foster's description sounds like a single-payer system.

"It all means many different things to many different people," Foster said from behind a volunteer table inside the warehouse Harder uses as his campaign headquarters. "It's all so complicated."

Across the country, catchphrases such as "Medicare-for-all," "single-payer," "public option" and "universal health care" are sweeping state and federal political races as Democrats tap into voter anger about GOP efforts to kill the Affordable Care Act and erode protections for people with preexisting conditions.

Republicans, including President Donald Trump, describe such proposals as "socialist" schemes that will cost taxpayers too much. They say their party is committed to providing affordable and accessible health insurance, which includes coverage for preexisting conditions, but with less government involvement.

Voters have become casualties as candidates toss around these catchphrases — sometimes vaguely and inaccurately. The sound bites often come across as "quick answers without a lot of detail," said Gerard Anderson, a professor of public health at the Johns Hopkins University Bloomberg School Public Health.

"It's quite understandable people don't understand the terms," Anderson added.

For example, U.S. Sen. Bernie Sanders (I-Vt.) advocates a single-payer national health care program that he calls Medicare-for-all, an idea that caught fire during his 2016 presidential bid.

But Sanders' labels are misleading, health experts agree, because Medicare isn't actually a single-payer system. Medicare allows private insurance companies to manage care in the program, which means the government is not the only payer of claims.

What Sanders wants is a federally run program charged with providing health coverage to everyone. Private insurance companies wouldn't participate.

In other words: single-payer, with the federal government at the helm.

Absent federal action, Democratic gubernatorial candidates Gavin Newsom in California, Jay Gonzales in Massachusetts and Andrew Gillum in Florida are pushing for state-run single-payer.

To complicate matters, some Democrats are simply calling for universal coverage, a vague philosophical idea subject to interpretation. Universal health care could mean a single-payer system, Medicare-for-all or building upon what exists today — a combination of public and private programs in which everyone has access to health care.

Others call for a "public option," a government plan open to everyone, including Democratic House candidates Antonio Delgado in New York and Cindy Axne in Iowa. Delgado wants the public option to be Medicare, but Axne proposes Medicare or Medicaid.

Are you confused yet?

Sacramento-area voter Sarah Grace, who describes herself as politically independent, said the dialogue is over her head.

"I was a health care professional for so long, and I don't even know," said Grace, 42, who worked as a paramedic for 16 years and now owns a holistic healing business. "That's telling."

In fact, most voters approached for this article declined to be interviewed, saying they didn't understand the issue. "I just don't know enough," Paul Her of Sacramento said candidly.

"You get all this conflicting information," said Her, 32, a medical instrument technician who was touring the state Capitol with two uncles visiting from Thailand. "Half the time, I'm just confused."

The confusion is all the more striking in a state where the expansion of coverage has dominated the political debate on and off for more than a decade. Although the issue clearly resonates with voters, the details of what might be done about it remain fuzzy.

A late-October poll by the Public Policy Institute of California shows the majority of Californians, nearly 60 percent, believe it is the responsibility of the federal government to make sure all Americans have health coverage. Other state and national surveys reveal that health care is one of the top concerns on voters' minds this midterm election.

Democrats have seized on the issue, pounding GOP incumbents for voting last year to repeal the Affordable Care Act and attempting to water down protections for people with preexisting medical conditions in the process. A Texas lawsuit brought by 18 Republican state attorneys general and two GOP governors could decimate protections for preexisting conditions under the ACA — or kill the law itself.

Republicans say the current health care system is broken, and they have criticized the rising premiums that have hit many Americans under the ACA.

Whether the Democratic focus on health care translates into votes remains to be seen in the party's drive to flip 23 seats to gain control of the House.

The Denham-Harder race is one of the most watched in the country, rated too close to call by most political analysts. Harder has aired blistering ads against Denham for his vote last year against the ACA, and he sought to distinguish himself from the incumbent by calling for Medicare-for-all — an issue he hopes will play well in a district where an estimated 146,000 people would lose coverage if the 2010 health law is overturned.

Yet Harder is not clinging to the Medicare-for-all label and said Democrats may need to talk more broadly about getting everyone health care coverage.

"I think there's a spectrum of options that we can talk about," Harder said. "I think the reality is we've got to keep all options open as we're thinking towards what the next 50 years of American health care should look like."

To some voters, what politicians call their plans is irrelevant. They just want reasonably priced coverage for everyone.

Sitting with his newspaper on the porch of a local coffee shop in Modesto, John Byron said he wants private health insurance companies out of the picture.

The 73-year-old retired grandfather said he has seen too many families struggle with their medical bills and believes a government-run system is the only way.

"I think it's the most effective and affordable," he said.

Linda Wahler of Santa Cruz, who drove to this Central Valley city to knock on doors for the Harder campaign, also thinks the government should play a larger role in providing coverage.

But unlike Byron, Wahler, 68, wants politicians to minimize confusion by better defining their health care pitches.

"I think we could use some more education in what it all means," she said.

Here are three big health issues that could be dramatically affected by Tuesday's vote.

This article first appeared November 02, 2018 on Kaiser Health News.

By Julie Rovner

Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many.

But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors' mansions and state legislatures around the country.

All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what's likely to happen — or not happen — over the next two years.

For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not.

Here are three big health issues that could be dramatically affected by Tuesday's vote.

1. The Affordable Care Act

Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans and the generic drug approval process, among other things.

Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate and the White House in 2017, Republicans found they could not reach agreement on how to "repeal and replace" the law.

This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect.

Polls suggest Cramer has a healthy lead in that race, but if Heitkamp pulled off a surprise win, health care might well get some of the credit.

And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care.

It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and two GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general — Missouri's Josh Hawley and West Virginia's Patrick Morrisey — are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016.

The attorneys general are running against Democratic incumbents — Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit.

Although Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts.

But in the end the fate of the ACA depends less on an individual race than on which party winds up in control of Congress.

"If Democrats take the House … then any attempt at repeal-and-replace will be kaput," said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health.

Conservative health care strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday.

"Republicans, if they maintain the majority in the House, will have a margin of a half dozen seats — if they are lucky," he said. That likely would not allow the party to push through another controversial effort to change the law. Currently there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017.

And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there.

2. Medicaid expansion

The Supreme Court in 2012 made optional the ACA's expansion of Medicaid to cover all low-income Americans up to 138 percent of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94 percent in 2018, gradually dropping to 90 percent in 2020.

Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid.

McDonough is confident that's about to change. "I'm wondering if we're on the cusp of a Medicaid wave," he said.

Four states — Nebraska, Idaho, Utah and Montana — have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana's question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state's increased Medicaid costs.

In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov. Butch Otter, who is retiring after three terms, endorsed it Tuesday.

But the issue is in play in other states, too. Several non-expansion states have close or closer-than-expected races for governor where the Democrat has made Medicaid expansion a priority.

In Florida, one of the largest states not to have expanded expanded Medicaid, the Republican candidate for governor, former U.S. Rep. Ron DeSantis, opposes expansion. His Democratic opponent, Tallahassee Mayor Andrew Gillum, supports it.

In Georgia, the gubernatorial candidates, Democrat Stacey Abrams and Republican Brian Kemp, also are on opposite sides of the Medicaid expansion debate.

However, the legislatures in both states have opposed the expansion, and it's not clear if they would be swayed by arguments from a new governor.

3. Medicare

Until recently, Republicans have remained relatively quiet about efforts to change the popular Medicare program for seniors and people with disabilities.

Their new talking point is that proposals to expand the program — such as the often touted "Medicare-for-all," which an increasing number of Democrats are embracing — could threaten the existing program.

"Medicare is at significant risk of being cut if Democrats take over the House," Rep. Greg Gianforte (R-Mont.) told the Lee Montana Newspapers. "Medicare-for-all is Medicare for none. It will gut Medicare, end the VA as we know it, and force Montana seniors to the back of the line."

Gianforte's Democratic opponent, Kathleen Williams, is proposing another idea popular with Democrats: allowing people age 55 and over to "buy into" Medicare coverage. That race, too, is very tight.

Meanwhile, back in Washington, congressional Republicans are more concerned with how Medicare and other large government social programs are threatening the budget.

"Sooner or later we are going to run out of other people's money," said Chris Jacobs.

Senate Majority Leader Mitch McConnell suggested in an Oct. 16 interview with Bloomberg News that entitlement programs like Medicare are "the real driver of the debt by any objective standard," but that bipartisan cooperation will be needed to address that problem

Republican Jacobs and Democrat McDonough think that's unlikely any time soon.

"Why would Democrats give that up as an issue heading into 2020?" asked McDonough, especially because Republicans in recent years have been proposing deep cuts to the Medicare program.

Agreed Jacobs, "Trump may not want that to be the centerpiece of a re-election campaign."

Despite federal rules requiring plans to keep up-to-date directories, consumers may lack access to clear information about which health plans have 'narrow networks' of providers or which hospitals and doctors are in or out of an insurer's network.

This article first appeared November 01, 2018 on Kaiser Health News.

By Steven Findlay

As a breast cancer survivor, Donna Catanuchi said she knows she can't go without health insurance. But her monthly premium of $855 was too high to afford.

"It was my biggest expense and killing me," said Catanuchi, 58, of Mullica Hill, N.J.

A "navigator" who helps people find coverage through the Affordable Care Act found a solution. But it required Catanuchi, who works part time cleaning offices, to switch to a less comprehensive plan, change doctors, drive farther to her appointments and pay $110 a visit out-of-pocket — or about three times what she was paying for her follow-up cancer care.

She now pays $40 a month for coverage, after she qualified for a substantial government subsidy.

Catanuchi's switch to a more affordable but restrictive plan reflects a broad trend in insurance plan design over the past few years. The cheaper plans offer far narrower networks of doctors and hospitals and less coverage of out-of-network care. But many consumers are overwhelmed or unaware of the trade-offs they entail, insurance commissioners and policy experts say.

With enrollment for ACA health plans beginning Nov. 1, they worry that consumers too often lack access to clear information about which health plans have "narrow networks" of medical providers or which hospitals and doctors are in or out of an insurer's network, despite federal rules requiring plans to keep up-to-date directories.

"It's very frustrating for consumers," said Betsy Imholz, who represents the advocacy group Consumers Union at the National Association of Insurance Commissioners. "Health plan provider directories are often inaccurate, and doctors are dropping in and out all the time."

These more restrictive plans expose people to larger out-of-pocket costs, less access to out-of-network specialists and hospitals, and "surprise" medical bills from unforeseen out-of-network care.

More than 14 million people buy health insurance on the individual market — largely through the ACA exchanges, and they will be shopping anew this coming month.

Trend Appears To Be Slowing

For 2018, 73 percent of plans offered through the exchanges were either health maintenance organizations (HMOs) or exclusive provider organizations (EPOs), up from 54 percent in 2015.

Both have more restrictive networks and offer less out-of-network coverage compared with preferred provider organizations (PPOs), which represented 21 percent of health plans offered through the ACA exchanges in 2018, according to Avalere, a health research firm in Washington, D.C.

PPOs typically provide easier access to out-of-network specialists and facilities, and partial — sometimes even generous — payment for such services.

Measured another way, the number of ACA plans offering any out-of-network coverage declined to 29 percent in 2018 from 58 percent in 2015, according to a recent analysis by the Robert Wood Johnson Foundation.

For example, in California, HMO and EPO enrollment through Covered California, the state's exchange, grew from 46 percent in 2016 to 70 percent in 2018, officials there said. Over the same period, PPO enrollment declined from 54 percent to 30 percent.

In contrast, PPOs have long been and remain the dominant type of health plan offered by employers nationwide. Forty-nine percent of the 152 million people and their dependents who were covered through work in 2018 were enrolled in a PPO-type plan. Only 16 percent were in HMOs, according to the Kaiser Family Foundation's annual survey of employment-based health insurance.

The good news for people buying health insurance on their own is that the trend toward narrow networks appears to be slowing.

"When premiums shot up over the past few years, insurers shifted to more restrictive plans with smaller provider networks to try and lower costs and premiums," said Chris Sloan, a director at Avalere. "With premium increases slowing, at least for now, that could stabilize."

Some research supports this prediction. Daniel Polsky, a health economist at the University of Pennsylvania, found that the number of ACA plans nationwide with narrow physician networks declined from 25 percent in 2016 to 21 percent in 2017.

Polsky is completing an analysis of 2018 plans and expects the percent of narrow network plans to remain "relatively constant" for this year and into 2019.

"Fewer insurers are exiting the marketplace, and there's less churn in the plans being offered," said Polsky. "That's good news for consumers."

Insurers may still be contracting with fewer hospitals, however, to constrain costs in that expensive arena of care, according to a report by the consulting firm McKinsey & Co. It found that 53 percent of plans had narrow hospital networks in 2017, up from 48 percent in 2014.

"Narrow networks are a trade-off," said Paul Ginsburg, a health care economist at the Brookings Institution. "They can be successful when done well. At a time when we need to find ways to control rising health care costs, narrow networks are one legitimate strategy."

Ginsburg also notes that there's no evidence to date that the quality of care is any less in narrow versus broader networks, or that people are being denied access to needed care.

Mike Kreidler, Washington state's insurance commissioner, said ACA insurers in that state "are figuring out they can't get away with provider networks that are inadequate to meet people's needs."

"People have voted with their feet, moving to more affordable choices like HMOs but they won't tolerate draconian restrictions," Kreidler said.

The state is stepping in, too. In December 2017, Kreidler fined one insurer — Coordinated Care — $1.5 million for failing to maintain an adequate network of doctors. The state suspended $1 million of the fine if the insurer had no further violations. In March 2018, the plan was docked another $100,000 for similar gaps, especially a paucity of specialists in immunology, dermatology and rheumatology. The $900,000 in potential fines continues to hang over the company's head.

Centene Corp, which owns Coordinated Care, has pledged to improve its network.

Pennsylvania Insurance Commissioner Jessica Altman said she expects residents buying insurance in the individual marketplace for 2019 to have a wider choice of providers in their networks.

"We think and hope insurers are gradually building more stable networks of providers," said Altman.

New State Laws

Bad publicity and recent state laws are pushing insurers to modify their practices and shore up their networks.

About 20 states now have laws restricting surprise bills or balance billing, or which mandate mediation over disputed medical bills, especially those stemming from emergency care.

Even more have rules on maintaining accurate, up-to-date provider directories.

The problem is the laws vary widely in the degree to which they "truly protect consumers," said Claire McAndrew, a health policy analyst at Families USA, a consumer advocacy group in Washington, D.C. "It's a patchwork system with some strong consumer protections and a lot of weaker ones."

"Some states don't have the resources to enforce rules in this area," said Justin Giovannelli, a researcher at the Center on Health Insurance Reforms at Georgetown University. "That takes us backward in assuring consumers get coverage that meets their needs."

The U.S. is grappling with a doctor shortage that’s expected to grow to as many as 120,000 physicians by 2030. Foreign-born doctors are vital to the national healthcare delivery system.

This article first appeared October 30, 2018 on Kaiser Health News.

By Max Blau, Andy Miller and Katja Ridderbusch, Georgia Health News and Kaiser Health News

ATLANTA — Dr. Alluri Raju, a native of India, vividly remembers how his ethnicity prompted concern and discrimination in the southwest Georgia town of Richland. Doctors there hesitated to grant the family practitioner and general surgeon privileges to the local hospital when he arrived in 1981.

"I guess they wanted to cut me off so that I wouldn't be a competitor," he recalled.

Yet, in the 37 years Raju has been practicing in Richland, more than 20 doctors have come and gone and he's the only physician left — not just in Richland, but in all of Stewart County and neighboring Webster County, an area roughly half the size of Rhode Island with a population of more than 8,000.

"Today, I'm it," he said. And his patients, he said, treat him with respect — and not as a foreigner.

Stories like Raju's are the common thread for many immigrant doctors in the United States.

The American Medical Association said that, as of last year, 18 percent of practicing physicians and medical residents in the U.S. in patient care were born in other countries. Georgia's percentage of foreign-born doctors is similar, at 17 percent.

Yet President Donald Trump's focus on securing U.S. borders and restricting immigration — and the bitter arguments between the national political parties on the issue during midterm campaigns — have sown concerns about opportunities for foreign-born doctors.

Many of these doctors, like Raju, work in rural areas that are desperate to attract medical professionals. Yet those areas are often reliable supporters of Trump and his strict immigration policies. A recent national poll found that immigration is the top concern for Republican voters.

Some health care experts say Trump's tough stance could make it harder for rural areas such as Richland to relieve critical physician shortages.

Georgia's Republican lawmakers have considered legislation in recent years that opponents say would have restricted the rights of some immigrants. And Republican candidates for governor here campaigned in the primary this year on cracking down on illegal immigrants, though advocates for that position say bias is not the motivation, but rather the need for border security.

Raju's patients say they don't see any problem in seeking care from an immigrant. Raju has been treating Willie Hawkins, a retired road worker, for 30 years, as well as his mother and his sister.

Sometimes, Hawkins said with a smile, he has to ask the nurse what the doctor just said.

"You know, he talks a little funny," said Hawkins, 66. "But who cares?"

Maybe when Raju first came here to practice, people were a bit skeptical, Hawkins recalled. Many had never met someone from India before, he said. "But today it just doesn't matter," he said.

Foreign-born doctors are vital to the national health system. The U.S. is grappling with a doctor shortage that's expected to grow to as many as 120,000 physicians by 2030, according to the Association of American Medical Colleges.

Even now, primary care doctors are relatively scarce in certain areas of the country. Georgia has a few counties without any doctors at all, and many counties lack a pediatrician or an OB-GYN.

These immigrants help fill some of the gaps, especially in primary care, said Dr. William Salazar of Augusta University's Medical College of Georgia, who came to the U.S. from Colombia. And rural Georgia has a higher percentage of immigrant doctors than do urban areas, said Jimmy Lewis of HomeTown Health, an association of rural hospitals mostly in Georgia.

"Foreign-born doctors go to places no one wants to go," said Dr. Gulshan Harjee, a Tanzanian-born physician who co-founded the Clarkston Community Health Center, a free clinic serving mainly immigrants and refugees in metro Atlanta.

Patients' Bias

Several foreign-born doctors here recalled awkward interactions with patients, occasionally experiencing bias.

"When they think you're different, they think you're not as smart, and think they won't understand what you're saying," said Salazar. "You develop skills to overcome that.''

But patients overall are getting used to people from other countries, he added.

Saeed Raees, a pharmacist originally from Pakistan who co-founded the Clarkston clinic, said that "you'll run into a small minority who don't want to be seen by a foreign-born doctor or a Muslim doctor."

Physicians from predominantly Muslim countries face increased pressure after the Trump administration tightened its visa and immigration policies. Several doctors said that their visa applications take longer than before or are on hold, and re-entry into the U.S. after traveling was difficult.

Nearly half of Muslim physicians in the U.S. felt more scrutiny at work compared with their peers, and many said they experienced discrimination in the workplace, according to a study by Dr. Aasim Padela at the University of Chicago. Nearly a tenth of the physicians surveyed reported that patients had refused their care because they were Muslim.

There is also acceptance.

Dr. Buthena Nagi, a native of Libya, is employed as a hospitalist at Navicent Health in Macon. Nagi, 40, completed her residency at Morehouse School of Medicine in Atlanta in 2015. But to stay in the country she has to meet immigration criteria.

Most foreign physicians complete their residency in the U.S., typically on a student visa. To remain beyond that, U.S. immigration law requires them to practice in a medically underserved area for at least three years. Afterward, they can apply for a green card and, eventually, American citizenship.

Nagi wears a hijab — a traditional head covering for many Muslim women — with her scrubs, and sometimes patients and colleagues ask her about it.

"I then explain that this is part of my religion," she said. "And once the dialogue kicks in, the fear dies down, and people seem to understand that I'm not an alien from outer space."

In metro Atlanta's highly diverse DeKalb County, about 75 percent of the patients at the free Clarkston health center are immigrants, refugees or migrant workers. Up to 30 languages are spoken there. Co-founder Harjee said she speaks "only six."

Sameera Vadsariya, 37, said through an interpreter that she loves the services there. She was born in India and is here on a visa. She has no health insurance, so the free services are worth the long wait for treatment.

Most of the volunteer doctors at the Clarkston clinic are foreign-born, said Harjee. "This is a passion for them. They want to give back.''

Opportunity Lost

Belsy Garcia Manrique also wants to play a role.

At age 7, she left her home in Zacapa, Guatemala, and headed north through Mexico with her mother and sister. It was a two-week odyssey — a combination of walking and driving — up to the southern tip of Texas. Her father, Felix, who had come to the U.S. two years earlier seeking political asylum, met them and drove the family to his home in Georgia.

For many years, she dreamed of being a doctor, hoping to treat Spanish-speaking patients in the parts of northwest Georgia where she was raised.

U.S. immigration policy, however, blocked her path to medical school. She was not a legal resident. Most states, including Georgia, prevented undocumented immigrant children like Garcia Manrique from qualifying for in-state tuition at public universities.

But Garcia Manrique caught a break when President Barack Obama issued an executive order six years ago that created the Deferred Action for Childhood Arrivals program. DACA offered more than 800,000 undocumented immigrants brought to the U.S. by their parents a chance to stay without fear of deportation.

From 2012 to 2016, medical schools from California to Massachusetts accepted roughly 100 DACA students, whose families hailed from Mexico, Pakistan, Venezuela and other countries. Garcia Manrique applied to nearly 40 schools. The Stritch School of Medicine at Loyola University Chicago, the first medical school to accept DACA students, was the only one that offered her admission.

Shortly after taking office in 2017, Trump rescinded DACA, a move that has become the subject of ongoing legal and political battles. If the law stands, Garcia Manrique will be allowed to stay in the U.S. But if it's overturned, she and DACA medical trainees won't be allowed to renew their work permits.

Garcia Manrique is finishing medical school and applying for a residency program to train in family medicine. Only two Georgia medical programs — at Emory University and Morehouse College — said they would consider a DACA recipient. She applied to both.

Of her 50 applications, Garcia Manrique received interview offers from nearly a dozen programs, including ones in Illinois, California and Washington. She hasn't heard from the ones in Georgia.

And these days she isn't sure if the Georgia she knew, and the Georgia she loved, is a place where she'd feel welcome.

"After a certain time of being looked down upon, being told 'no,' going the extra mile to get the same benefits, you get tired of that," Garcia Manrique said. "I've seen many immigrants who have talent in the South move out. Why not be somewhere where you're wanted?"