Four Ways Trump's 'One Big Beautiful Bill' Would Undermine Access to Obamacare

KFF Health News, June 11, 2025

Millions of people might drop or lose coverage by 2034 as a result, according to the nonpartisan CBO.

This article was published on Wednesday, June 11, in KFF Health News.

By Julie Appleby

Major changes could be in store for the more than 24 million people with health coverage under the Affordable Care Act, including how and when they can enroll, the paperwork required, and, crucially, the premiums they pay.

A driver behind these changes is the "One Big Beautiful Bill," the name given to spending and tax legislation designed to advance the policy agenda of President Donald Trump. It passed the House on May 22 and is pending in the Senate.

The changes also would come from regulations the Trump administration proposed in March and the potential expiration of larger premium subsidies put in place during the covid-19 pandemic.

Millions of people might drop or lose coverage by 2034 as a result, according to the nonpartisan Congressional Budget Office.

Combined, the moves by Trump and his allies could "devastate access" to ACA plans, said Katie Keith, director of the Center for Health Policy and the Law at the O'Neill Institute, a health policy research group at Georgetown University.

States that run their own Obamacare marketplaces and the National Association of Insurance Commissioners have also raised concerns about added costs and reduced access. But House Republicans and some conservative think tanks say the ACA needs revamping to rein in fraud, part of which they pin on certain Biden administration changes the measures would undo.

Senate Republicans must now weigh whether to include the House's proposals in their own bill, with the aim of getting it through the chamber by July 4.

Here are four key ways Trump's policies could undermine Obamacare enrollment and coverage.

More Enrollment Hoops

The House-passed One Big Beautiful Bill Act, which runs more than 1,000 pages, would create paperwork requirements that could delay access to tax credits for some enrollees, potentially raising the cost of their insurance.

More than 90% of ACA enrollees receive tax credits to defray monthly premiums for their coverage. There are two key provisions for them to watch.

One would end automatic reenrollment for most ACA policyholders each year. More than 10 million people were automatically reenrolled in their coverage for the 2025 plan year, with their eligibility for tax credits confirmed via a system that allows ACA marketplaces to check government or other data sources.

The House bill would instead require every new or returning policyholder each year to provide information on income, household size, immigration status, and other factors, starting in 2028. If they don't, they won't get a premium tax credit, which could put the price of coverage out of reach.

"Everyone who wants to either purchase or renew a marketplace plan will have to come with a shoebox filled with documents, scan in and upload them or mail them in, and sit and wait while someone reviews and confirms them," said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

She and other policy experts fear that many consumers will become uninsured because they don't understand the requirements or find them burdensome. If too many young and healthy people, for example, decide it's not worth the hassle, that could leave more older and sicker people for ACA insurers to cover — potentially raising premiums for everyone.

But supporters of the House bill say the current approach needs changing because it is vulnerable to waste, fraud, and abuse.

"This would ensure that enrollees need to return to the exchange to update their information and obtain an updated eligibility determination for a subsidy — best protecting the public against excess subsidies paid to insurers that can never be recovered," the conservative Paragon Institute wrote in an April letter to top Department of Health and Human Services officials.

Having a Baby? Getting Married? Expect Coverage Delays

Today, people who experience life changes — losing a job, getting married or divorced, or having a baby, for instance — are considered provisionally eligible for tax credits to reduce their premiums if they sign up or change their ACA plans. That means they would be eligible to receive these subsidies for at least 90 days while their applications are checked against government data or other sources, or marketplaces follow up with requests for additional information.

The House bill would end that, requiring documentation before receiving tax credits. That could create particular hardship for new parents, who can't confirm that babies are eligible for premium subsidies until they receive Social Security numbers weeks after they're born.

Policy experts following the debate "did not expect the end to provisional eligibility," Corlette said. "I don't know what the reaction in the Senate will be, as I'm not sure everyone understands the full implications of these provisions because they are so new."

It can take up to six weeks for the Social Security Administration to process a number for a newborn, and an additional two weeks for parents to get the card, according to a white paper that analyzed provisions of the House bill and was co-authored by Jason Levitis, a senior fellow at the Urban Institute, and Christen Linke Young, a visiting fellow with Brookings' Center on Health Policy.

Without a Social Security number, any application to add a newborn to an ACA policy would automatically generate a hold on premium tax credits for that family, they wrote — increasing their out-of-pocket costs, at least temporarily.

"It puts consumers on the hook for any delays the marketplace is taking," while the Centers for Medicare & Medicaid Services, which administers the ACA marketplaces, "is cutting staff and adding a lot more paperwork to burden the staff they have," Levitis said.

Provisions in the House bill that would require ACA enrollees to provide information each year that they reenroll — or when seeking to add or change a policy due to a life circumstance — would increase the number of people without health insurance by 700,000 in 2034, according to the latest CBO estimate.

Less Time To Sign Up

The House bill would turn into law a Trump proposal to shorten the ACA open enrollment period. The start date would continue to be Nov. 1. But the window would be shortened by about a month, with an end date of Dec. 15. This affects people in states that use the federal marketplace as well as the 19 states and the District of Columbia that run their own, most of which offer open enrollment into at least mid-January.

Also, as soon as the end of this year, a special enrollment period the Biden administration created would be done away with. It allowed people with lower incomes — those who earn up to 1.5 times the 2024 federal poverty level, or about $38,730 for a family of three — to sign up anytime during the year.

Critics, including the Paragon Institute, argue that this enrollment opening led to fraud, partly blaming it for a steep increase last year in instances of insurance agents seeking commissions by enrolling or switching consumers into plans without their consent, or fudging their incomes to qualify them for tax credits so large they paid no monthly premiums at all.

But supporters — including some states that run their own ACA exchange — say there are other ways to address fraud.

"We anticipate that much of the improper activity can be prevented by security and integrity upgrades to the federal marketplace, which we understand the Centers for Medicare and Medicaid Services (CMS) is implementing," the National Association of Insurance Commissioners wrote in a May 29 letter to congressional leaders.

Premiums and Out-of-Pocket Costs Will Likely Increase

The reason? Enhanced tax credits created during the pandemic expire at the end of the year. The House bill doesn't extend them. Those more generous payments are credited with helping double ACA enrollment since 2020.

The CBO estimates that extending the subsidies would cost $335 billion over 10 years. The House bill instead funds an extension of Trump's tax cuts, which largely benefit wealthier families.

If the enhanced credits are allowed to expire, not only would premium subsidies be smaller for many people, but there would also be an abrupt eligibility cutoff — an income cliff — for households above four times the federal poverty rate, or about $103,280 for a family of three for this plan year.

Taking into account the smaller subsidies and the cliff, KFF estimates a national average premium increase of 75% for enrollees if the enhanced subsidies expire. The CBO expects that about 4.2 million more people will be uninsured in 2034 as a result.

Julie Appleby: jappleby@kff.org, @Julie_appleby

What Are 'Improper' Medicaid Payments, and Are They as High as a Trump Official Said?

KFF Health News, June 11, 2025

"One out of every $5 or $6 in Medicaid [payments] is improper," said Russell Vought in an interview on CNN’s "State of the Union."

This article was published on Wednesday, June 11, 2025 in KFF Health News.

By Louis Jacobson, PolitiFact 

Responding to charges that President Donald Trump's tax and spending bill would cut Medicaid coverage for millions of Americans, Trump administration officials misleadingly counter that it targets only waste, fraud, and abuse.

During an interview on CNN's "State of the Union," Russell Vought, the administration's director of the Office of Management and Budget, framed Medicaid as sagging under the weight of improper payments.

An "improper" payment refers to payments made erroneously to beneficiaries and their providers or without sufficient documentation.

Pressed June 1 by CNN host Dana Bash about concerns that low-income Americans would suffer if the bill becomes law, Vought called such arguments "totally ridiculous."

"This bill will preserve and protect the programs, the social safety net, but it will make it much more commonsense," Vought said. "Look, one out of every $5 or $6 in Medicaid [payments] is improper."

That would mean Medicaid's improper payment rate is 16% to 20%.

In a 2024 report covering the years 2022, 2023, and 2024, Medicaid's parent agency — the Centers for Medicare & Medicaid Services — said the rate was about 5.1%.

One conservative group, the Paragon Health Institute, said the agency has been using an incomplete calculation method and that the percentage could be as high as 25%. Other experts told PolitiFact that the actual numbers could be higher than what the federal government reports, although not as high as Paragon's estimate.

The White House did not respond to an inquiry for this article.

How High Is the Medicaid Improper Payment Rate?

Medicaid and its closely related Children's Health Insurance program provides health care and long-term care to roughly 83 million lower-income beneficiaries, accounting for about one-fifth of health care spending overall. It is funded through a mix of federal and state money and is administered by states under federal government rules.

Every year, the Centers for Medicare & Medicaid Services publishes official numbers for the share of improper Medicaid payments, and in other federal health insurance programs the agency oversees.

In a 2024 review of payments made in 2022, 2023, and 2024, the agency found that 5.09% of Medicaid payments totaling $31.10 billion were improper.

The 5.09% rate represented a decrease from the 8.58% rate cited in its 2023 report, which was also based on a three-year time span. The 2024 figure represented the third consecutive annual decline.

Are These Numbers Complete?

In March 2025, Brian Blase, a conservative health policy analyst and president of Paragon Health, a health policy think tank, co-authored a report that said the official CMS improper payment rate figures were unrealistically low for eight of the past 10 years, because in some years the agency failed to undergo widespread auditing of its beneficiaries' Medicaid eligibility.

From 2017 to 2019, during Trump's first term, Blase served as Trump's special assistant for economic policy. Before that, he served as a health policy analyst for the Senate Republican Policy Committee and has worked for the Heritage Foundation, a conservative think tank.

The report said if the agency's analysis had looked at eligibility checks every year, more ineligible beneficiaries and payments on their behalf would have been discovered. The report said this might have increased the improper payment rate as high as 25%, based on the rates found in 2020 and 2021, when a high number of eligibility checks were included in the agency's methodology.

However, it's hard to confirm whether lack of eligibility auditing caused higher improper payment rates in 2020 and 2021, said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, a liberal think tank.

Wagner said Medicaid enrollment procedures have fluctuated, which could help explain the higher rates in some years rather than others. Using two years of data to generalize about trends across a decade, she said, is not necessarily valid.

Robert Westbrooks, the federal Pandemic Response Accountability Committee executive director who worked in government oversight roles during Democratic and Republican administrations, told PolitiFact it's plausible that the officially reported improper payment rates for Medicaid could be too low.

However, Westbrooks said pinpointing how much higher the rate is in reality is a speculative process. "I don't believe anyone can credibly quantify the [difference]," he said.

What Is an Improper Payment?

Health care experts emphasized that improper payments are not the same thing as waste, fraud, or abuse.

CMS maintains official definitions for these terms:

  • Fraud: "When someone knowingly deceives, conceals, or misrepresents to obtain money or property from any health care benefit program."
  • Waste: "Overusing services or other practices that directly or indirectly result in unnecessary costs to any health care benefit program. Examples of waste are conducting excessive office visits, prescribing more medications than necessary, and ordering excessive laboratory tests."
  • Abuse: "When health care providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any health care benefit program," which can include overbilling or misusing billing codes.

By contrast, an improper payment "includes any payment to an ineligible recipient, any payment for an ineligible good or service, any duplicate payment, any payment for a good or service not received, and any payment that does not account for credit for applicable discounts," KFF, a health information nonprofit that includes KFF Health News, wrote this year.

"Although all fraudulent payments are improper, not all improper payments are fraudulent," said Jessica Tillipman, associate dean for government procurement law at George Washington University's law school. "Most providers identify the improper payments and return them knowing how aggressively enforced" the legal provisions are. "When they don't, they open the door to significant liability."

CMS said about 79% of improper payments happened when there was insufficient documentation.

This typically involved cases in which a state or provider missed an administrative step, and it did not necessarily indicate fraud or abuse, the agency said. Instead, it could be an accidental oversight or mistake.

In other words, it was rare for ordinary beneficiaries to be scamming the government. "The vast majority of fraud in Medicaid is committed by providers or other actors, not enrollees," Wagner said.

Our Ruling

Vought said that "one out of every $5 or $6 in Medicaid [payments] is improper."

The official improper payment rate calculated by the Centers for Medicare & Medicaid Services in 2024 was about 5%, smaller than the 16% to 20% rate Vought described.

A health policy analyst and former Trump adviser said methodological shortcomings in the agency's analysis could mean the rate is as high as 25%. Although it's possible the rate is higher than the 5% the government reported, how much higher is speculative.

The statement contains an element of truth but ignores critical facts, namely the federal government's own data. We rate the statement Mostly False.

Our Sources

Russell Vought, interview with CNN's "State of the Union," June 1, 2025.

Centers for Medicare & Medicaid Services, "Fiscal Year 2024 Improper Payments Fact Sheet," Nov. 15, 2024.

Centers for Medicare & Medicaid Services, "PERM Error Rate Findings and Reports," accessed June 4, 2025.

Centers for Medicare & Medicaid Services, "2024 Medicaid & CHIP Supplemental Improper Payment Data," accessed June 4, 2025.

Paymentaccuracy.gov, "Annual Improper Payments Datasets," accessed June 3, 2025.

KFF, "5 Key Facts About Medicaid Program Integrity — Fraud, Waste, Abuse and Improper Payments," March 18, 2025.

KFF, "Virtual Event Transcript — The Health Wonk Shop: Understanding Fraud and Abuse in Medicaid," April 24, 2025.

Paragon Health Institute, "Medicaid's True Improper Payments Double Those Reported by CMS," March 3, 2025.

Government Accountability Office, "Improper Payments: Information on Agencies' Fiscal Year 2024 Estimates," March 11, 2025.

Email interviews with Tammie Smith and Craig Palosky, spokespersons for KFF, June 2, 2025.

Email interview with Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities.

Email interview with Jessica Tillipman, associate dean for government procurement law at George Washington University's law school, June 3, 2025.

Email interview with Robert Westbrooks, Pandemic Response Accountability Committee executive director who worked in government oversight roles during Democratic and Republican administrations, June 3, 2025.

Asthma Sufferers Could Be at Greater Risk if Trump Cuts Health Program

KFF Health News, June 6, 2025

Asthma experts fear the cumulative impact of the reductions could result in more ER visits and deaths.

This article was published on Friday, June 6, 2025 in KFF Health News.

By Miranda Green

Esther Bejarano's son was 11 months old when asthma landed him inhh the hospital. She didn't know what had triggered his symptoms — neither she nor her husband had asthma — but she suspected it was the pesticides sprayed on the agricultural fields near her family's home.

Pesticides are a known contributor to asthma and are commonly used where Bejarano lives in California's Imperial Valley, a landlocked region that straddles two counties on the U.S.-Mexico border and is one of the main producers of the nation's winter crops. It also has some of the worst air pollution in the nation and one of the highest rates of childhood asthma emergency room visits in the state, according to data collected by the California Department of Public Health.

Bejarano has since learned to manage her now-19-year-old son's asthma and works at Comite Civico del Valle, a local rights organization focused on environmental justice in the Imperial Valley. The organization trains health care workers to educate patients on proper asthma management, enabling them to avoid hospitalization and eliminate triggers at home. The course is so popular that there's a waiting list, Bejarano said.

But the group's Asthma Management Academy program and similar initiatives nationwide face extinction with the Trump administration's mass layoffs, grant cancellations, and proposed budget cuts at the Department of Health and Human Services and the Environmental Protection Agency. Asthma experts fear the cumulative impact of the reductions could result in more ER visits and deaths, particularly for children and people in low-income communities — populations disproportionately vulnerable to the disease.

"Asthma is a preventive condition," Bejarano said. "No one should die of asthma."

Asthma can block airways, making it hard to breathe, and in severe cases can cause death if not treated quickly. Nearly 28 million people in the U.S. have asthma, and about 10 people still die every day from the disease, according to the Asthma and Allergy Foundation of America.

In May, the White House released a budget proposal that would permanently shutter the Centers for Disease Control and Prevention's National Asthma Control Program, which was already gutted by federal health department layoffs in April. It's unclear whether Congress will approve the closure.

Last year, the program allotted $33.5 million to state-administered initiatives in 27 states, Puerto Rico, and Washington, D.C., to help communities with asthma education. The funding is distributed in four-year grant cycles, during which the programs receive up to $725,000 each annually.

Comite Civico del Valle's academy in Southern California, a clinician workshop in Houston, and asthma medical management training in Allentown, Pennsylvania — ranked the most challenging U.S. city to live in with asthma — are among the programs largely surviving on these grants. The first year of the current grant cycle ends Aug. 31, and it's unknown whether funding will continue beyond then.

Data suggests that the CDC's National Asthma Control Program has had a significant impact. The agency's own research has shown that the program saves $71 in health care costs for every $1 invested. And the asthma death rate decreased 44% between the 1999 launch of the program and 2021, according to the American Lung Association.

"Losing support from the CDC will have devastating impacts on asthma programs in states and communities across the country, programs that we know are improving the lives of millions of people with asthma," said Anne Kelsey Lamb, director of the Public Health Institute's Regional Asthma Management and Prevention program. "And the thing is that we know a lot about what works to help people keep their asthma well controlled, and that's why it's so devastating."

The Trump administration cited cost savings and efficiency in its April announcement of the cuts to HHS. Requests for comment from the White House and CDC about cuts to federal asthma and related programs were not answered.

The Information Wars

Fresno, in the heart of California's Central Valley, is one of the country's top 20 "asthma capitals," with high rates of asthma and related emergencies and deaths. It's home to programs that receive funding through the National Asthma Control Program. Health care professionals there also rely on another aspect of the program that is under threat if it's shuttered: countrywide data.

The federal asthma program collects information on asthma rates and offers a tool to study prevalence and rates of death from the disease, see what populations are most affected, and assess state and local trends. Asthma educators and health care providers worry that the loss of these numbers could be the biggest impact of the cuts, because it would mean a dearth of information crucial to forming educated recommendations and treatment plans.

"How do we justify the services we provide if the data isn't there?" said Graciela Anaya, director of community health at the Central California Asthma Collaborative in Fresno.

Mitchell Grayson, chair of the Asthma and Allergy Foundation's Medical Scientific Council, is similarly concerned.

"My fear is we're going to live in a world that is frozen in Jan. 19, 2025, as far as data, because that was the last time you know that this information was safely collected," he said.

Grayson, an allergist who practices in Columbus, Ohio, said he also worries government websites will delete important recommendations that asthma sufferers avoid heavy air pollution, get annual flu shots, and get covid-19 vaccines.

Disproportionate Risk

Asthma disproportionately affects communities of color because of "historic structural issues," said Lynda Mitchell, CEO of the Asthma and Allergy Network, citing a higher likelihood of living in public housing or near highways and other pollution sources.

She and other experts in the field said cuts to diversity initiatives across federal agencies, combined with the rollback of environmental protections, will have an outsize impact on these at-risk populations.

In December, the Biden administration awarded nearly $1.6 billion through the EPA's Community Change Grants program to help disadvantaged communities address pollution and climate threats. The Trump administration moved to cut this funding in March. The grant freezes, which have been temporarily blocked by the courts, are part of a broader effort by the Trump EPA to eliminate aid to environmental justice programs across the agency.

In 2023 and 2024, the National Institutes of Health's Climate Change and Health Initiative received $40 million for research, including on the link between asthma and climate change. The Trump administration has moved to cut that money. And a March memo essentially halted all NIH grants focused on diversity, equity, and inclusion, or DEI — funds many of the asthma programs serving low-income communities rely on to operate.

On top of those cuts, environmental advocates like Isabel González Whitaker of Memphis, Tennessee, worry that the proposed reversals of environmental regulations will further harm the health of communities like hers that are already reeling from the effects of climate change. Shelby County, home to Memphis, recently received an F on the American Lung Association's annual report card for having so many high ozone days. González Whitaker is director of EcoMadres, a program within the national organization Moms for Clean Air that advocates for better environmental conditions for Latino communities.

"Urgent asthma needs in communities are getting defunded at a time when I just see things getting worse in terms of deregulation," said González Whitaker, who took her 12-year-old son to the hospital because of breathing issues for the first time this year. "We're being assaulted by this data and science, which is clearly stating that we need to be doing better around preserving the regulations."

Back in California's Imperial Valley — where the majority-Hispanic, working-class population surrounds California's largest lake, the Salton Sea — is an area called Bombay Beach. Bejarano calls it the "forgotten community." Homes there lack clean running water, because of naturally occurring arsenic in the groundwater, and residents frequently experience a smell like rotten eggs blowing off the drying lakebed, exposing decades of pesticide-tinged dirt.

In 2022, a 12-year-old girl died in Bombay Beach after an asthma attack. Bejarano said she later learned that the girl's school had recommended that she take part in Comite Civico del Valle's at-home asthma education program. She said the girl was on the waiting list when she died.

"It hit home. Her death showed the personal need we have here in Imperial County," Bejarano said. "Deaths are preventable. Asthma is reversible. If you have asthma, you should be able to live a healthy life."

Miranda Green: mirandac.green@gmail.com, @mirandacgreen

Podcast: A Mathematical Solution for U.S. Hospitals?

KFF Health News, June 4, 2025

Eugene Litvak has been on a mission to save U.S. hospitals money and improve the lives of doctors, nurses, and patients.

This podcast was released on Wednesday, June 4, 2025 in KFF Health News.

By Dan Weissmann

What do the KGB and the former CEO of Cincinnati Children's Hospital have in common?

Eugene Litvak.

The Soviet intelligence agency and the children's hospital have each separately looked to the Ukrainian émigré with a PhD in mathematics for help. He turned down the KGB, but Litvak saved Cincinnati Children's Hospital more than $100 million a year. 

For decades, Litvak has been on a mission to save U.S. hospitals money and improve the lives of doctors, nurses, and patients. He says he has just the formula to do it.

Prominent experts vouch for his model, and he has documented impressive results so far: financial savings, fewer hospital-related deaths, lower staff turnover, and shorter wait times. Still, Litvak and his allies have struggled to persuade more hospitals to try his method.

Host Dan Weissmann speaks with Litvak about his unique life story, how he found the fix that he says could revolutionize American hospitals, and why he won't stop fighting for it.

Watch: In a 'Dead Zone,' Doctors Don't Practice and Telehealth Doesn't Reach

KFF Health News, June 3, 2025

Millions of rural Americans live in counties with doctor shortages and where high-speed internet connections aren't adequate to access advanced telehealth services. A KFF Health News analysis found people in these 'dead zones' live sicker and die younger on average than their peers in well-connected regions.

The video was posted on Tuesday, June 3, 2025 in KFF Health News.

By Sarah Jane Tribble

Ballad Health's Hospital Monopoly Underperformed. Then TN Lowered the Bar.

KFF Health News, June 3, 2025

The monopoly can now be considered a 'clear and convincing' benefit to the public with performance that would earn a 'D' on most A-to-F grading scales.

This article was published on Tuesday, June 3, 2025 in KFF Health News.

By Brett Kelman

Despite years of patient complaints and quality-of-care concerns, Ballad Health — the nation's largest state-sanctioned hospital monopoly — will now be held to a lower standard by the Tennessee government, and state data that holds the monopoly accountable will be kept from the public for two years.

Ballad is the only option for hospital care for most of the approximately 1.1 million people in a 29-county swath of Appalachia. Such a monopoly would normally be prohibited by federal law. But under deals negotiated with Tennessee and Virginia years ago, the monopoly is permitted if both states affirm each year that it is an overall benefit to the public.

However, according to a newly renegotiated agreement between Ballad and Tennessee, the monopoly can now be considered a "clear and convincing" benefit to the public with performance that would earn a "D" on most A-to-F grading scales.

And the monopoly can be allowed to continue even with a score that most would consider an "F."

"It's an extreme disservice to the people of northeast Tennessee and southwest Virginia," said Dani Cook, who has organized protests against Ballad's monopoly for years. "We shouldn't have lowered the bar. We should be raising the bar."

The Ballad monopoly, which encompasses 20 hospitals and straddles the border of Tennessee and Virginia, was created in 2018 after lawmakers in both states, in an effort to prevent hospital closures, waived federal antitrust laws so two rival health systems could merge. Although Ballad has largely succeeded at keeping its hospitals open, staffing shortages and patient complaints have left some residents wary, afraid, or unwilling to seek care at Ballad hospitals, according to an investigation by KFF Health News published last year.

In Tennessee, the Ballad monopoly is regulated through a 10-year Certificate of Public Advantage agreement, or COPA — now in its seventh year — that establishes the state's goals and a scoring rubric for hospital performance. Tennessee Department of Health documents show Ballad has fallen short of about three-fourths of the state's quality-of-care goals over the past four fiscal years. But the monopoly has been allowed to continue, at least in part, because the scoring rubric doesn't prioritize quality of care, according to the documents.

Angie Odom, a county commissioner in Tennessee's Carter County, where leaders have clashed with Ballad, said she has driven her 12-year-old daughter more than 100 miles to Knoxville to avoid surgery at a Ballad hospital.

After years of disappointment in Tennessee's oversight of the monopoly, Odom said she was "not surprised" by Ballad's new grading scale.

"They've made a way that they can fail and still pass," she said.

Virginia regulates Ballad with a different agreement and scoring method, and its reviews generally track about one or two years behind Tennessee's. Both states have found Ballad to be an overall benefit in every year they've released a decision.

Neither Ballad Health nor the Tennessee Department of Health, which has the most direct oversight of the monopoly, answered questions submitted in writing about the renegotiated agreement. In an emailed statement, Molly Luton, a Ballad spokesperson, said the company's quality of care has steadily improved in recent years, and she raised repeated complaints from the hospital system about KFF Health News' reporting. The news organization has reviewed every complaint from Ballad and has never found a correction or clarification to be warranted in the coverage.

Tennessee Health Commissioner Ralph Alvarado, who has more than once described the regulation of Ballad Health as a matter of national importance, has declined or not responded to more than a dozen interview requests from KFF Health News to discuss the monopoly.

"Our effort and progress serve as a model for health care in Tennessee, the Appalachia Region, and the entire nation," Alvarado said in a May news release about the monopoly, adding, "We do not take our role lightly as we remain committed to transparency in our COPA oversight."

Tennessee's revised agreement was negotiated behind closed doors for more than a year and announced to the public in early May. As part of that announcement, Tennessee said it wouldn't score Ballad next year, to give the company time to adjust to the new scoring process.

Under that process, the minimum score Ballad needs to meet to show a "clear and convincing" public benefit has been lowered from 85 out of 100 to 70 out of 100. The new agreement also awards Ballad up to 20 points for providing Tennessee with data and records — for example, a report on patient satisfaction — regardless of the level of performance documented. The state can also raise or lower Ballad's overall score by up to 5 points in light of "reputable information" that is not spelled out in the scoring rubric.

Therefore, Ballad can score as low as 65 out of 100, with nearly a third of that score awarded for merely giving information to the state, and still be found to be a "clear and convincing" benefit to the public, which is the highest finding Tennessee can bestow, according to the agreement. And Ballad could score as low as 55 out of 100 without the monopoly facing a risk of being broken up, according to the new agreement.

The agreement also increases how much of Ballad's annual score is directly attributed to the quality of care provided in its hospitals, from 5% to 32%. But the agreement obscures how this will be measured.

Tennessee sets "baseline" goals for Ballad across dozens of quality-of-care issues — like infection rates and speed of emergency room care — and then tracks whether Ballad meets the goals. The new agreement resets these baselines to values that were not made public, leaving it unclear how much the goals for Ballad have changed. Health department spokesperson Dean Flener said the new baselines would not be disclosed until 2027.

Cook, the longtime leader of protests against Ballad, said she believes Tennessee is attempting to silence data-supported criticism until the final year of the 10-year COPA agreement, which ends in 2028.

By then, any outrage would be largely moot, she said.

"If you are going to wait until the last year to tell us the new measurements, why bother?" Cook said. "It is clear, without a shadow of a doubt, that the Tennessee Department of Health is putting the needs and concerns of a corporation above the health and well-being of people."

Brett Kelman: bkelman@kff.org, @BrettKelman

RFK Jr. Says Healthy Pregnant Women Don't Need COVID Boosters. What the Science Says.

KFF Health News, June 2, 2025

Pregnant women who contracted COVID-19 were more likely to become severely ill and to be hospitalized than non-pregnant women.

This article was published on Monday, June 2, 2025 in KFF Health News.

By Jackie Fortiér

You're pregnant, healthy, and hearing mixed messages: Health and Human Services Secretary Robert F. Kennedy Jr., who is not a scientist or doctor, says you don't need the COVID vaccine, but experts at the Centers for Disease Control and Protection still put you in a high-risk group of people who ought to receive boosters. The science is on the side of the shots.

Pregnant women who contracted COVID-19 were more likely to become severely ill and to be hospitalized than non-pregnant women of the same age and demographics, especially early in the COVID pandemic.

A meta-analysis of 435 studies found that pregnant and recently pregnant women who were infected with the virus that causes COVID were more likely to end up in intensive care units, be on invasive ventilation, and die than women who weren't pregnant but had a similar health profile. This was before COVID vaccines were available.

Neil Silverman, a professor of clinical obstetrics and gynecology and the director of the Infectious Diseases in Pregnancy Program at the David Geffen School of Medicine at UCLA, said he still sees more bad outcomes in pregnant patients who have COVID. The risk of severe COVID fluctuated as new variants arose and vaccinations became available, Silverman said, but the threat is still meaningful. "No matter what the politics say, the science is the science, and we know that, objectively, pregnant patients are at substantially increased risk of having complications," Silverman said.

A request for comment regarding the scientific literature that supports COVID vaccination for pregnant women sent to HHS' public affairs office elicited an unsigned email unrelated to the question. The office did not respond when asked for an on-the-record comment.

Kennedy, a longtime anti-vaccine activist before joining the Trump administration, announced May 27 that COVID vaccines would be removed from the CDC's immunization schedule for healthy pregnant women and healthy children. His announcement, made in a video posted on the social media platform X, blindsided CDC officials and circumvented the agency's established, scientific processes for adding and removing shots from its recommended schedules, The Washington Post reported.

There's still much unknown about how COVID affects a pregnant person. The physiological relationship between COVID infections and mothers and fetuses at different stages of a pregnancy is complex, said Angela Rasmussen, a virologist at the University of Saskatchewan.

The increased risk to pregnant patients comes in part because pregnancy changes the immune system, Rasmussen said.

"There is natural immune suppression so that the mother's body doesn't attack the developing fetus," Rasmussen said. "While the mother does still have a functioning immune system, it's not functioning at full capacity."

Pregnant patients are more likely to get sick and have a harder time fighting off any infection as a result.

In addition to changing how the immune system works, being pregnant also makes women five times as likely to have blood clots. That risk is increased if they contract COVID, said Sallie Permar, chair of pediatrics at Weill Cornell Medicine.

The virus that causes COVID can affect the vascular endothelium — specialized cells that line blood vessels and help with blood flow, Rasmussen said. In a healthy person, the endothelium helps prevent blood clots by producing chemicals that tweak the vascular system to keep it running. In a person infected with the COVID virus, the balance is thrown off and the production of those molecules is disrupted, which research shows can lead to blood clots or other blood disorders.

Permar said that those clots can be especially dangerous to both pregnant women and fetuses. Inflammation and blood clots in the placenta could be connected to an increased risk of stillbirth, especially from certain COVID variants, according to studies published in major medical journals as well as by the CDC.

When the placenta is inflamed, it's harder for blood carrying oxygen and nutrients to get to the developing baby, said Mary Prahl, an associate professor of pediatrics at the University of California-San Francisco School of Medicine.

"If anything is interrupting those functions — inflammation or clotting or differences in how the blood is flowing — that's really going to affect how the placenta is working and being able to allow the fetus to grow and develop appropriately," she said.

It makes sense that we see the effects of COVID in the placenta, Silverman said. "The placenta is nothing more than a hyper-specialized collection of blood vessels, so it is like a magnetic target for the virus."

Blood vessels in the placenta are smaller and may clot more easily than in the mother's circulatory system, he said.

Permar said recent data suggests that pregnant women sick with COVID still have a higher risk of pregnancy complications such as preeclampsia, preterm birth, and miscarriage, even with existing immunity from previous infection or vaccination. COVID, she said, can still land women in the hospital with pregnancy complications.

Prahl said the connection between stillbirth and COVID may be changing given the immunity many people have developed from vaccination or prior infection. It's an area in which she'd like to see more research.

There's already strong evidence that both mRNA-based and non-mRNA COVID vaccines are safe for pregnant women.

Prahl co-authored a small, early study that found no adverse outcomes and showed antibody protection persisted for both the mother and the baby after birth. "What we learned very quickly is that pregnant individuals want answers and many of them want to be involved in research," she said. Later studies, including one published in the journal Nature Medicine showing that getting a booster in pregnancy cut newborn hospitalizations in the first four months of life, backed up her team's findings.

Prahl expects more evidence will be available soon to support the benefits of mothers receiving a COVID booster during pregnancy.

"I can say, kind of behind the scenes, I'm seeing a lot of this preliminary data," she said.

She blames the delay in part on the Biden administration's scaling back of federal efforts to track COVID. "A lot of the surveillance of these data were pulled back," she said. The Trump administration is further cutting money used to track COVID.

But because the vaccines give a pregnant woman's immune system a boost by increasing neutralizing antibodies, virologist Rasmussen is confident that getting one while pregnant makes it less likely a pregnant woman will end up in the hospital if she gets COVID.

"It will protect the pregnant person from more severe disease," she said.

Getting a COVID vaccine while pregnant also helps protect newborns after birth. Pregnant women who get vaccinated pass that protection to their young babies, who can't get their own shots until they are at least 6 months old.

According to data released by the CDC in 2024, nearly 90% of babies who had to be hospitalized with COVID had mothers who didn't get the vaccine while they were pregnant.

As recently as April 2024, research showed that babies too young to be vaccinated had the highest COVID hospitalization rate of any age group except people 75 and older.

The Trump administration's decision to remove the COVID vaccine from the list of shots it recommends for pregnant women means insurance companies might no longer cover it. Pregnant women who want to get it anyway may have to pay hundreds of dollars out-of-pocket.

"I don't want to be that doctor who just says, ‘Well, it's really important. You have to vaccinate yourself and your kids no matter what, even if you have to pay for it out-of-pocket,' because everyone has their own priorities and budgetary concerns, especially in the current economic climate," Silverman said. "I can't tell a family that the vaccine is more important than feeding their kids."

But he and his colleagues will keep advising pregnant women to try to get the shots anyway.

"Newborns will be completely naive to COVID exposure," he said. "Vaccinating pregnant women to protect their newborns is still a valid reason to continue this effort."

Jackie Fortiér: jfortier@kff.org, @JackieFortier

U.S. Docs Are Moving to Canada to Escape the Trump Administration

KFF Health News, May 30, 2025

The number of U.S. doctors taking 'the first step' to being licensed in Canada has increased more than 750%.

This article was published on Friday, May 30, 2025 in KFF Health News.

By Brett Kelman

Earlier this year, as President Donald Trump was beginning to reshape the American government, Michael, an emergency room doctor who was born, raised, and trained in the United States, packed up his family and got out.

Michael now works in a small-town hospital in Canada. KFF Health News and NPR granted him anonymity because of fears he might face reprisal from the Trump administration if he returns to the U.S. He said he feels some guilt that he did not stay to resist the Trump agenda but is assured in his decision to leave. Too much of America has simply grown too comfortable with violence and cruelty, he said.

"Part of being a physician is being kind to people who are in their weakest place," Michael said. "And I feel like our country is devolving to really step on people who are weak and vulnerable."

Michael is among a new wave of doctors who are leaving the United States to escape the Trump administration. In the months since Trump was reelected and returned to the White House, American doctors have shown skyrocketing interest in becoming licensed in Canada, where dozens more than normal have already been cleared to practice, according to Canadian licensing officials and recruiting businesses.

The Medical Council of Canada said in an email statement that the number of American doctors creating accounts on physiciansapply.ca, which is "typically the first step" to being licensed in Canada, has increased more than 750% over the past seven months compared with the same time period last year — from 71 applicants to 615. Separately, medical licensing organizations in Canada's most populous provinces reported a rise in Americans either applying for or receiving Canadian licenses, with at least some doctors disclosing they were moving specifically because of Trump.

"The doctors that we are talking to are embarrassed to say they're Americans," said John Philpott, CEO of CanAm Physician Recruiting, which recruits doctors into Canada. "They state that right out of the gate: 'I have to leave this country. It is not what it used to be.'"

Canada, which has universal publicly funded health care, has long been an option for U.S.-trained doctors seeking an alternative to the American health care system. While it was once more difficult for American doctors to practice in Canada due to discrepancies in medical education standards, Canadian provinces have relaxed some licensing regulations in recent years, and some are expediting licensing for U.S.-trained physicians.

In mere months, the Trump administration has jeopardized the economy with tariffs, ignored court orders and due process, and threatened the sovereignty of U.S. allies, including Canada. The administration has also taken steps that may unnerve doctors specifically, including appointing Robert F. Kennedy Jr. to lead federal health agencies, shifting money away from pandemic preparedness, discouraging gender-affirming care, demonizing fluoride, and supporting deep cuts to Medicaid.

The Trump administration did not provide any comment for this article. When asked to respond to doctors' leaving the U.S. for Canada, White House spokesperson Kush Desai asked whether KFF Health News knew the precise number of doctors and their "citizenship status," then provided no further comment. KFF Health News did not have or provide this information.

Philpott, who founded CanAm Physician Recruiting in the 1990s, said the cross-border movement of American and Canadian doctors has for decades ebbed and flowed in reaction to political and economic fluctuations, but that the pull toward Canada has never been as strong as now.

Philpott said CanAm had seen a 65% increase in American doctors looking for Canadian jobs from January to April, and that the company has been contacted by as many as 15 American doctors a day.

Rohini Patel, a CanAm recruiter and doctor, said some consider pay cuts to move quickly.

"They're ready to move to Canada tomorrow," she said. "They are not concerned about what their income is."

The College of Physicians and Surgeons of Ontario, which handles licensing in Canada's most populous province, said in a statement that it registered 116 U.S.-trained doctors in the first quarter of 2025 — an increase of at least 50% over the prior two quarters. Ontario also received license applications from about 260 U.S.-trained doctors in the first quarter of this year, the organization said.

British Columbia, another populous province, saw a surge of licensure applications from U.S.-trained doctors after Election Day, according to an email statement from the College of Physicians and Surgeons of British Columbia. The statement also said the organization licensed 28 such doctors in the fiscal year that ended in February — triple the total of the prior year.

Quebec's College of Physicians said applications from U.S.-trained doctors have increased, along with the number of Canadian doctors returning from America to practice within the province, but it did not provide specifics. In a statement, the organization said some applicants were trying to get permitted to practice in Canada "specifically because of the actual presidential administration."

Michael, the physician who moved to Canada this year, said he had long been wary of what he described as escalating right-ring political rhetoric and unchecked gun violence in the United States, the latter of which he witnessed firsthand during a decade working in American emergency rooms.

Michael said he began considering the move as Trump was running for reelection in 2020. His breaking point came on Jan. 6, 2021, when a violent mob of Trump supporters besieged the U.S. Capitol in an attempt to stop the certification of the election of Joe Biden as president.

"Civil discourse was falling apart," he said. "I had a conversation with my family about how Biden was going to be a one-term president and we were still headed in a direction of being increasingly radicalized toward the right and an acceptance of vigilantism."

It then took about a year for Michael to become licensed in Canada, then longer for him to finalize his job and move, he said. While the licensing process was "not difficult," he said, it did require him to obtain certified documents from his medical school and residency program.

"The process wasn't any harder than getting your first license in the United States, which is also very bureaucratic," Michael said. "The difference is, I think most people practicing in the U.S. have got so much administrative fatigue that they don't want to go through that process again."

Michael said he now receives near-daily emails or texts from American doctors who are seeking advice about moving to Canada.

This desire to leave has also been striking to Hippocratic Adventures, a small business that helps American doctors practice medicine in other countries.

The company was co-founded by Ashwini Bapat, a Yale-educated doctor who moved to Portugal in 2020 in part because she was "terrified that Trump would win again." For years, Hippocratic Adventures catered to physicians with wanderlust, guiding them through the bureaucracy of getting licensed in foreign nations or conducting telemedicine from afar, Bapat said.

But after Trump was reelected, customers were no longer seeking grand travels across the globe, Bapat said. Now they were searching for the nearest emergency exit, she said.

"Previously it had been about adventure," Bapat said. "But the biggest spike that we saw, for sure, hands down, was when Trump won reelection in November. And then Inauguration Day. And basically every single day since then."

At least one Canadian province is actively marketing itself to American doctors.

Doctors Manitoba, which represents physicians in the rural province that struggles with one of Canada's worst doctor shortages, launched a recruiting campaign after the election to capitalize on Trump and the rise of far-right politics in the U.S.

The campaign focuses on Florida and North and South Dakota and advertises "zero political interference in physician patient relationship" as a selling point.

Alison Carleton, a family medicine doctor who moved from Iowa to Manitoba in 2017, said she left to escape the daily grind of America's for-profit healthcare system and because she was appalled that Trump was elected the first time.

Carleton said she now runs a small-town clinic with low stress, less paperwork, and no fear of burying her patients in medical debt.

She dropped her American citizenship last year.

"People I know have said, 'You left just in time,'" Carleton said. "I tell people, 'I know. When are you going to move?'"

Brett Kelman: bkelman@kff.org, @BrettKelman

Oona Zenda: ozenda@kff.org

Bill of the Month: A Medicaid Patient Had a Heart Attack While Traveling. He Owed Almost $78K.

KFF Health News, May 29, 2025

A South Dakota hospital refused to bill to a Florida Medicaid plan, instead sending it to the patient with a threat to call a debt collector.

This article was published on Thursday, May 29, 2025 in KFF Health News.

By Arielle Zionts

On Christmas Day at the WaTiki indoor water park, Hans Wirt was getting winded from following his son up the stairs to the waterslides.

Wirt's breathing became more labored once they returned to the nearby hotel where they and Wirt's girlfriend were staying while visiting family in Rapid City, South Dakota.

Then he grew nauseated and went pale. Wirt thought the cause might have been the altitude change between his home in Deltona, Florida — 33 feet above sea level — and Rapid City, at the edge of the Black Hills. But his 12-year-old son was worried and called for an ambulance.

"I could tell by the look in his eyes that there was something a little more to this," Wirt said. "So I can kind of thank my son for saving my life."

It turned out the 62-year-old was having a heart attack. A "lousy Christmas present," Wirt said.

Medics stabilized Wirt before taking him to Monument Health — the only hospital in Rapid City with an emergency room — where he was treated over two days.

Then the bill came.

The Medical Procedure

Paramedics used a defibrillator to restore a normal heart rhythm. Doctors at the hospital gave Wirt various medications, used an electrocardiograph and other diagnostic and monitoring devices, and inserted stents into his arteries to improve blood flow to his heart.

The Final Bill

$95,523.73, including $32,998.90 for medical supplies, mostly related to the stents, and $28,879 for treatment in a cardiac catheterization lab. After unspecified hospital adjustments to the bill, Wirt owed $77,574.44.

The Billing Problem: Medicaid Across State Lines

Wirt is covered by Florida's Medicaid program through Sunshine Health, a managed-care plan. But the South Dakota hospital refused to submit the bill to his out-of-state Medicaid plan, instead sending it to Wirt and eventually threatening to send the debt to a collection agency.

Medicaid, the government health insurance program primarily for low-income people and those with disabilities, is jointly funded by the federal government and states. States are responsible for administering Medicaid, and most contract with private insurance companies like Sunshine Health.

Federal law says state Medicaid programs must reimburse out-of-state hospitals for beneficiaries' care in an emergency.

Many hospitals bill out-of-state Medicaid plans in such situations. If they don't, they risk not being reimbursed at all, since Medicaid recipients probably won't be able to afford large bills, said Katy DeBriere, who was legal director for the Florida Health Justice Project when she spoke with KFF Health News in April.

But there's no federal law that requires them to do so, she said.

Federal court opinions have noted that hospitals are not required to bill Medicaid for every individual beneficiary they treat, even if they generally accept Medicaid.

Monument Health didn't bill Wirt's insurance because the hospital isn't enrolled as a healthcare provider with Florida Medicaid, said hospital spokesperson Stephany Chalberg. She told KFF Health News that Monument bills Medicaid plans only in South Dakota and four bordering states: Wyoming, Montana, Nebraska, and Minnesota.

The hospital's website says Medicaid patients who are not enrolled in one of those states "are responsible for any charges."

"Due to the significant credentialing requirements of our multiple hospitals and hundreds of physicians we do not participate with all states," a hospital representative wrote in a message to Wirt.

According to Florida's Medicaid website, out-of-state providers who have treated one of its enrollees must submit five documents to bill the program, including a six-page application, a copy of the provider's license, and a claim form.

The process is different in each state, and many Medicaid programs reimburse out-of-state providers at lower rates than those that are in-state, according to the Medicaid and CHIP Payment and Access Commission, a federal agency that advises Congress.

Provider enrollment barriers leave "beneficiaries in an untenable situation, preventing them from accessing the coverage to which they are legally entitled," Chalberg said.

Wirt decided to submit his bill to his Medicaid plan on his own. But he said Sunshine Health told him it can only process bills received directly from providers.

Elizabeth Boyd, a spokesperson for Sunshine Health, told KFF Health News that its staff contacted the hospital on Wirt's behalf. She did not respond when asked why the plan can't process bills submitted by patients or what more it could have done to help Wirt.

The Resolution

A few days after KFF Health News emailed officials at Monument Health for this story, Wirt noticed his balance due fell from more than $77,000 to $0.

Chalberg told KFF Health News that Monument Health covered Wirt's bill through its charity care program. She said that "appropriate patients" are told about the program and that "before any bill is sent to collections, it is evaluated to determine whether the patient may qualify for our financial assistance policy."

To retain tax-exempt status, nonprofit hospitals must have programs that provide free or discounted care to patients who can't afford their bills.

But Wirt said that when he first contacted Monument Health after receiving his bill and said he couldn't afford to pay it, officials didn't mention the program. He said they didn't share any resources when he asked whether there were outside groups that could help him pay the bill. Wirt said hospital officials just recommended setting up a payment plan, but the monthly bills were still too high for him to afford. "There's a reason why I'm on Medicaid," Wirt said. "It's just beyond me how they can expect somebody who had Medicaid to come up with that kind of money. It's unrealistic."

The Takeaway

Sarah Somers, legal director at the National Health Law Program, said the various "cogs in the Medicaid system" didn't operate correctly in Wirt's situation. "Nobody's exerting themselves enough to just smooth the way for this person."

States are responsible for managing Medicaid and are therefore the main "cog," Somers said. She said Medicaid managed-care companies are also supposed to intervene.

Somers and DeBriere said Medicaid recipients who receive bills they don't think they owe should file a complaint with their state's Medicaid program and, if they have one, their managed-care plan. They can also ask whether there is a Medicaid or managed-care caseworker who can advocate on their behalf.

The attorneys said patients should also contact a legal aid clinic or a consumer protection firm that specializes in medical debt. DeBriere said those organizations can help file complaints and communicate with the hospital.

DeBriere said that, had she assisted Wirt, she would have immediately sent a letter to Monument Health ordering it to stop billing him and to either register with Florida Medicaid to submit his bill or offer him charity care.

Wirt said the doctors who treated him and the medical care he received at Monument Health were excellent. He said he spoke out about the hospital's billing practices because he doesn't want others to endure the same experience.

"If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state," he joked.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post's Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

Arielle Zionts: azionts@kff.org, @Ajzionts

Language Service Cutbacks Raise Fear of Medical Errors, Misdiagnoses, Deaths

KFF Health News, May 29, 2025

Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. 

This article was published on Thursday, May 29, 2025 in KFF Health News.

By Vanessa G. Sánchez and Jazmin Orozco Rodriguez

SAN FRANCISCO — Health nonprofits and medical interpreters warn that federal cuts have eliminated dozens of positions in California for community workers who help non-English speakers sign up for insurance coverage and navigate the healthcare system.

At the same time, people with limited English proficiency have scaled back their requests for language services, which healthcare advocates attribute in part to President Donald Trump's immigration crackdown and his executive order declaring English as the national language.

Such policy and funding changes could leave some without lifesaving care, particularly children and seniors. "People are going to have a hard time accessing benefits they're entitled to and need to live independently," said Carol Wong, a senior rights attorney for Justice in Aging, a national advocacy group.

Nearly 69 million people in the U.S. speak a language other than English, and 26 million of them speak English less than "very well," according to the most recent U.S. Census data available, from 2023. A KFF-Los Angeles Times survey from that year found that immigrants with limited English proficiency reported more barriers accessing healthcare and worse health than English-proficient immigrants.

Health advocates fear that, without adequate support, millions of people in the U.S. with limited English proficiency will be more likely to experience medical errors, misdiagnosis, neglect, and other adverse outcomes. During the start of the pandemic in 2020, ProPublica reported that a woman with coronavirus symptoms died in Brooklyn after missing out on timely treatment because emergency room staffers could not communicate with her in Hungarian. And, at the height of the crisis, The Virginian-Pilot first reported that a Spanish translation on a state website erroneously stated that the covid-19 vaccine was not necessary.

In 2000, President Bill Clinton signed an executive order aimed at improving access to federal services for people with limited English proficiency. Research shows language assistance results in higher patient satisfaction, as well as fewer medical errors, misdiagnoses, and adverse health outcomes. Language services also save the healthcare system money by reducing hospital stays and readmissions.

Trump's order repealed Clinton's directive and left it up to each federal agency to decide whether to maintain or adopt a new language policy. Some have already scaled back: The Department of Homeland Security and the Social Security Administration reportedly reduced language services, and the Justice Department says it is reviewing guidance materials. A link to its language plan is broken.

It's unclear what the Department of Health and Human Services intends to do. HHS did not respond to questions from KFF Health News.

An HHS plan implemented under President Joe Biden, including guidance during public health emergencies and disasters, has been archived, meaning it may not reflect current policies. However, HHS's Office for Civil Rights still informs patients of their right to language assistance services when they pick up a prescription, apply for a health insurance plan, or visit a doctor.

And the office added protections in July that prohibit health providers from using untrained staff, family members, or children to provide interpretation during medical visits. It also required that translation of sensitive information using artificial intelligence be reviewed by a qualified human translator for accuracy.

Those safeguards could be undone by the Trump administration, said Mara Youdelman, a managing director at the National Health Law Program, a national legal and health policy advocacy organization. "There's a process that needs to be followed," she said, about making changes with public input. "I would strongly urge them to consider the dire consequences when people don't have effective communication."

Even if the federal government ultimately doesn't offer language services for the public, Youdelman said, hospitals and health providers are required to provide language assistance at no charge to patients.

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race or national origin, protections that extend to language. And the 2010 Affordable Care Act, which expanded health coverage for millions of Americans and adopted numerous consumer protections, requires health providers receiving federal funds to make language services, including translation and interpretation, available. 

"English can be the official language and people still have a right to get language services when they go to access healthcare," Youdelman said. "Nothing in the executive order changed the actual law."

Insurers still need to include multi-language taglines in their correspondence to enrollees explaining how they can access language services. And health facilities must post visible notices informing patients about language assistance services and guarantee certified and qualified interpreters.

State and local governments could broaden their own language access requirements. A few states have taken such actions in recent years, and California state lawmakers are considering a bill that would establish a language access director, mandate human review of AI translations, and improve surveys assessing language needs.

"With increasing uncertainty at the federal level, state and local access laws and policies are even more consequential," said Jake Hofstetter, policy analyst at the Migration Policy Institute.

The Los Angeles Department of Public Health and San Francisco's Office of Civic Engagement and Immigrants Affairs said their language services have not been affected by Trump's executive order or federal funding cuts.

Demand, however, has dropped. Aurora Pedro of Comunidades Indígenas en Liderazgo, one of the few medical interpreters in Los Angeles who speaks Akatek and Qʼanjobʼal, Mayan languages from Guatemala, said she has received fewer calls for her services since Trump took office.  

And other pockets of California have reduced language services because of the federal funding cuts. 

Hernán Treviño, a spokesperson for the Fresno County Department of Public Health, said the county cut the number of community health workers by more than half, from 49 to 20 positions. That reduced the availability of on-the-ground navigators who speak Spanish, Hmong, or Indigenous languages from Latin America and help immigrants enroll in health plans and schedule routine screenings.

Treviño said staffers are still available to support residents in Spanish, Hmong, Lao, and Punjabi at county offices. A free phone line is also available to help residents access services in their preferred language.

Mary Anne Foo, executive director of the Orange County Asian and Pacific Islander Community Alliance, said the federal Substance Abuse and Mental Health Services Administration froze $394,000 left in a two-year contract to improve mental health services. As a result, the alliance is planning to let go 27 of its 62 bilingual therapists, psychiatrists, and case managers. The organization serves more than 80,000 patients who speak over 20 languages.

"We can only keep them through June 30," Foo said. "We're still trying to figure it out — if we can cover people."

Orozco Rodriguez reported from Elko, Nevada.

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

Jazmin Orozco Rodriguez: jorozco@kff.org, @jazmin1orozco

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