For more than two decades, the community health worker has supported hundreds of families throughout southeast Los Angeles by helping them sign up for food assistance, sharing information about affordable health coverage, and managing medications for their chronic illnesses. She’s guided by the expression “an ounce of prevention is worth a pound of cure.”

But she makes only around $20 an hour from a community health organization and must hold down a second job to make ends meet. “They pay us very little and expect too much,” she said in Spanish. “We build trust. We offer support. We’re the shoulder people rely on, but we don’t get fair wages.”

California looked to professionalize thousands of community health workers such as Hernández to improve the health of immigrant populations, particularly Hispanic residents, who often experience of chronic diseases, are more , and face more cultural and linguistic barriers when trying to access services. Studies show their work hospitalizations as well as emergency room and urgent care visits.

The state hewed closely to a series of put out in 2019 to standardize training and certification, integrate these workers into the health care workforce, and provide fair wages, including reimbursements through Medi-Cal, the state’s Medicaid health insurance program, to compensate for work that traditionally has been done on a volunteer basis or for low pay. But six years in, California has backed out of many of those initiatives.

The state has eliminated a certification program and rolled back nearly all funding to train and expand this workforce even though it set a goal of by this year. Although Medi-Cal began covering their services, participating health plans set uneven billing requirements, making it difficult for workers to get reimbursed. And the state didn’t follow through on a planned pay raise.

With federal funding cuts just passed and President Donald Trump targeting immigrants for deportation — even with the Department of Homeland Security — advocates fear California is abandoning its health equity initiative for immigrants, people of color, and people with low incomes when they say that effort is needed most.

“We’re in a very dire situation right now,” said Cary Sanders, senior policy director for the California Pan-Ethnic Health Network, a statewide health equity advocacy group.

A spokesperson for Gov. Gavin Newsom, Elana Ross, said “the state has taken difficult but necessary steps to ensure fiscal stability” and that the administration continues to have a dialogue with community health workers. Ross added that the Democratic governor, a , remains committed to defending immigrants being targeted by the Trump administration.

‘Our Office Is on the Street’

There are more than 60,000 community health workers nationwide, including roughly 9,200 in California, and this workforce is projected to grow 13% over the next decade, three times as fast as for all occupations, according to from the U.S Bureau of Labor Statistics. But experts say these numbers are an undercount given the various titles community health workers hold and that many work outside of health care and governmental institutions.

Community health worker is an umbrella term that includes peer supporters and community health representatives. These workers, often known as promotores, who work in clinics, hospitals, public health departments, and local nonprofits, places where they are trusted and have a grasp of their community’s most pressing health needs.

Besides helping people manage chronic illnesses such as heart disease and diabetes, they promote reproductive health, children’s health, and oral hygiene, and they help prevent injuries and review medications. They can make people feel safe when reporting domestic violence and other abuses. They also connect people to housing and food assistance. “The community health worker is not sitting at a desk,” Hernández said. “Our office is on the street.”

Back in 2019, the California Future Health Workforce Commission recommended integrating community health workers into the health care system, and in 2022, the state authorized over three years for the California Department of Health Care Access and Information, which oversees health care workforce development, to recruit, train, and certify them.

The agency sought to standardize training and certification, but some community groups feared that would create barriers to entry by not giving enough credit for lived experiences and cultural competency. But just as the agency offered more flexibility and allowed community-based training, the state slashed $250 million in funding last year due to budget constraints. This year, the certification program was officially eliminated.

Spokesperson Andrew DiLuccia said the agency is now considering a program to accredit community organizations rather than individual workers and plans to spend its remaining $12 million on technical assistance, workforce development, and salaries for those working with immigrant communities.

According to the National Academy for State Health Policy, offer a voluntary or mandatory community health worker certification program.

Some community health advocates say California’s missing an opportunity to carve a career path for this workforce. Currently, some courses offered by nonprofits, counties, and colleges , a degree, English fluency, or prior experience. Most are concentrated in the San Francisco or Los Angeles area, leaving in much of the state.

Lourdes Bernis, a dentist from Ecuador, is a model for how community health workers could be integrated into the health care system. She began as a volunteer promotora more than a decade ago and in 2019 received free training from Los Angeles County, allowing her to move into a full-time job with benefits for the county’s Department of Mental Health to help Spanish-speaking women manage depression and anxiety as they recover from drug use.

Bernis now plans to become a peer-to-peer support specialist inside hospitals and clinics. Meanwhile, many of her colleagues with decades of experience remain stuck in low-paying roles and can’t afford training to advance. “There are promotoras who have 20 to 25 years of experience, but they are still volunteering,” Bernis said in Spanish.

Medi-Cal’s Role

To pay community health workers, Medi-Cal began covering their services in July 2022, but California for them after voters approved Proposition 35, which hiked the pay of physicians, hospitals, community clinics, and other providers instead. Since then, the state has yet to establish a uniform system for how health plans should contract with organizations that employ community health workers.

“We have to jump through hoops,” said Maria Lemus, executive director at Visión y Compromiso, a Los Angeles-based nonprofit representing community health workers. “It just causes havoc, because each plan could have different requirements.”

Lemus said it took the organization nearly six months to establish payment with one health plan.

And though Medi-Cal reimbursements are tied to individual tasks, ranging from $9.46 to $27.54 for 30 minutes of work, advocates say they aren’t fully compensated for the time they spend building trust and following up with patients. Advocates say these workers should earn at least $30 a visit, with benefits, but many earn about , often without benefits.

Advocates say they’re surprised by how infrequently these services are used in a program with 15 million Californians. More than 16,000 Medi-Cal enrollees used these services in the first year, rising to 68,000 last year, according to state data. “I don’t think it’s reached the potential that the governor talked about, and that we all imagined that it could possibly achieve,” Sanders said.

Griselda Melgoza, a spokesperson for the California Department of Health Care Services, said the agency, which administers Medi-Cal, has seen “a steady, upward trend” and believes the data underestimates utilization because the benefit is sometimes bundled with other services.

to assess whether Medi-Cal managed care plans are doing enough outreach and education to enrollees about community health services died this year.

More Crucial Than Ever

With health funding cuts from the Trump administration and passage of the GOP’s tax and spending legislation, advocates fear there will be even less funding and support for community health worker positions, shrinking a workforce tackling health disparities. Already, Fresno County’s Department of Public Health said it has cut its community health workers by more than half, from 49 positions to 20.

Yet, outreach is more crucial than ever. As the Trump administration continues immigration raids, which appear to have targeted in the state, advocates and policy researchers say community health workers could act as intermediaries for immigrant patients afraid to seek medical care in hospitals and clinics.

Without a state certification program, no raises, and dwindling training funds, the path to professionalizing community health workers is unclear, leaving workers feeling left behind.

“The community trusts me,” said Hernández, the veteran community health worker, “but at the government level, there’s still a long way to go before this work is valued and fairly compensated.”

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Durante más de dos décadas, esta trabajadora de salud comunitaria ha ayudado a cientos de familias del sureste de Los Ángeles a inscribirse en programas de ayuda alimentaria, ha informado sobre seguros médicos asequibles y ha ayudado con medicamentos para sus afecciones crónicas. Su frase favorita: “más vale prevenir que curar”.

Pero sólo gana unos $20 la hora en una organización de salud comunitaria y tiene un segundo trabajo para poder llegar a fin de mes. “Nos pagan muy poco y esperan demasiado”, dijo. “Generamos confianza. Ofrecemos apoyo. Somos el hombro en el que muchos se apoyan, pero no recibimos un salario justo”.

California buscaba profesionalizar a miles de trabajadores de salud comunitarios como Hernández. La meta era mejorar la salud de las poblaciones inmigrantes, en particular los residentes hispanos, que a menudo padecen de enfermedades crónicas, son más y se enfrentan a más barreras culturales y lingüísticas para acceder a servicios.

Estudios demuestran que su trabajo las hospitalizaciones, y las visitas a las salas de emergencias y a las clínicas de urgencias.

El estado siguió al pie de la letra una serie de publicadas en 2019 para estandarizar la formación y la certificación de estos profesionales. Así, poder integrarlos a las plantillas de trabajadores de salud y ofrecerles salarios justos, incluyendo reembolsos a través de Medi-Cal, el Medicaid estatal, para compensar el trabajo que tradicionalmente se ha realizado de forma voluntaria o con salarios bajos.

Pero seis años después, California ha dado marcha atrás en muchas de esas iniciativas.

El estado ha eliminado un programa de certificación y ha recortado casi toda la financiación para formar y ampliar esta plantilla, a pesar de que se había fijado el objetivo de contar con para este año.

Aunque Medi-Cal comenzó a cubrir sus servicios, los planes de salud participantes establecieron requisitos de facturación desiguales, lo que dificulta que los trabajadores obtengan el reembolso. Además, el estado no cumplió con el aumento salarial previsto.

Con los recortes de fondos federales recién aprobados y el foco del presidente Donald Trump en la deportación de inmigrantes, incluso con el Departamento de Seguridad Nacional, los activistas temen que California abandone su iniciativa de equidad en la salud para los inmigrantes, las personas de color y las personas con bajos ingresos. En un momento en el que, aseguran, esa labor es más necesaria que nunca.

“Estamos en una situación muy grave en este momento”, afirmó Cary Sanders, directora en la California Pan-Ethnic Health Network, una organización estatal que aboga por la equidad en la salud.

Elana Ross, vocera del gobernador Gavin Newsom, dijo que “el estado ha tomado medidas difíciles pero necesarias para garantizar la estabilidad fiscal” y que la administración sigue dialogando con los trabajadores de salud comunitarios.

Ross agregó que el gobernador demócrata, , sigue comprometido con la defensa de los inmigrantes perseguidos por la administración Trump.

“Nuestra oficina está en la calle”

Hay más de 60.000 trabajadores de salud comunitarios en todo el país, incluidos unos 9.200 en California, y se prevé que esta fuerza laboral crezca un 13% en la próxima década, tres veces más rápido que el conjunto de todas las profesiones, según de la Oficina de Estadísticas Laborales de Estados Unidos.

Sin embargo, expertos afirman que estas cifras están subvaloradas, dada la variedad de títulos que poseen estos trabajadores y el hecho de que muchos no trabajan en el cuidado de salud propiamente dicho ni en instituciones gubernamentales.

“Trabajador de salud comunitario” es un término genérico que incluye a distintos tipos de trabajadores. A menudo conocidos como promotores, que trabajan en clínicas, hospitales, departamentos de salud pública y organizaciones sin fines de lucro locales, en lugares en los que se les tiene confianza y donde conocen las necesidades más urgentes de su comunidad.

Además de ayudar a las personas a controlar afecciones crónicas como las cardiopatías y la diabetes, promueven la salud reproductiva, la salud infantil y la higiene bucal, y ayudan a a prevenir lesiones y manejar sus medicamentos.

Pueden hacer que las personas se sientan seguras al denunciar la violencia doméstica y otros abusos. También las conectan con servicios de asistencia para la vivienda y la alimentación. “El trabajador de salud comunitario no se sienta en un escritorio”, dijo Hernández. “Nuestra oficina está en la calle”.

En 2019, la California Future Health Workforce Commission recomendó integrar a estos trabajadores en el sistema de salud, y en 2022, el estado autorizó durante tres años para el Departamento de Acceso e Información de Salud de California, que supervisa el desarrollo del personal de este sector, con el fin de reclutar, formar y certificar a estos trabajadores.

La agencia trató de estandarizar la formación y la certificación, pero algunos grupos comunitarios temían que eso creara barreras de acceso al no dar suficiente crédito a la experiencia y a la competencia cultural.

Pero el año pasado, justo cuando la agencia ofrecía más flexibilidad y permitía la formación basada en el trabajo comunitario, el estado recortó $250 millones en financiación debido a restricciones presupuestarias. Este año, el programa de certificación ha sido oficialmente eliminado.

El vocero Andrew DiLuccia señaló que la agencia establecerá un programa para acreditar a las organizaciones comunitarias en lugar de a los trabajadores individuales y que tiene previsto gastar los $12 millones restantes en asistencia técnica, desarrollo de la fuerza laboral y salarios para quienes trabajan con las comunidades inmigrantes.

Según la National Academy for State Health Policy, ofrecen algún tipo de programa de certificación para trabajadores de salud comunitarios ya sea voluntario o bien obligatorio.

Algunos activistas afirman que California está perdiendo la oportunidad de establecer una trayectoria profesional para esta mano de obra. Muchos de los cursos que ofrecen hoy en día por organizaciones sin fines de lucro, condados y universidades , un título, dominio del inglés o experiencia previa. La mayoría se concentran en el área de San Francisco o Los Ángeles, lo que crea en gran parte del estado.

Lourdes Bernis, una dentista de Ecuador, es un ejemplo de cómo los trabajadores de salud comunitarios podrían integrarse en el sistema de salud. Comenzó como promotora voluntaria hace más de una década y en 2019 recibió formación gratuita del condado de Los Ángeles, lo que le permitió conseguir un trabajo a tiempo completo, con beneficios, en el Departamento de Salud Mental del condado para ayudar a mujeres hispanohablantes a gestionar la depresión y la ansiedad mientras se recuperan del consumo de drogas.

Bernis ahora quiere convertirse en especialista de apoyo entre pares en hospitales y clínicas. Mientras tanto, muchos de sus colegas con décadas de experiencia siguen atrapados en puestos mal pagados y no pueden permitirse costear cursos de formación para avanzar. “Hay promotoras que tienen entre 20 y 25 años de experiencia, pero siguen trabajando como voluntarias”, dijo Bernis.

El papel de Medi-Cal

Para pagar a los trabajadores de salud comunitarios, Medi-Cal comenzó a cubrir sus servicios en julio de 2022, pero California previsto para ellos después que los votantes aprobaran la Proposición 35, que aumentaba los pagos a médicos, hospitales, clínicas comunitarias y otros proveedores.

Desde entonces, el estado aún no ha establecido un sistema uniforme sobre cómo los planes de salud deben contratar a las organizaciones que emplean a trabajadores de salud comunitarios.

“Tenemos que hacer malabares”, dijo María Lemus, directora ejecutiva de Visión y Compromiso, una organización sin fines de lucro con sede en Los Ángeles que representa a estos trabajadores. “Esto sólo causa caos, porque cada plan puede tener requisitos diferentes”.

Lemus agregó que la organización tardó casi seis meses en establecer el pago con un plan de salud.

Y aunque los reembolsos de Medi-Cal están vinculados a tareas individuales, que oscilan entre $9.46 y $27.54 por 30 minutos de trabajo, los activistas afirman que no se les compensa totalmente por el tiempo que dedican a ganarse la confianza de los pacientes y a hacer seguimiento.

Según los activistas, estos trabajadores deberían ganar al menos $30 por visita, con beneficios, pero muchos ganan unos $21 la hora, a menudo sin beneficios.

Lo que sorprende a los activistas es la poca frecuencia con la que se utilizan estos servicios en un programa que cuenta con 15 millones de californianos. Más de 16,000 afiliados a Medi-Cal utilizaron estos servicios durante el primer año, cifra que aumentó a 68,000 el año pasado, según datos del estado. “No creo que se haya alcanzado el potencial del que hablaba el gobernador y que todos imaginábamos que se podría alcanzar”, señaló Sanders.

Griselda Melgoza, vocera del Departamento de Servicios de Salud de California, dijo que la agencia, que administra Medi-Cal, ha observado “una tendencia constante al alza” y cree que los datos subestiman la utilización porque este beneficio a veces se incluye en otros servicios.

Este año se rechazó una para evaluar si los planes de atención médica gestionada de Medi-Cal realizan la divulgación y educación suficiente entre los afiliados sobre los servicios de salud comunitarios.

Más crucial que nunca

Con los recortes a la financiación de la salud por parte de la administración Trump y la aprobación de la legislación fiscal y de gasto del Partido Republicano, los activistas temen que haya aún menos fondos y apoyo para estos puestos, lo que reduciría las plantillas que se ocupan de las desigualdades en materia de salud.

El Departamento de Salud Pública del condado de Fresno ya ha anunciado el recorte de más de la mitad de sus trabajadores comunitarios: pasarán de 49 puestos a 20.

Sin embargo, la divulgación es más crucial que nunca. Mientras la administración Trump continúa con las redadas de inmigración, que parecen haber tenido como objetivo en el estado, los activistas y los investigadores advierten que los trabajadores de salud comunitarios podrían actuar como intermediarios para los pacientes inmigrantes que temen buscar atención médica en hospitales y clínicas.

Sin un programa de certificación estatal, sin aumentos salariales y con fondos de capacitación cada vez más escasos, el camino hacia la profesionalización es incierto, lo que hace que esta fuerza laboral se sienta abandonada.

“La comunidad confía en mí”, afirmó Hernández, una veterana trabajadora de salud comunitaria, “pero a nivel gubernamental aún queda mucho camino por recorrer antes de que este trabajo sea valorado y pagado como se merece”.

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Patients need to communicate clearly with their health care provider. But that’s getting more difficult for those in the U.S. who don’t speak English.Ìý

Budget cuts by the Trump administration have left some providers scrambling to keep qualified medical interpreters. And an executive order designating English the official language of the United States has created confusion among providers about what services should be offered.Ìý

Patients who don’t speak English are left afraid, and perhaps at risk for medical mistakes. What happens when those who need help are too frightened to ask?Ìý

In WAMU’s July 9 “Health Hub” segment, Â鶹ŮÓÅ Health News correspondent Vanessa G. Sánchez explained why health advocates worry these changes could lead to worse patient outcomes.Ìý

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

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At the same time, people with limited English proficiency have scaled back their requests for language services, which health care advocates attribute in part to President Donald Trump’s immigration crackdown and his 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 available, from 2023. A from that year found that immigrants with limited English proficiency reported more barriers accessing health care 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, 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, that on a state website erroneously stated that the covid-19 vaccine was not necessary.

In 2000, President Bill Clinton signed an aimed at improving access to federal services for people with limited English proficiency. Research shows language assistance results in higher , as well as , misdiagnoses, and adverse health outcomes. Language services also 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 and the reportedly reduced language services, and the Justice Department says it is . A is broken.

It’s unclear what the Department of Health and Human Services intends to do. HHS did not respond to questions from Â鶹ŮÓÅ Health News.

implemented under President Joe Biden, during public health emergencies and disasters, has been archived, meaning it may not reflect current policies. However, HHS’s 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 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.Ìý

“English can be the official language and people still have a right to get language services when they go to access health care,” 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 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 Qʼ²¹²ÔÂá´Ç²úʼ²¹±ô, Mayan languages from Guatemala, said she has received fewer calls for her services since Trump took office. Ìý

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

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.

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Al mismo tiempo, las personas con dominio limitado del inglés están pidiendo menos servicios lingüísticos, lo que los defensores de la atención de salud atribuyen en parte a la ofensiva migratoria del presidente Donald Trump y a su declarando al inglés como idioma nacional.

Estos cambios en las políticas y la financiación podrían dejar a algunas personas sin atención vital, especialmente a niños y adultos mayores.

“Las personas tendrán dificultades para acceder a beneficios a los que tienen derecho y que necesitan para vivir de forma independiente”, expresó Carol Wong, abogada senior de derechos humanos de Justice in Aging, un grupo nacional de defensa.

Cerca de 69 millones de personas en el país hablan un idioma que no es inglés, y 26 millones de ellas hablan inglés a un nivel por debajo de “muy bien”, según los disponibles de 2023 de la Oficina del Censo de Estados Unidos.

Una de ese año reveló que los inmigrantes con un dominio limitado del inglés reportaron más obstáculos para acceder a la atención médica y peor salud que los que hablan mejor inglés.

Los defensores de salud temen que, sin el apoyo adecuado, millones de personas con un dominio limitado del inglés sean más propensas a sufrir errores médicos, diagnósticos equivocados, negligencia y otros resultados adversos.

Al inicio de la pandemia en 2020, informó que una mujer con síntomas de coronavirus murió en Brooklyn luego de no recibir tratamiento oportuno porque el personal de emergencias no pudo comunicarse con ella en húngaro.

Y, en el punto álgido de la crisis, fue el primero en informar que una en un sitio web estatal afirmaba erróneamente que la vacuna contra covid-19 no era necesaria.

En el año 2000, el presidente Bill Clinton firmó destinada a mejorar el acceso a los servicios federales para las personas con inglés limitado. Investigaciones muestran que la asistencia lingüística se traduce en una del paciente, y también en una , diagnósticos equivocados y consecuencias adversas para la salud.

Los servicios de interpretación de idiomas también al reducir las estadías en el hospital y los reingresos.

La orden de Trump derogó la directiva de Clinton y dejó en manos de cada agencia federal la decisión de mantener o adoptar una nueva política sobre lenguas. Algunas ya han reducido sus servicios: según se ha informado, el y la redujeron los servicios de idiomas, y el Departamento de Justicia afirma estar . El enlace a su plan de lenguas .

No está claro qué pretende hacer el Departamento de Salud y Servicios Humanos (HHS). El HHS no respondió a las preguntas de Â鶹ŮÓÅ Health News.

Un implementado durante la presidencia de Joe Biden, que durante emergencias y desastres de salud pública, ha sido archivado, lo que significa que podría no reflejar las políticas actuales. Sin embargo, la del HHS sigue informando a los pacientes sobre su derecho a recibir servicios de asistencia en sus idiomas nativos cuando recogen una receta médica, solicitan un seguro de salud o van al médico.

Además, en julio pasado, la oficina que prohíben a los proveedores de salud utilizar personal no capacitado, familiares o niños para brindar interpretación durante las consultas médicas. También requiere que un traductor humano calificado revise traducciones de información confidencialÌý realizadas con herramientas de inteligencia artificial (IA), para garantizar su precisión.

La administración Trump podría anular estas salvaguardas, afirmó Mara Youdelman, directora general del National Health Law Program, una organización nacional de defensa de políticas legales y de salud. “Hay un proceso que debe seguirse”, agregó, refiriéndose a la implementación de cambios con la participación del público.

“Les insto encarecidamente a que consideren las graves consecuencias cuando las personas no tienen una comunicación efectiva”, enfatizó.

Youdelman dijo que, incluso si el gobierno federal finalmente no ofrece servicios de idiomas al público, los hospitales y proveedores de salud están obligados a proporcionar esta asistencia a los pacientes de manera gratuita. El Título VI de la Ley de Derechos Civiles de 1964 prohíbe la discriminación por raza u origen nacional, y sus protecciones se extienden al idioma. Además, la Ley de Cuidado de Salud a Bajo Precio (ACA) de 2010, que amplió la cobertura médica para millones de estadounidenses y adoptó numerosas protecciones al consumidor, exige que los proveedores de salud que reciben fondos federales ofrezcan servicios de idiomas, incluyendo traducción e interpretación.

“El inglés puede ser el idioma oficial y las personas aún tienen derecho a obtener servicios de idiomas cuando acceden a la atención médica”, dijo Youdelman. “Nada en la orden ejecutiva cambió la ley vigente”.

Las aseguradoras aún deben incluir eslóganes multilingües en la correspondencia a sus miembros, explicando cómo pueden acceder a los servicios de idiomas.

Los centros de salud deben colocar avisos visibles que informen a los pacientes sobre los servicios de asistencia lingüística, y garantizar intérpretes certificados y calificados.

Los gobiernos estatales y locales podrían ampliar sus propios requisitos de acceso a idiomas. Algunos estados han tomado medidas similares en los últimos años, y los legisladores estatales de California están que establecería un director de acceso lingüístico, exigiría la revisión humana de las traducciones de IA y mejoraría las encuestas que evalúan las necesidades lingüísticas.

“Con la creciente incertidumbre a nivel federal, las leyes y políticas de acceso estatales y locales son aún más importantes”, afirmó Jake Hofstetter, analista de políticas del Migration Policy Institute.

En California, el Departamento de Salud Pública de Los Ángeles y la Oficina de Participación Cívica y Asuntos de Inmigrantes de San Francisco afirmaron que sus servicios de idiomas no se han visto afectados por la orden ejecutiva de Trump ni por los recortes de fondos federales.

Sin embargo, la demanda ha disminuido. Aurora Pedro, de Comunidades Indígenas en Liderazgo, una de las pocas intérpretes médicas en Los Ángeles que habla akatek y qʼ²¹²ÔÂá´Ç²úʼ²¹±ô, lenguas mayas de Guatemala, dijo que recibe menos llamadas solicitando sus servicios desde que asumió Trump.

Y otras áreas de California han reducido los servicios lingüísticos por los recortes de fondos federales.

Hernán Treviño, vocero del Departamento de Salud Pública del condado de Fresno, dijo que el condado redujo el número de trabajadores de salud comunitarios a más de la mitad, de 49 a 20 puestos. Esto ha limitado la disponibilidad de guías locales que hablan español, hmong o lenguas indígenas de Latinoamérica, y que ayudan a los inmigrantes a inscribirse en planes de salud y programar exámenes de rutina.

Treviño indicó que, en las oficinas del condado, el personal sigue disponible para atender a los residentes en español, hmong, lao y panyabí. También hay una línea telefónica gratuita disponible para ayudar a acceder a servicios en el idioma preferido.

Mary Anne Foo, directora ejecutiva de la Asian and Pacific Islander Community Alliance del condado de Orange, informó que la Administración de Servicios de Abuso de Sustancias y Salud Mental congeló los $394.000 restantes de un contrato de dos años para mejorar los servicios de salud mental. Como resultado, la alianza planea despedir a 27 de sus 62 terapeutas, psiquiatras y administradores de casos bilingües. La alianza atiende a más de 80.000 pacientes que hablan más de 20 idiomas.

“Solo podemos mantenerlos hasta el 30 de junio”, dijo Foo. “Todavía estamos tratando de ver si podremos cubrir a las personas”.

Orozco Rodríguez reportó desde Elko, Nevada.

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It’s a striking reversal for the Democrat, who had promised universal health care and called health coverage for immigrants the . But a, potential federal spending cuts, and larger-than-expected Medi-Cal enrollment have forced him to dial back.

Newsom said he had no other choice but to call for major cost-cutting measures affecting how some immigrants are covered by Medi-Cal, the state’s Medicaid program, which covers about 15 million Californians.

“The challenge that we face this year and the challenge we will face for many years is on growth of our Medicaid system, Medi-Cal,” Newsom told reporters at his budget presentation. “Instead of rolling back the program, cutting people off for basic care, we have to adjust the comprehensive nature of the care.”

California is that offer health coverage to low-income adults regardless of immigration status, and that has put the program in the political crosshairs of national Republicans. The would cut Medicaid funding by 10 percentage points for states that provide coverage for immigrants without legal status — an approach Newsom on Wednesday described as legally questionable. Meanwhile, the Trump administration cited California’s health coverage of noncitizens as an example of states “” when it issued a proposed rule Monday to overhaul Medicaid provider taxes.

Some 1.6 million immigrants — most without legal status — are enrolled in Medi-Cal. Federal law prohibits Medicaid dollars from being used to cover unauthorized residents, meaning California must foot the bill for the vast majority of their health care. And those costs have ballooned.

Newsom cautioned that California, like other states, could soon be in a more dire budget situation if Republicans advance their proposal to cut Medicaid. That plan includes work requirements and would cap taxes levied on providers that help states draw additional federal money. However, the governor’s budget proposal was silent on potential federal cuts.

The $321.9 billion budget proposes a for immigrants 19 and older without legal status, starting Jan. 1. Beginning in 2027, immigrants 19 and older in the country illegally, as well as those with legal residency for less than five years, would be required to pay $100 monthly premiums to maintain coverage.

The Newsom administration estimated those two moves would save the state $5.4 billion by the 2028-29 fiscal year. The governor also called for eliminating dental and long-term care benefits for those without legal status and for legal residents who arrived in the U.S. less than five years ago, according to California Department of Finance spokesperson H.D. Palmer.

The changes would not apply to the roughly 217,000 children and young adults without legal status covered by Medi-Cal. Those 18 and under were the first to receive Medi-Cal coverage, in 2016. Children are generally healthier and require less care, and a Â鶹ŮÓÅ Health News analysis showed that, in many cases, children lacking legal status were cheaper to cover than citizens.

Maria, a street vendor from Los Angeles, said the monthly premium alone would force her and others to forgo care.

“They say they are one of the largest economies, but they don’t want to help us,” said Maria, who didn’t want to give her full name, out of fear of retaliation from immigration authorities. “We are contributing to the state. It’s not fair that we, the poor, have to pay what we don’t have.”

“Where am I going to get the $100?” Maria asked.

Federal law prohibits charging the poorest Medicaid enrollees a premium, and Newsom’s $100 monthly payment would be considered unaffordable for current beneficiaries, said Laurel Lucia, director of the health care program at the University of California-Berkeley Labor Center.

Newsom is proposing a $194.5 billion Medi-Cal budget for 2025-26. Lawmakers have until June 15 to pass the budget. Democratic leaders signaled their intent to protect health care for the state’s poorest residents.

The governor and Assembly Speaker Robert Rivas blamed fiscal headwinds brought on by President Donald Trump’s tariffs, which they said had led to a massive $16 billion dip in state tax revenue forecasts since April. But Medi-Cal spending surged well before the tariffs took effect. State costs to cover Californians with “unsatisfactory immigration status” — those without status and legal residents who have been here less than five years — is roughly $10.8 billion per year, up from the $6.4 billion officials projected in November. The federal government pays $1.2 billion of that to cover mandated emergency and pregnancy care.

“It’s laughable that he’s trying to blame Trump for anything,” Republican Assembly member Joe Patterson, who sits on the Assembly Budget Committee, said of Newsom. “He overpromised to them, and he’s pulling the carpet out from underneath them.”

Other states that have extended coverage to immigrants are also struggling with escalating costs. Minnesota, for example, originally projected that 5,700 residents without legal status would sign up for the state Medicaid program, known as MinnesotaCare, at a cost of $200 million. Both figures have increased roughly threefold.

Illinois is ending services for adult immigrants, except seniors, on , citing higher-than-anticipated enrollment. The mostly state-funded health plan will stop covering around 30,000 noncitizens ages 42 to 64, including those living in the country without authorization.

Newsom said Wednesday that without a suite of his proposed changes to Medi-Cal, program costs could grow by an additional $10 billion through June 2026 and would “contribute significantly to the structural imbalance in future years.”

But consumer advocates and lawmakers said the move is a betrayal of the governor’s commitment to bring California closer to universal health care and warned it would push immigrants into costly emergency room care. Sen. María Elena Durazo, a Democrat who championed the Medi-Cal expansion, said California shouldn’t single out immigrants to solve its budget deficit.

“I don’t agree that we should be isolating and abandoning and separating a particular group of Californians, as if they are responsible for the problem,” Durazo said. “I don’t care what you call them, they work, they contribute.”

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Reddy can’t match the salaries offered by larger health systems — a difficulty compounded by a widespread shortage of primary care doctors.

The shortage is tied largely to the lower pay and relative lack of prestige associated with primary care, making recruitment difficult. “It certainly is challenging to expose medical students early in their careers to the joys of this kind of integrated health care,” Reddy said. “The relationships we build and the care we provide truly allow people to live longer with a better quality of life.”

Hoping to increase revenue so Acacia can afford to pay more, Reddy has signed the practice up for alternative payment methods with health plans that offer bonuses for meeting certain primary care goals tied to child vaccinations, blood pressure control, and screenings for breast cancer, colorectal cancer, and mental health. Such pay-for-performance arrangements are among the many efforts by industry players and state officials to confront the problems plaguing primary care.

frequently opt not to go into primary care, and that’s not good for patients. People with regular primary care providers are more likely to that avoids serious illnesses and feel more empowered to advocate for themselves. They’re also less likely to encounter language barriers, resort to costly emergency room visits, or forgo care.

Six years after the influential California Future Health Workforce Commission made a to plug a projected shortage of 4,100 primary care providers in 2030, a number of public and private initiatives have proliferated around the state to address the problem. They include new residency slots, debt forgiveness, waived medical school tuition, new ways of paying doctors, expanded nurse practitioner roles, and a statewide target to increase primary care spending. Hundreds of millions of taxpayer dollars have been allocated for some of these efforts.

But numerous academic experts and medical professionals believe those moves, while well intended, have been scattershot and insufficient. “The pieces are there,” said Monica Soni, chief medical officer of Covered California, the state’s Affordable Care Act health insurance marketplace. “I am worried we started a little too late, and I think it’s a little too siloed.”

A by the California Health Care Foundation found that substantial progress had been made on some of those goals, including recruitment of students from low-income households and communities of color. A separate analysis from the foundation showed that, from 2020 to 2023, California jumped about 10 spots in a ranking of states by primary care residents and fellows per capita.

However, the latest state data shows nearly 15 million Californians live in areas without enough primary care providers to meet patient needs.

State budget constraints and , especially to Medicaid, could exacerbate shortages in areas already desperate for clinicians and dampen hopes of building a robust primary care system that state officials and virtually everyone in the industry agree would be a strong defense against serious — and costly — illnesses. Federal cuts could also hit medical training and hospital systems.

“Many of us are very scared about threats from both the Trump administration and Republicans in Congress,” said , a family community medicine professor at the University of California-San Francisco.

Acute Primary Care Shortages

California’s lack of primary care providers, including doctors, nurse practitioners, and physician assistants, is most acute in rural parts of the state, particularly in the north and the Central Valley. Entire rural counties, including Del Norte, Madera, Tulare, and Yuba, are designated shortage areas, according to state data. Some densely populated urban areas, including parts of Los Angeles, also confront shortages.

Many Californians face months-long waits for appointments or have to travel long distances or go to emergency rooms for nonurgent medical needs, which means hours spent in crowded waiting rooms for unnecessarily expensive care.

In Chico, 90 miles north of Sacramento, the emergency room at the only hospital in town has seen a sharp increase in patients over the past decade, due in part to a lack of primary care providers in the area.

“People who don’t have a primary care provider — which is a lot, because there are not enough — end up in the ER when they need routine care,” said David Alonso, a local internal medicine doctor. “The ER then says, ‘OK, you should follow up with your primary care provider,’ and they’re like, ‘We don’t have one.’”

, director of the Robert Graham Center for Policy Studies, a health policy think tank, said failure to invest robustly in primary care has robbed the public of its benefits.

The field has historically been underfunded, accounting for of national health care spending in 2022, according to the Milbank Memorial Fund, a national nonprofit focused on population health and health equity.

The consequences are clear.

The U.S. spends significantly more per capita on health care than other industrialized nations, and yet Americans aren’t any healthier. Chronic conditions such as heart disease, diabetes, arthritis, and Alzheimer's, as well as mental illness, account for 90% of the $4.5 trillion spent on health care .

Medical students, often faced with staggering educational debt, are increasingly over primary care. The average salary of a family medicine physician is slightly over $300,000, compared with more than $565,000 for a cardiologist and over $763,000 for a neurosurgeon, according to .

“If you are going to pay over $300,000 to go to medical school, you want to be a neurosurgeon; you don’t want to be a family practice doctor,” said William Barcellona, executive vice president of government affairs at , a Los Angeles-based professional association representing 360 medical groups and independent practice associations nationwide.

Barcellona said the Golden State’s high housing costs also make recruiting difficult.

But it’s not only pay that tempers enthusiasm for primary care. It’s also burnout from so many unpaid hours spent recording details of medical visits in electronic health records; haggling with insurance companies for treatment authorization; answering phone calls and emails from patients; or searching far and wide — often in a health care desert — for specialists with the right expertise.

Debby Lee, the daughter of Hmong immigrants from Laos, experienced this kind of frustration firsthand.

Cultural and linguistic barriers faced by her family motivated her to pursue internal medicine. Lee worked part of her residency at a community clinic serving Hmong in the Sacramento area. She loved the patients, as well as her co-workers. But she was burdened by outdated technology that limited the number of patients she could see. “I just saw myself kind of burning out being in that setting,” Lee said.

When the clinic invited her to stay, she declined, taking a job with a bigger health system.

Solutions to the Shortage

Besides residencies, other efforts support primary care.

The Health Plan of San Mateo offers grants to help medical practices retain and add to primary care staff. In exchange, the practices — some single physicians serving patients in California’s Medicaid program, Medi-Cal — must show they have increased their patient load and retained newly hired providers for five years.

The idea is to provide capital so doctors can hire the staff they need to run their practices efficiently, increase salaries, offer bonuses, and even take sabbaticals. Such efforts are consistent with one of the main thrusts of the 2019 workforce report: to increase investment in primary care.

California recently joined several other states, including Connecticut, Oklahoma, and Rhode Island, in setting a target to increase primary care spending. So far, those policies have yielded .

Late last year, California’s Office of Health Care Affordability set a target to make primary care of total health care spending by 2034, more than double the current proportion. It imposes no requirements, relying on the goodwill of health plans to work with medical providers.

Greater spending on primary care would mean better pay and more people working in the field, said Richard Kronick, a public health professor at UC-San Diego and a member of the OHCA board. “That’s a big change. Will it happen? I don’t think anyone can predict the future with any certainty.”

Stephen Shortell, a professor emeritus of health policy and management at UC-Berkeley, said “some of that increase might occur, but at some point, it might need to be made mandatory.”

In its report, the workforce commission also cited the importance of alternative forms of primary care payment that offer extra cash for quality care. The affordability office has to encourage such payment methods. The aim is to transform the system from one in which every medical service has a price tag to one that treats people holistically, and in which adherence to medical standards brings more money to doctors and their office staff.

Such arrangements are common among HMOs, though less so in primary care practices. Where they do exist, different health plans and other payers generally design them differently, which means primary care practices manage multiple payment models, adding to their administrative burden.

Reddy’s family practice is participating in a one-year demonstration project intended to reduce that burden by having multiple insurers work together in one payment plan.

The project brings together three large insurers — Health Net, Aetna, and Blue Shield of California — and 10 independent practices across the state with the goal of improving care while boosting revenue for the medical groups. It is administered by two industry groups, the and the .

On top of customary payments, either for services rendered or monthly per-member allotments, the medical practices receive bonuses for meeting targets or improving their performance on .

Participating practices also receive monthly per-patient payments for “population health management,” which means managing the collective health of their patients. And they can search a single platform to find all their patients covered by one of the three plans.

In addition to extra payments and fewer administrative hassles, the health plans pay for a “practice coach,” whose job is to help primary care groups meet their targets and provide more seamless care.

The idea is to add more insurers and medical groups over time, said Todd May, Health Net’s medical director for commercial health plans, who is among those driving the project. “In addition to better outcomes, we’d like to see a stronger, more robust, and more satisfied primary care workforce,” he said.

Reddy hopes she can increase Acacia’s revenue by 20%, using the extra money from this and other pay-for-performance arrangements. That, she said, would enable her to raise pay for her staff and hire clinicians.

For many years, her practice has limited the number of patients it has accepted. But after searching for the better part of five years, Reddy has hired a doctor on a half-time basis and another is coming on board in June.

“This is the most hopeful I have felt in decades,” Reddy said.

Phillip Reese contributed to this report.

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Josephine, 16, has been diagnosed with , severe autism, severe obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder, among other conditions, which will require constant assistance and supervision for the rest of her life.

Ortiz, 25, is Josephine’s caregiver. A Venezuelan immigrant, Ortiz helps Josephine eat, bathe, and perform other daily tasks that the teen cannot do alone at her home in West Orange, New Jersey. Over the past 2½ years, Ortiz said, she has developed an instinct for spotting potential triggers before they escalate. She closes doors and peels barcode stickers off apples to ease Josephine’s anxiety.

But Ortiz’s ability to work in the U.S. has been thrown into doubt by the Trump administration, which to the temporary protected status program for some Venezuelans on April 7. On March 31, a federal judge , giving the administration a week to appeal. If the termination goes through, Ortiz would have to leave the country or risk detention and deportation.

“Our family would be gutted beyond belief,” said Krysta Senek, Josephine’s mother, who has been trying to win a reprieve for Ortiz.

Americans depend on many such foreign-born workers to help care for family members who are older, injured, or disabled and cannot care for themselves. Nearly 6 million people receive personal care in a private home or a group home, and about 2 million people use these services in a nursing home or other long-term care institution, according to a .

Increasingly, the workers who provide that care are immigrants such as Ortiz. The foreign-born share of nursing home workers rose three percentage points from 2007 to 2021, to about 18%, according to an by the Baker Institute for Public Policy at Rice University in Houston.

And foreign-born workers make up a high share of other direct care providers. More than 40% of home health aides, 28% of personal care workers, and 21% of nursing assistants were foreign-born in 2022, compared with 18% of workers overall that year, according to .

That workforce is in jeopardy amid an immigration crackdown President Donald Trump launched on his first day back in office. He signed executive orders that without a court hearing, , and more recently for nationals of Cuba, Haiti, Nicaragua, and Venezuela.

In to deport Venezuelans and attempting to for others, the Trump administration has sparked fear that even those who have followed the nation’s immigration rules could be targeted.

“There's just a general anxiety about what this could all mean, even if somebody is here legally,” said , president of LeadingAge, a nonprofit representing more than 5,000 nursing homes, assisted living facilities, and other services for aging patients. “There's concern about unfair targeting, unfair activity that could just create trauma, even if they don't ultimately end up being deported, and that's disruptive to a health care environment.”

Shutting down pathways for immigrants to work in the United States, Smith Sloan said, also means many other foreign workers may go instead to countries where they are welcomed and needed.

“We are in competition for the same pool of workers,” she said.

Growing Demand as Labor Pool Likely To Shrink

Demand for caregivers is predicted to surge in the U.S. as the youngest baby boomers reach retirement age, with the need for home health and personal care aides over a decade, according to the Bureau of Labor Statistics. Those 820,000 additional positions represent the most of any occupation. The need for also is projected to grow, by about 65,000 positions.

Caregiving is often low-paying and physically demanding work that doesn’t attract enough native-born Americans. The median pay ranges from about to a year, according to the Bureau of Labor Statistics.

Nursing homes, assisted living facilities, and home health agencies have long struggled with high turnover rates and staffing shortages, Smith Sloan said, and they now fear that Trump’s immigration policies will choke off a key source of workers, leaving many older and disabled Americans without someone to help them eat, dress, and perform daily activities.

With the Trump administration , which runs programs supporting older adults and people with disabilities, and Congress considering deep cuts to Medicaid, the largest payer for long-term care in the nation, the president’s anti-immigration policies are creating “a perfect storm” for a sector that has not recovered from the covid-19 pandemic, said , an executive vice president of the Service Employees International Union, which represents nursing facility workers and home health aides.

The relationships caregivers build with their clients can take years to develop, Frane said, and replacements are already hard to find.

In September, LeadingAge to help the industry meet staffing needs by raising caps on work-related immigration visas, expanding refugee status to more people, and allowing immigrants to test for professional licenses in their native language, among other recommendations.

But, Smith Sloan said, “There's not a lot of appetite for our message right now.”

The White House did not respond to questions about how the administration would address the need for workers in long-term care. Spokesperson Kush Desai said the president was given “a resounding mandate from the American people to enforce our immigration laws and put Americans first” while building on the “progress made during the first Trump presidency to bolster our healthcare workforce and increase healthcare affordability.”

Refugees Fill Nursing Home Jobs in Wisconsin

Until Trump suspended the refugee resettlement program, some nursing homes in Wisconsin had partnered with local churches and job placement programs to hire foreign-born workers, said Robin Wolzenburg, a senior vice president for LeadingAge Wisconsin.

Many work in food service and housekeeping, roles that free up nurses and nursing assistants to work directly with patients. Wolzenburg said many immigrants are interested in direct care roles but take on ancillary roles because they cannot speak English fluently or lack U.S. certification.

Through a partnership with the Wisconsin health department and local schools, Wolzenburg said, nursing homes have begun to offer training in English, Spanish, and Hmong for immigrant workers to become direct care professionals. Wolzenburg said the group planned to roll out training in Swahili soon for Congolese women in the state.

Over the past 2½ years, she said, the partnership helped Wisconsin nursing homes fill more than two dozen jobs. Because refugee admissions are suspended, Wolzenburg said, resettlement agencies aren’t taking on new candidates and have paused job placements to nursing homes.

Many older and disabled immigrants who are permanent residents rely on foreign-born caregivers who speak their native language and know their customs. Frane with the SEIU noted that many members of San Francisco’s large Chinese American community want their aging parents to be cared for at home, preferably by someone who can speak the language.

“In California alone, we have members who speak 12 different languages,” Frane said. “That skill translates into a kind of care and connection with consumers that will be very difficult to replicate if the supply of immigrant caregivers is diminished.”

The Ecosystem a Caregiver Supports

Caregiving is the kind of work that makes other work possible, Frane said. Without outside caregivers, the lives of the patient and their loved ones become more difficult logistically and economically.

“Think of it like pulling out a Jenga stick from a Jenga pile, and the thing starts to topple,” she said.

Thanks to the one-on-one care from Ortiz, Josephine has learned to communicate when she’s hungry or needs help. She now picks up her clothes and is learning to do her own hair. With her anxiety more under control, the violent meltdowns that once marked her weeks have become far less frequent, Ortiz said.

“We live in Josephine’s world,” Ortiz said in Spanish. “I try to help her find her voice and communicate her feelings.”

Ortiz moved to New Jersey from Venezuela in 2022 as part of an au pair program that connects foreign-born workers with people who are older or children with disabilities who need a caregiver at home. Fearing political unrest and crime in her home country, she got temporary protected status when her visa expired last year to keep her authorization to work in the United States and stay with Josephine.

Losing Ortiz would upend Josephine’s progress, Senek said. The teen would lose not only a caregiver, but also a sister and her best friend. The emotional impact would be devastating.

“You have no way to explain to her, ‘Oh, Alanys is being kicked out of the country, and she can't come back,’” she said.

It’s not just Josephine: Senek and her husband depend on Ortiz so they can work full-time jobs and take care of themselves and their marriage. “She's not just an au pair,” Senek said.

The family has called its congressional representatives for help. Even a relative who voted for Trump sent a letter to the president asking him to reconsider his decision.

In the March 31 court decision, U.S. District Judge Edward Chen wrote that canceling the protection could “inflict irreparable harm on hundreds of thousands of persons whose lives, families, and livelihoods will be severely disrupted.”

‘Doing the Work That Their Own People Don’t Want To Do’

News of immigration dragnets that sweep up and are causing a lot of stress, even for those who have followed the rules, said Nelly Prieto, 62, who cares for an 88-year-old man with Alzheimer’s disease and a man in his 30s with Down syndrome in Yakima County, Washington.

Born in Mexico, she immigrated to the United States at age 12 and became a U.S. citizen under authorized by President Ronald Reagan that made any immigrant who entered the country before 1982 eligible for amnesty. So, she’s not worried for herself. But, she said, some of her co-workers working under are very afraid.

“It kills me to see them when they talk to me about things like that, the fear in their faces,” she said. “They even have letters, notarized letters, ready in case something like that happens, saying where their kids can go.”

Foreign-born home health workers feel they are contributing a valuable service to American society by caring for its most vulnerable, Prieto said. But their efforts are overshadowed by rhetoric and policies that make immigrants feel as if they don’t belong.

“If they cannot appreciate our work, if they cannot appreciate us taking care of their own parents, their own grandparents, their own children, then what else do they want?” she said. “We’re only doing the work that their own people don’t want to do.”

In New Jersey, Ortiz said life has not been the same since she received the news that her TPS authorization was slated to end soon. When she walks outside, she fears that immigration agents will detain her just because she’s from Venezuela.

She’s become extra cautious, always carrying proof that she’s authorized to work and live in the U.S.

Ortiz worries that she’ll end up in a detention center. But even if the U.S. now feels less welcoming, she said, going back to Venezuela is not a safe option.

“I might not mean anything to someone who supports deportations,” Ortiz said. “I know I'm important to three people who need me."

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Josephine tiene 16 años y ha sido diagnosticada con , autismo severo, trastorno obsesivo-compulsivo grave y trastorno por déficit de atención con hiperactividad, entre otras afecciones. Todo esto significa que necesitará asistencia y acompañamiento constantes toda su vida.

Ortiz, de 25 años, es la cuidadora de Josephine. Esta inmigrante venezolana la ayuda a comer, bañarse y hacer tareas diarias que la adolescente no puede hacer sola en su casa en West Orange, Nueva Jersey.

Ortiz cuenta que, en los últimos dos años y medio, ha desarrollado un instinto que le permite detectar posibles factores desencadenantes de las crisis antes de que se agudicen. Por ejemplo, cierra las puertas y les quita las etiquetas de códigos de barras a las manzanas para reducir la ansiedad de Josephine.

Sin embargo, la posibilidad de trabajar en Estados Unidos puede estar en peligro para Ortiz. La administración Trump al programa de Estatus de Protección Temporal (TPS) para algunos venezolanos a partir del 7 de abril. El 31 de marzo, un juez federal , dando a la administración una semana para apelar.

Si el programa se suspende, Ortiz tendrá que abandonar el país o arriesgarse a ser detenida y deportada.

“Nuestra familia quedaría devastada más allá de lo imaginable”, afirma Krysta Senek, la madre de Josephine, quien ha estado buscando un indulto para Ortiz.

Los estadounidenses dependen de muchos trabajadores nacidos en el extranjero para cuidar a sus familiares mayores, lesionados o discapacitados que no pueden valerse por sí mismos.

Según un análisis de la , casi 6 millones de personas reciben atención personal en un hogar privado o en una residencia grupal, y alrededor de 2 millones utilizan estos servicios en residencias para personas mayores u otras instituciones de cuidado a largo plazo.

Cada vez con más frecuencia, estos cuidadores son inmigrantes como Ortiz. En los centros de cuidados para adultos mayores, la proporción de trabajadores nacidos en el extranjero aumentó tres puntos porcentuales entre 2007 y 2021, hasta alcanzar aproximadamente el 18%, según un del Instituto Baker de Política Pública de la Universidad Rice, en Houston.

Además, los trabajadores nacidos en el extranjero representan una gran parte de otros proveedores de cuidados directos.

En 2022, más del 40% de los asistentes de salud a domicilio, el 28% de los trabajadores de cuidado personal y el 21% de los asistentes de enfermería habían nacido en el extranjero, un número superior al 18% de extranjeros en el total de la economía ese año, según datos de

Esa fuerza laboral está en riesgo como consecuencia de la ofensiva contra los inmigrantes que Donald Trump lanzó en el primer día de su segunda administración.

El presidente firmó órdenes ejecutivas que en los que se pueden decidir las deportaciones sin audiencia judicial, de los refugiados y, más recientemente, para ciudadanos de Cuba, Haití, Nicaragua y Venezuela.

para deportar a venezolanos e intentando de otros, la administración Trump ha generado temor incluso entre aquellos que han seguido las reglas de inmigración del país.

"Hay una ansiedad general sobre lo que esto podría significar, incluso si alguien está aquí legalmente", dijo presidenta de LeadingAge, una organización sin fines de lucro que representa a más de 5.000 residencias, hogares de cuidados asistidos y otros servicios para adultos mayores.

“Existe preocupación por la persecución injusta, por acciones que pueden ser traumáticas incluso si finalmente esas personas no terminan siendo deportadas. Pero toda esa situación, ya de por sí, altera el entorno de atención de salud”.

Según explicó Smith Sloan, cerrar las vías legales para que los inmigrantes trabajen en Estados Unidos también implica que muchos optarán por irse a países donde sí son bienvenidos y necesarios.

“Estamos compitiendo por el mismo grupo de trabajadores”, afirmó.

Más demanda, menos trabajadores

Se prevé que la demanda de trabajadores que realizan tareas de cuidado aumente considerablemente en el país, a medida que los baby boomers más jóvenes lleguen a la edad de su jubilación.

Según las proyecciones de la Oficina de Estadísticas Laborales, la necesidad de asistentes de salud y de cuidado personal a domicilio crecerá hasta cerca del en el transcurso de la próxima década.

Esos 820.000 puestos adicionales representan el mayor aumento entre todas las actividades laborales. También se proyecta un de auxiliares de enfermería y camilleros, con un incremento de alrededor de 65.000 puestos.

El trabajo de cuidado suele ser mal remunerado y físicamente exigente, por lo que en general no atrae a suficientes estadounidenses nativos. El salario medio oscila, según la misma Oficina, entre y anuales.

Los hogares para adultos mayores, las residencias geriátricas con asistencia y las agencias de atención domiciliaria han lidiado durante mucho tiempo con altas tasas de rotación de personal y escasez de empleados, señaló Smith Sloan.

Ahora, además, temen que las políticas migratorias de Trump corten una fuente clave de trabajadores, dejando a muchas personas de edad avanzada, o con discapacidades, sin alguien que las ayude a comer, a vestirse y a realizar sus actividades cotidianas.

Con el gobierno de Trump reorganizando la —encargada de los programas que apoyan a adultos mayores y personas con discapacidades— y el Congreso considerando recortes radicales a Medicaid (el mayor financiador de cuidados a largo plazo en el país), las políticas antiinmigración del presidente están generando “la tormenta perfecta” para un sector que aún no se ha recuperado de la pandemia de covid-19, opinó , vicepresidenta ejecutiva del Sindicato Internacional de Empleados de Servicios, que representa a estos trabajadores.

Frane señaló que la relación que los cuidadores construyen con sus pacientes puede tardar años en desarrollarse, y que hoy ya es muy complicado encontrar personas que los reemplacen.

En septiembre, la organización LeadingAge hizo para que ayudara a la industria a cubrir sus necesidades de personal. Le propuso, entre otras recomendaciones, que aumentara los cupos de visas de inmigración relacionadas con estos trabajos, ampliara el estatus de refugiado a más personas y permitiera que los inmigrantes rindieran los exámenes de certificación profesional en su idioma nativo.

Pero, agregó Smith Sloan, “en este momento no hay mucho interés en nuestro mensaje”.

La Casa Blanca no respondió a las preguntas sobre cómo la administración abordaría la necesidad de aumentar el número de trabajadores en el sector de cuidados a largo plazo.

El vocero Kush Desai declaró que el presidente recibió “un mandato contundente del pueblo estadounidense para hacer cumplir nuestras leyes migratorias y poner a los estadounidenses en primer lugar”, al tiempo que -dijo- continúa con “los avances logrados durante la primera presidencia de Trump para fortalecer al personal del sector salud y hacer que la atención médica sea más accesible”.

En Wisconsin, refugiados trabajan con adultos mayores

Hasta que Trump suspendió el programa de reasentamiento de refugiados, en Wisconsin algunas residencias de adultos mayores se habían asociado con iglesias locales y programas de inserción laboral para contratar trabajadores nacidos en el extranjero, explicó Robin Wolzenburg, vicepresidente senior de LeadingAge Wisconsin.

Muchas de estas personas trabajan en el servicio de comidas y en la limpieza, funciones que liberan a las enfermeras y auxiliares de enfermería para que puedan atender directamente a los pacientes.

Sin embargo, Wolzenburg agregó que muchos inmigrantes están interesados en asumir funciones de atención directa, pero que se emplean en funciones auxiliares porque no hablan inglés con fluidez o no tienen una certificación válida estadounidense.

Wolzenburg contó que, a través de una asociación con el departamento de salud de Wisconsin y las escuelas locales, los hogares de adultos mayores han comenzado a ofrecer formación en inglés, español y hmong para que los trabajadores inmigrantes puedan convertirse en profesionales de atención directa.

Dijo también que el grupo planeaba impartir pronto una capacitación en swahili para las mujeres congoleñas que viven en el estado.

En los últimos dos años y medio, esta colaboración ayudó a los centros de cuidados para personas mayores de Wisconsin a cubrir más de una veintena de puestos de trabajo, dijo.

Sin embargo, Wolzenburg explicó que, por la suspensión de las admisiones de refugiados, las agencias de reasentamiento no están incorporando nuevos candidatos y han puesto una pausa a la incorporación de estos trabajadores.

Muchos inmigrantes mayores o que tienen alguna discapacidad, y a la vez son residentes permanentes, dependen de cuidadores nacidos en el extranjero que hablen su idioma y conozcan sus costumbres.

Frane, del sindicato SEIU, señaló que muchos miembros de la numerosa comunidad chino-estadounidense de San Francisco quieren que sus padres mayores reciban atención en casa, preferiblemente de alguien que hable su mismo idioma.

“Solo en California, tenemos miembros del sindicato que hablan 12 lenguas diferentes, dijo Frane. Esa habilidad se traduce en una calidad de atención y una conexión con los usuarios que será muy difícil de replicar si disminuye la cantidad de cuidadores inmigrantes”.

El ecosistema que depende del trabajo de un cuidador

Las tareas de cuidado son el tipo de trabajo que permite que otros trabajos sean posibles, sostuvo Frane. Sin cuidadores externos, la vida de los pacientes y de sus seres queridos se vuelve más difícil desde el punto de vista logístico y económico.

“Es como sacar el pilar que sostiene todo lo demás: el sistema entero tambalea”, agregó.

Gracias a la atención personalizada de Ortiz, Josephine ha aprendido a comunicar cuando tiene hambre o necesita ayuda. Ahora recoge su ropa y está comenzando a peinarse sola. Como su ansiedad está más controlada, las crisis violentas que antes solían repetirse semana tras semana se han vuelto mucho menos frecuentes, dijo Ortiz.

"Vivimos en el mundo de Josephine", explica Ortiz en español. "Intento ayudarla a encontrar su voz y a expresar sus sentimientos".

Ortiz llegó a Nueva Jersey desde Venezuela en 2022 a través de un programa de Au Pair para conectar trabajadores nacidos en el extranjero con personas mayores o niños con discapacidades que necesitan cuidados en su hogar.

Temerosa de la inestabilidad política y la inseguridad en su país, cuando su visa expiró obtuvo el TPS el año pasado. Quería seguir trabajando en Estados Unidos, y quedarse con Josephine.

Perder a Ortiz sería un golpe devastador para el progreso de Josephine, aseguró Senek. La adolescente no solo se quedaría sin su cuidadora, sino también sin una hermana y su mejor amiga. El impacto emocional sería enorme.

"Nosotros no tenemos ninguna manera de explicarle a Josephine que Alanys está siendo expulsada del país y que no puede volver'", dijo Senek.

No se trata solo de Josephine: Senek y su esposo también dependen de Ortiz para poder trabajar a tiempo completo y cuidar de sí mismos y de su matrimonio. “Ella no es solo una Au Pair”, dijo Senek.

La familia ha contactado a sus representantes en el Congreso en busca de ayuda. Incluso un familiar que votó por Trump le envió una carta al presidente pidiéndole que reconsiderara su decisión.

En el fallo judicial del 31 de marzo, el juez federal Edward Chen escribió que cancelar esta protección podría “ocasionar un daño irreparable a cientos de miles de personas cuyas vidas, familias y medios de subsistencia se verán gravemente afectados”.

“Solo estamos haciendo el trabajo que su propia gente no quiere hacer”

Las noticias sobre redadas migratorias que detienen incluso a y las están generando mucho estrés, incluso entre quienes han seguido todas las reglas, comentó Nelly Prieto, de 62 años, quien cuida a un hombre de 88 con Alzheimer y a otro de unos 30 con síndrome de Down en el condado de Yakima, Washington.

Nacida en México, Prieto emigró a Estados Unidos a los 12 años y se convirtió en ciudadana estadounidense en virtud de impulsada por el presidente Ronald Reagan que ofrecía amnistía a cualquier inmigrante que hubiera entrado en el país antes de 1982. Así que ella no está preocupada por sí misma. Pero, dijo, algunos de sus compañeros de trabajo con tienen mucho miedo.

“Me parte el alma verlos cuando me hablan de estas cosas, el miedo en sus rostros”, dijo. “Incluso tienen preparadas cartas firmadas ante un notario diciendo con quién deben quedarse sus hijos, por si algo llega a pasar”.

Los trabajadores de salud a domicilio que nacieron en el extranjero sienten que están contribuyendo con un servicio valioso a la sociedad estadounidense al cuidar de sus miembros más vulnerables, dijo Prieto. Pero sus esfuerzos se ven ensombrecidos por los discursos y las políticas que hacen que los inmigrantes se sientan como si fueran ajenos al país.

“Si no pueden apreciar nuestro trabajo, si no pueden apreciar que cuidemos de sus propios padres, de sus propios abuelos, de sus propios hijos, entonces, ¿qué más quieren?”, dijo. “Solo estamos haciendo el trabajo que su propia gente no quiere hacer”.

En Nueva Jersey, Ortiz contó que su vida no ha sido la misma desde que recibió la noticia de que su permiso bajo el TPS está por terminar. Cada vez que sale a la calle, teme que agentes de inmigración la detengan solo por ser venezolana.

Se ha vuelto mucho más precavida: siempre lleva consigo documentos que prueban que tiene autorización para vivir y trabajar en Estados Unidos.

Ortiz teme terminar en un centro de detención. Aunque Estados Unidos ahora no es un lugar acogedor, consideró que regresar a Venezuela no es una opción segura.

“Puede que yo no signifique nada para alguien que apoya las deportaciones”, dijo Ortiz. “Pero sé que soy importante para tres personas que me necesitan”.

Esta historia fue producida por , que publicaÌý, un servicio editorialmente independiente de laÌý.

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When patients picked up prescriptions for testosterone replacement therapy, law enforcement retrieved their names and addresses .

And when a father was arrested by immigration authorities, agents his personal information from a medical clinic where he received diabetes treatment.

Progressive California lawmakers have proposed a number of bills aimed at bolstering privacy protections for women, transgender people, and immigrants in response to such intrusions by anti-abortion groups, conservative states, and federal law enforcement agencies as President Donald Trump declares the nation “” and flexes his executive power to roll back rights.

Democrats have supermajorities in the state legislature, but even if they pass the proposals, they may first need to lobby one of their own: Gov. Gavin Newsom, who has noticeably tempered his once harsh criticism of Trump.

Last month, the Democratic governor issued against a bill that would expand the state’s sanctuary law to limit cooperation between state prisons and federal immigration agents. And Newsom recently called transgender athletes’ participation in women’s sports on his new podcast with guest Charlie Kirk, a founder of the conservative group Turning Point USA. Newsom went on to tell Kirk that he had a “” the way the right talks about transgender people.

Billions of dollars are also on the line for California. Newsom visited the White House last month seeking for wildfire victims in Los Angeles, and the state relies on Washington for over 60% of its Medicaid budget, which is vulnerable to significant cuts under the GOP’s budget blueprint.

“California’s leaders have not been as aggressive, out of recognition that there are many things that the state needs federal cooperation on,” said , a political science professor at the University of California-San Diego.

A Newsom spokesperson declined to comment on pending legislation. He has a track record of supporting abortion, transgender, and immigrant rights.

Since taking office, Trump has granted the Elon Musk-controlled Department of Government Efficiency — created through a Trump executive order — access to , including medical information, raising concerns that sensitive information could be exposed without proper safeguards.Ìý

The White House did not respond to requests for comment.

While most Americans are familiar with the Health Insurance Portability and Accountability Act, known as HIPAA, it offers only narrow protection for patients in health care settings. There’s no comprehensive federal law protecting data privacy.

Health care information has increasingly become a tool of surveillance and enforcement, and in states that have banned certain medical treatments or toughened immigration laws, vulnerable populations are at greater risk, said Suzanne Bernstein, a health privacy rights expert with the Electronic Privacy Information Center.

Progressive Democrats are concerned that personal information and people’s medical decisions could be used to monitor or criminalize patients, facilitate arrests in or near health care facilities, or jeopardize access to health care services.

They and health privacy advocates say now is the time to shore up protections for the nearly 2 million immigrants living in California without authorization, the more than transgender adults in the state, and — living in the state or out of state — in need of abortion care in California each year. Some of these laws could take effect immediately if signed.

“This is about making sure that people are able to access critical health care in California and to take the politics out of our hospitals and health clinics,” said state Sen. Jesse Arreguín, who hopes the governor would sign his .

The bills are expected to be debated in Sacramento in the coming months.

Since the Supreme Court overturned the constitutional right to abortion, anti-abortion groups have purchased location information from consumer data companies to target people seeking abortion care with anti-abortion ads. And authorities in states with abortion bans have to enforce laws beyond their borders.

A bill introduced by state Assembly member Rebecca Bauer-Kahan, , would make geofencing, the collection of phone location by data brokers, illegal around health care facilities that provide in-person services. It would reproductive health information collected during research from being disclosed in response to out-of-state requests.

Conservative organizations said the proposal would single them out by restricting their ability to inform women about alternatives to abortion, including services offered by crisis pregnancy centers.

“I think that could very well be a First Amendment violation,” said Jonathan Keller, president of the California Family Council, a statewide anti-abortion nonprofit. “It doesn’t seem like the bill would be prohibiting or putting any restrictions on a group like Planned Parenthood if they wanted to market or target to a local high school or college.”

So far this year, lawmakers in 49 states have introduced more than 700 anti-transgender bills, seeking to ban gender-affirming care, prohibit gender identity education in schools, or restrict transgender students from participating in sports, according to the , a national research organization tracking bills affecting transgender people. Transgender adults represent of the U.S. population.

And some states with bans or restrictions on gender-affirming care have been targeting health care data. In 2023, requested that Florida universities release data on the number of individuals who have been diagnosed with gender dysphoria or received treatment at campus clinics. That same year, Missouri’s Republican attorney general, Andrew Bailey, submitted to one hospital seeking information about gender-affirming care procedures.

Trump has issued a series of executive orders to ban access to gender-affirming care for minors. Federal judges some portions of his orders.

To guard against other states that criminalize or ban gender-affirming care, California state Sen. Scott Wiener wants to expand current protections for minors to include adults.

His bill, , would require law enforcement to obtain a warrant to access state databases on gender-affirming care and make it a misdemeanor to release the data to unauthorized parties. It would also prohibit health care providers, employers, and insurers from releasing information about a person who seeks or obtains gender-affirming physical and mental health care to an agency or individual from another state.

“We want to make sure that we are as comprehensively as possible shielding trans people from hate emanating from the federal government, other states, and private parties,” Wiener said.

Keller countered that authorities in states with bans on abortion or gender-affirming care should have access to medical information as they investigate providers who could harm patients or coerce them into procedures against their will. He cited a over a teenager who detransitioned after undergoing gender-affirming care. A found it was uncommon for people undergoing gender-affirming care to decide to permanently detransition.

“The only way that you’re able to uncover that level of widespread malpractice and malfeasance is if these health care records are able to be accessed,” Keller said.

The California Family Council plans to oppose both bills.

Earlier this year, Trump rescinded a long-standing policy of not making immigration arrests near hospitals, schools, or churches. The decision has providers fearful that Immigration and Customs Enforcement agents will disrupt their work at health facilities and prompt immigrants to skip medical care — for themselves or, of particular concern, their children.

Anticipating the move, California’s Democratic attorney general, Rob Bonta, issued guidance in December advising health care providers how best to respond if ICE comes to their doorstep. But while private entities are encouraged to follow these policies, only state-run facilities are required to adopt them.

“Some health care providers have implemented them, but not everyone has,” Arreguín said.

Arreguín’s would require all health care facilities, including hospitals and community-based clinics, to follow state guidance to limit cooperation with immigration authorities. It would also prohibit providers from granting access to private areas or places where a patient is actively receiving treatment or care, unless there’s a warrant.

Another immigration bill, , would limit the sharing of local law enforcement information if agents plan to make an arrest within a one-mile radius of a hospital or medical office, a child care or day care facility, a religious institution, or a place of worship. California law enforcement has some discretion to share information with immigration agents when an individual has been convicted of a serious crime or felony.

Kousser said immigration is more complicated for California politicians than health privacy. Although a February poll by the Public Policy Institute of California found that Californians think immigrants are a benefit to the state, Kousser said that lawmakers, especially those who won by narrow margins in contested districts, still have to make tough political choices.

Senate Republican leader Brian Jones, who represents a predominantly Democratic district in San Diego, to change California’s sanctuary policies to require law enforcement to share information with ICE when a person has been convicted of a serious crime.

“When these violent felons are released from local custody, they go right back into the communities that they came from to re-victimize those same immigrant communities,” Jones said.

But Jones acknowledged the need for nuance when it comes to health privacy.

“Look, the bottom line for me on this immigration reform in America is it needs to be humanitarian and it needs to make sense,” Jones said. “And so, if there are areas that we need to protect folks, it might make sense.”

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

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