The lawsuit, settled on confidential terms last year, blamed not only the managers of City Creek Post-Acute and Assisted Living but also the building’s owner, a real estate investment trust, or REIT.

In the year Darby died, City Creek paid CareTrust REIT more than $1 million in rent, while the Sacramento, California, nursing home ran a deficit, court records show.

Federal tax rules ban REITs from running health care facilities, but CareTrust was not an absentee landlord either, according to internal records filed in the case. It chose the nursing home’s management company and required through the lease that the home keep at least 80% of beds occupied. CareTrust granularly tracked how well the home kept to its financial plan, down to the money spent monthly on nurses and food, the records said. And the documents showed that the real estate company kept tabs on government safety inspection findings and Medicare quality ratings.

Both CareTrust and the nursing home operator denied liability for Darby’s death. CareTrust officials said in court papers that it is not involved in day-to-day nursing home decisions or patient care, and that it monitors facilities to ensure nothing jeopardizes rent payments. In a written statement, CareTrust Corporate Counsel Joseph Layne told Â鶹ŮÓÅ Health News: “We are the property owners, not the operators.”

Landlords With Influence

Over the past decade, real estate investment trusts have bought thousands of buildings that house nursing homes, hospitals, assisted living facilities, and medical offices. A Â鶹ŮÓÅ Health News examination of court filings and corporate records shows that these landlords have more influence than the health care facilities publicly acknowledge.

The documents reveal REITs often select the management who oversee the operations and leave them in place even when they are aware of threadbare staffing, floundering governance, repeated safety violations, or other problems that hamper quality of care. A California jury in March awarded $92 million in punitive damages against a former REIT over the death of a 100-year-old resident with dementia who froze to death outside her assisted living facility.

“The REITs are in charge,” said Laraclay Parker, one of the lawyers who represent Darby’s daughter.

Absence of Oversight

Despite their ubiquity, REITs remain invisible to state and federal health regulators. Hospitals and nursing homes are not required to disclose rent payments or landlord identities in the annual reports they submit to Medicare.

Under President Donald Trump, the Centers for Medicare & Medicaid Services a Biden-era requirement that nursing homes . Catherine Howden, a CMS spokesperson, said in a statement that the agency does not regulate facilities based on their tax status or corporate form and instead focuses on the quality of the care they provide.

REITs now of the nation’s senior housing, which includes assisted living, memory care, and independent living, according to an industry analysis. REITs also hold investments in nursing homes. Publicly traded REITs that focus on health care are now worth nearly a quarter of a trillion dollars, according to Nareit, an industry association.

While one research study found REIT investments were associated with , another concluded that after being bought by REITs, nursing homes frequently with less skilled nurses and aides. A concluded that health inspection results were worse after REIT investment.

Researchers also found that investor-owned hospital chains that sold buildings to REITs were or go bankrupt, with Steward Health Care. Often, private equity investors kept the sale proceeds as profits while the hospitals were burdened with new rent costs. “There were no improvements in clinical outcomes,” said Thomas Tsai, an associate professor at the Harvard T.H. Chan School of Public Health.

REITs are required to distribute most of their income and don’t have to pay the 21% federal corporate income tax on it. There is a catch: A REIT that “directly or indirectly operates or manages” a health care facility for five years. Typically, a REIT leases the property to another company that runs the nursing home or assisted living facility and maintains its tax break. Nareit said health care REITs distributed more than $7 billion in dividends in 2024.

Michael Stroyeck, head of health care analysis at Green Street, a real estate research company, said “there’s definitely a symbiotic relationship” between REITs and facility managers because they have the same goals. He said he has seen REITs replace operators that are having difficulties or go bankrupt.

John Kane, a senior vice president at the American Health Care Association and the National Center for Assisted Living, an industry group that represents nursing homes, said in a statement: “Given government funding often falls short, REITs have been valuable partners in helping to invest in long term care without influencing daily operations.”

Low Staffing at a Chain

Strawberry Fields REIT, which like CareTrust trades on the New York Stock Exchange, owns or controls the buildings of 131 nursing home facilities. The nursing home operations inside 66 of those facilities are owned by Moishe Gubin, Strawberry Fields’ chief executive, and Michael Blisko, one of its directors, according to Strawberry Fields’ for last year.

Gubin and Blisko also jointly own , which manages their nursing homes; Blisko is Infinity’s CEO. On average, Infinity-affiliated nursing homes provided an hour and a quarter less nursing care per resident per day than the national average of four hours, a Â鶹ŮÓÅ Health News analysis of federal records found.

Infinity and several of its nursing homes have recently settled 30 death and injury lawsuits in Cook County, Illinois, totaling more than $4 million, said Margaret Battersby Black, a Chicago lawyer. A jury last year awarded $12 million in a lawsuit brought against Infinity and one of its Chicago nursing homes over the 2023 death of Shirley Adams. A retired candy factory worker, Adams died after developing infected bedsores at Lakeview Rehabilitation and Nursing Center, according to the lawsuit.

“She had wounds that no one could explain,” one of her adult children, Leslie Adams, testified at trial. Medicare its lowest quality rating, one star out of five.

Paul Connery, a lawyer for Adams’ family, said they are still trying to collect on the judgment against the nursing home and management company, which now totals $17 million with interest and attorney fees.

“If I get caught speeding and I went to court, they issue me a ticket and I’ve got a fine to pay,” Adams said in an interview. “How are they able to still continue to move on with business like nothing has happened?”

In a phone interview and an email, Gubin said Strawberry Fields, Infinity, and the nursing homes are all legally distinct and that he has not played an active role in Infinity in more than a decade. He said nursing homes get sued all the time but that the verdict against Lakeview is so large that it will force the home to declare bankruptcy or shut down.

“The whole thing is unfortunate,” Gubin said by phone. “For 15 years they were a perfectly good guardian” and “a well-run building,” he said. “You wouldn’t think it was fair to be judged on your worst day.”

Blisko and an Infinity lawyer did not respond to requests for comment.

Strawberry Fields, which owns 10 assisted living facilities and two long-term care hospitals in addition to the nursing homes, earned net income last year of from $155 million in rent, a 21% profit margin, securities filings show. Gubin said those weren’t excessive returns.

A $110 Million Verdict

Traditionally, REIT leases make the operating companies responsible for paying property taxes, insurance premiums, and maintenance costs. In 2008, Congress gave health care REITs a new option to make money: On top of collecting rents, they could set up subsidiaries and take profits directly from health care businesses. They still must have independent management overseeing care decisions. Many REITs have embraced the role even though the subsidiaries must pay corporate taxes and risk losing money if the businesses do poorly.

Colony Capital was a REIT that through layers of shell corporations owned both the building and the operation of Greenhaven Estates, a Sacramento assisted living and memory care facility. In 2018 Greenhaven paid Colony $1.4 million in rent, nearly a third of its $4.5 million in revenue that year, according to financial records filed in court.

Greenhaven also was on the verge of losing its license, according to a revocation notice filed in November 2018 by the California Department of Social Services. Greenhaven had racked up years of health violations, including from letting untrained workers administer medications, lacking enough employees to care for people with dementia, and neglecting a resident who smeared feces over his body, bed, floor, and bathroom, the notice said.

In February 2019, a few weeks after celebrating her 100th birthday, Mildred Hernandez, a resident with Alzheimer’s, wandered out of Greenhaven in the middle of the night. Her assisted living wing had no exit door alarms even though it housed several residents with dementia, court records showed. Berta Lepe, one of Greenhaven’s caregivers, found Hernandez under a bush, wearing only a shirt and underwear. The temperature was in the 30s.

“She was talking, but I couldn’t understand what she was saying,” Lepe testified at trial over a lawsuit from Hernandez’s family. Hernandez died of hypothermia a few hours later, according to her death certificate.

Frontier Management, the company that Colony had hired to manage Greenhaven, denied liability and settled the lawsuit on undisclosed terms.

Since the lawsuit, Colony has changed its name to DigitalBridge, which no longer owns Greenhaven and gave up its REIT status. At trial earlier this year, DigitalBridge said resident care was the responsibility of Frontier and that Colony “encouraged” Frontier to address problems. Richard Welch, a former Colony executive, testified that replacing management is disruptive. “I viewed it as a last resort,” he said.

In March, a jury awarded Hernandez’s family $110 million: $10 million in compensatory damages, $92 million in punitive damages against DigitalBridge, and $8 million in punitive damages against Formation Capital, an asset management company.

“REIT money is very detached from knowing about or caring about patient or resident outcomes, because it’s not in their business model,” Ed Dudensing, a lawyer for the family, said in an interview. “Their allegiance is to their investors.”

DigitalBridge has asked the judge to delay finalizing the judgment while its legal challenges to the lawsuit and the verdict are evaluated. A DigitalBridge attorney and a corporate spokesperson did not respond to requests for comment, a Formation attorney declined comment, and a Frontier attorney and a spokesperson did not respond to a request for comment.

‘Wet From Head to Toe’

When CareTrust bought City Creek Post-Acute and Assisted Living in 2019, the Sacramento nursing home where Pearlene Darby lived had a one-star Medicare rating and was losing money. CareTrust leased the building to a management company called Kalesta Healthcare Group based on the business plan Kalesta submitted.

While CareTrust was not the operator, it held periodic phone calls with Kalesta, which provided “a full update of what’s happening at the facility,” including changes in leadership, financial progress, and health inspection survey results, according to deposition testimony by Ryan Williams, a Kalesta co-founder.

According to a state inspection report, in 2020, the year Darby died, City Creek left a resident in soiled linens “wet from head to toe lying in bed” for more than eight hours. During a different visit, a health inspector cited the home after watching a nurse put a dirty diaper back onto a resident after caring for a wound. “It was just a small stool and it is far from where the wound is,” the nurse told the inspector, according to the report.

James Callister, CareTrust’s chief investment officer, said in his deposition that CareTrust officials “review results of regulatory surveys provided to us by the tenant. We review the five-star rating.” He said, “We evaluate results of care, but we do not evaluate types of care given or how or when, no.”

Darby had been living in City Creek since 2011 after a stroke left her in a wheelchair. She needed help getting in and out of bed. From September through November 2020, Darby lost 30 pounds, her family’s lawsuit alleged. During those months, employees dropped her three times as one worker rather than the required two operated the mechanical lift, the lawsuit said.

The suit alleged City Creek failed to reposition her every two hours in bed or her wheelchair, which is the clinical standard for people at risk of bedsores, and to promptly order devices to protect her skin.

In November, the nursing home sent Darby to the hospital. A blood test found bacteria had entered her bloodstream from her feces’ touching open skin wounds, according to the lawsuit. The hospital diagnosed her with sepsis. A surgeon said she needed an operation to redirect fecal waste from her intestines but concluded she wasn’t medically stable enough for surgery, the suit said.

Darby began receiving comfort care measures and was sent back to City Creek. She died two weeks later. In court filings, CareTrust and Kalesta denied the allegations.

In a phone interview, Williams, the Kalesta co-founder, said Darby’s death occurred during the most challenging point of the covid pandemic, when California rules required any nurses testing positive for the virus to be sent home and nurses were quitting out of fear for their health. “It was the most herculean of professional efforts to secure enough staff,” he said.

While expressing sympathy for Darby and her family, he said it was “unconscionable” that personal injury lawyers sued nursing homes over care failures during “the worst of times.”

In court, CareTrust petitioned Judge Richard Miadich to dismiss it from the lawsuit before trial. “This case does not concern a property condition,” CareTrust’s lawyers wrote. “CareTrust is simply a landlord.” But the judge ruled last year a jury should decide whether CareTrust “exercised actual control over City Creek.”

The case was settled out of court a few months later. All parties declined to reveal the settlement terms.

A 67% Profit

As recently as November 2023 — four years after its acquisition — City Creek earned one star from Medicare. It was cited for failing to have the minimum nursing home staffing required by California law during five of 24 randomly selected days in 2022, according to an inspection report. Williams said in the interview that Kalesta had increased spending on nursing over the course of its ownership, including boosting wages, but that it takes a year or two to turn around a troubled nursing home. He said the home’s star rating in 2023 was dragged down by its poor inspection history from before Kalesta took over.

City Creek’s rating has climbed in the past two years, and it now has the top overall rating of five, according to Medicare. Medicare rates City Creek’s current staffing levels as average. That’s better than most nursing homes in more than 200 buildings CareTrust bought before 2025, according to a Â鶹ŮÓÅ Health News analysis of federal data. On average, CareTrust nursing homes provided a half hour less nursing care per resident per day than the national average of four hours.

In its statement to Â鶹ŮÓÅ Health News, CareTrust’s counsel Layne said the REIT worked to “identify quality operators as tenants,” and that the homes the REIT rents out have more nurses and aides than the minimum required for nursing homes by their state governments. “The operators are licensed by state regulators and retain sole responsibility for operations,” the statement said.

CareTrust, which now owns more than 500 senior housing and nursing home buildings, reported net income last year of $320 million from in rents and other revenue — a 67% profit margin. By comparison, HCA Healthcare, one of the nation’s largest for-profit hospital and health care chains, for last year.

Lesley Ann Clement, one of Darby’s lawyers, said cases like hers show the nursing home industry is wrong to complain it lacks financial resources for more staffing.

“There’s plenty of money,” Clement said. “They’re just not spending it on patient care.”

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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Le gustan especialmente las aplicaciones para recibir comentarios y apoyo, aunque a veces lo regañan o hacen que se pelee con su ex esposa. “Me dan ganas de compartir más”, dijo Lahey. “No me importa la percepción que tengan de mí”.

Hay muchas personas como Lahey.

La demanda de atención de salud mental ha aumentado. Los días de mala salud mental reportados por las personas subieron 25% desde la década de 1990, que analizó datos de encuestas. De acuerdo con los Centros para el Control y la Prevención de Enfermedades (CDC), las tasas de suicidio en 2022 , algo que no se veía en casi 80 años.

Muchos pacientes consideran muy atractivo un terapeuta no humano impulsado por inteligencia artificial, incluso más atractivo que una persona en un sillón reclinable y con actitud severa. abundan de personas que piden un terapeuta que “no esté contando el tiempo”, que juzgue menos o que simplemente sea más barato.

La mayoría de las personas que necesitan atención no la reciben, dijo Tom Insel, ex director del Instituto Nacional de Salud Mental (NIMH), citando investigaciones de esa agencia. De los que sí reciben atención, el 40% obtiene una atención “mínimamente aceptable”.

“Hay una enorme necesidad de terapia de alta calidad”, dijo. “Vivimos en un mundo en el que la situación actual es realmente pésima, usando un término científico”.

Insel dijo que ingenieros de OpenAI le comentaron, el otoño pasado, que entre 5% y 10% de la base de usuarios de la empresa, que entonces era de aproximadamente 800 millones, depende de ChatGPT para apoyo en salud mental.

Las encuestas sugieren que estos chatbots de IA pueden ser aún más populares entre los adultos jóvenes. Una encuesta de Â鶹ŮÓÅ encontró que 3 de cada 10 personas de 18 a 29 años para pedir consejos sobre salud mental o emocional en el último año. Los adultos sin seguro médico tenían aproximadamente el doble de probabilidad que quienes sí tenían seguro de reportar uso de herramientas de IA. Y casi un 60% de los adultos que usaron un chatbot para salud mental no consultaron después a un profesional humano.

La aplicación te llevará al diván

Una creciente industria de aplicaciones ofrece terapeutas de IA con avatares parecidos a humanos, a menudo poco realistas y muy atractivos, que sirven como espacio de desahogo para personas con ansiedad, depresión y otras condiciones.

Â鶹ŮÓÅ Health News identificó unas 45 aplicaciones de terapia con IA en la App Store de Apple en marzo. Aunque muchas cobran precios altos por sus servicios —una ofrecía un plan anual de $690—, por lo general siguen siendo más baratas que la terapia conversacional, que puede costar cientos de dólares por hora sin cobertura.

En la App Store, “therapy” suele usarse como término de mercadeo, con letras pequeñas que aclaran que las aplicaciones no pueden diagnosticar ni tratar enfermedades. Una aplicación llamada OhSofia! AI Therapy Chat tenía cientos de miles de descargas, dijo en diciembre Anton Ilin, fundador de OhSofia!

“La gente busca terapia”, afirmó Ilin. Por un lado, el nombre del producto ; por otro, su advierte que “no ofrece consejo médico, diagnóstico, tratamiento ni intervención en crisis y no sustituye servicios profesionales de salud”. Los ejecutivos no creen que eso cause confusión, ya que la aplicación incluye advertencias.

Las aplicaciones prometen grandes resultados sin ningún tipo de respaldo. “ayuda inmediata durante ataques de pánico”. que fue “probada como efectiva por investigadores” y que ofrece alivio 2,3 veces más rápido para ansiedad y estrés. (No dice comparado con qué).

Existen pocas barreras legislativas o regulatorias sobre cómo los desarrolladores describen sus productos, o incluso sobre si son seguros o eficaces, dijo Vaile Wright, directora de la oficina de innovación en atención médica de la Asociación americana de Psicología (APA). Ni siquiera se aplican las protecciones federales de privacidad del paciente, señaló.

“La terapia no es un término legalmente protegido”, dijo Wright. “Así que, básicamente, cualquiera puede decir que ofrece terapia”.

Muchas de las aplicaciones “se presentan como más de lo que son”, dijo John Torous, psiquiatra e informático clínico del Centro Médico Beth Israel Deaconess. “Engañar a las personas haciéndoles creer que recibieron tratamiento cuando en realidad no lo recibieron tiene muchas consecuencias negativas”, entre ellas retrasar la atención real, agregó.

Estados como Nevada, Illinois y California intentan ordenar el caos regulatorio y aprobaron leyes que prohíben a las aplicaciones describir a sus chatbots como terapeutas de IA.

“Es una profesión. Los profesionales estudian. Obtienen una licencia para ejercer”, afirmó Jovan Jackson, legislador de Nevada y coautor de una ley que prohíbe a las aplicaciones presentarse como profesionales de salud mental.

Detrás de la publicidad, investigadores externos y representantes de las propias empresas han declarado ante la Administración de Alimentos y Medicamentos (FDA) y el Congreso que existe poca evidencia que respalde la eficacia de estos productos. Los estudios disponibles ofrecen , y algunas que los chatbots enfocados en acompañamiento son “consistentemente malos” para manejar crisis.

“Cuando se trata de chatbots, no tenemos buena evidencia de que funcionen”, dijo Charlotte Blease, profesora de la Universidad de Uppsala, en Suecia, especializada en diseño de ensayos para productos digitales de salud.

La falta de ensayos clínicos de “buena calidad” se debe a que la FDA no ha dado recomendaciones sobre cómo probar estos productos, señaló. “La FDA no ofrece orientación rigurosa sobre cuáles deberían ser los estándares”.

Emily Hilliard, vocera del Departamento de Salud y Servicios Humanos, respondió que “la seguridad del paciente es la máxima prioridad de la FDA” y que los productos basados en IA están sujetos a regulaciones que exigen demostrar una “garantía razonable de seguridad y eficacia antes de que puedan comercializarse en Estados Unidos”

Aplicaciones persuasivas

Preston Roche, médico residente en psiquiatría y , recibe muchas preguntas sobre si la IA es una buena terapeuta. Tras probar ChatGPT, dijo que al principio quedó “impresionado” porque podía usar técnicas de para ayudarlo a poner pensamientos negativos “a prueba”.

Pero Roche dijo que después de ver publicaciones sobre personas que desarrollaron psicosis o fueron alentadas a tomar decisiones dañinas, se desilusionó. Concluyó que los bots son complacientes.

“Cuando miro de forma global las responsabilidades de un terapeuta, simplemente fracasó por completo”, dijo.

Esa complacencia —la tendencia de aplicaciones basadas en grandes modelos de lenguaje a empatizar, halagar o reforzar ideas erróneas de la persona usuaria— está incorporada en el diseño de estas aplicaciones, según expertos en salud digital.

“Los modelos fueron desarrollados para responder una pregunta o instrucción que le haces y darte lo que buscas”, dijo Insel, exdirector del NIMH, “y son muy buenos básicamente para confirmar lo que sientes y brindar apoyo psicológico, como un buen amigo”.

Pero eso no es lo que hace un buen terapeuta. “El objetivo de la psicoterapia es, sobre todo, hacer que enfrentes las cosas que has estado evitando”, señaló.

Aunque las encuestas sugieren que muchos usuarios están satisfechos con lo que obtienen de ChatGPT y otras aplicaciones, ha habido sobre el servicio o aliento para autolesionarse.

Y de o se han presentado contra OpenAI después de que usuarios de ChatGPT murieran por suicidio o fueran hospitalizados. En la mayoría de esos casos, los demandantes alegan que comenzaron usando las aplicaciones con otro fin —como tareas escolares— antes de confiarles asuntos personales. Estos casos se están consolidando en

Google y la startup Character.ai —financiada por Google y creadora de “avatares” con personalidades específicas, como atletas, celebridades, compañeros de estudio o terapeutas— están resolviendo otras demandas por muerte injusta,

El director ejecutivo de OpenAI, Sam Altman, ha dicho que hasta podrían hablar sobre suicidio en ChatGPT.

“Hemos visto un problema en el que personas en situaciones psiquiátricas frágiles que usan un modelo como 4o pueden terminar peor”, dijo Altman en una sesión pública de preguntas y respuestas reportada por , refiriéndose a un modelo específico de ChatGPT presentado en 2024. “No creo que esta sea la última vez que enfrentemos desafíos como este con un modelo”.

Un vocero de OpenAI no respondió a solicitudes de comentarios.

La empresa ha dicho que en medidas de protección, como referir a usuarios al 988, la línea nacional de prevención del suicidio. Sin embargo, las demandas contra OpenAI sostienen que las medidas actuales no son suficientes, y algunas investigaciones muestran que . OpenAI sugiriendo lo contrario.

OpenAI y, en una etapa inicial de un caso, presentó varias defensas que van desde negar que su producto causó autolesiones hasta alegar que el demandado usó mal el producto al inducirlo a hablar sobre suicidio. También ha dicho que trabaja para .

Aplicaciones más pequeñas también dependen de OpenAI u otros modelos de IA para impulsar sus productos, dijeron ejecutivos a Â鶹ŮÓÅ Health News. En entrevistas, fundadores de startups y otros expertos dijeron que les preocupa que si una empresa simplemente incorpora esos modelos en su propio servicio, pueda duplicar fallas de seguridad ya presentes en el producto original.

Riesgos de datos

La revisión de Â鶹ŮÓÅ Health News de la App Store encontró que las protecciones por edad son mínimas: 15 de las casi cuatro docenas de aplicaciones dicen que pueden ser descargadas por usuarios de 4 años; otras 11 dicen que pueden ser descargadas por personas de 12 años en adelante.

Los estándares de privacidad son opacos. En la App Store, varias aplicaciones se describen como productos que no rastrean datos personales identificables ni los comparten con anunciantes. Pero en sus sitios web, las políticas de privacidad contenían descripciones contrarias, hablando del uso de esos datos y de compartir información con anunciantes como AdMob.

En respuesta a una solicitud de comentarios, Adam Dema, vocero de Apple, a las políticas de la App Store, que prohíben usar datos de salud para publicidad y exigen mostrar información general sobre el uso de datos. Dema no respondió una nueva solicitud sobre cómo Apple hace cumplir esas políticas.

Investigadores y defensores de políticas públicas dijeron que compartir datos psiquiátricos con empresas de redes sociales significa que los pacientes podrían ser perfilados. Podrían ser blanco de empresas de tratamiento de dudosa fiabilidad o recibir precios diferentes por productos según su salud.

Â鶹ŮÓÅ Health News contactó a varios desarrolladores sobre estas discrepancias; dos de los que respondieron dijeron que sus políticas de privacidad habían sido redactadas por error y prometieron cambiarlas para reflejar su postura contra la publicidad. (Un tercero, el equipo de OhSofia!, dijo simplemente que no hace publicidad, aunque la de su aplicación señala que los usuarios “pueden optar por no recibir comunicaciones de mercadeo”).

Un ejecutivo dijo a Â鶹ŮÓÅ Health News que existe presión comercial para mantener acceso a los datos.

“Mi sensación general es que un modelo por suscripción es mucho, mucho mejor que cualquier tipo de publicidad”, dijo Tim Rubin, fundador de Wellness AI, y agregó que cambiaría la descripción en la política de privacidad de su aplicación.

Según Rubin, un inversionista le aconsejó no renunciar a la publicidad. “Básicamente, eso es lo más valioso de tener una aplicación como esta: esos datos”.

“Creo que todavía estamos al comienzo de lo que será una revolución en la forma en que las personas buscan apoyo psicológico e incluso, en algunos casos, terapia”, dijo Insel. “Y mi preocupación es que simplemente no existe ningún marco para nada de esto”.

Si tú o alguien que conoces pudiera estar experimentando una crisis de salud mental, comunícate con la Línea de Vida para la Prevención del Suicidio y Crisis (988 Suicide & Crisis Lifeline) llamando o enviando un mensaje de texto al 988.

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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This story can be republished for free (details).

Vince Lahey of Carefree, Arizona, embraces chatbots. From Big Tech products to “shady” ones, they offer “someone that I could share more secrets with than my therapist.”

He especially likes the apps for feedback and support, even though sometimes they berate him or lead him to fight with his ex-wife. “I feel more inclined to share more,” Lahey said. “I don’t care about their perception of me.”

There are a lot of people like Lahey.

Demand for mental health care has grown. Self-reported poor mental health days rose by 25% since the 1990s, analyzing survey data. According to the Centers for Disease Control and Prevention, suicide rates in 2022 that hadn’t been seen in nearly 80 years.

There are many patients who find a nonhuman therapist, powered by artificial intelligence, highly appealing — more appealing than a human with a reclining couch and stern manner. with begging for a therapist who’s “not on the clock,” who’s less judgmental, or who’s just less expensive.

Most people who need care don’t get it, said Tom Insel, former head of the National Institute of Mental Health, citing his former agency’s research. Of those who do, 40% receive “minimally acceptable care.”

“There’s a massive need for high-quality therapy,” he said. “We’re in a world in which the status quo is really crappy, to use a scientific term.”

Insel said engineers from OpenAI told him last fall that about 5% to 10% of the company’s then-roughly 800 million-strong user base rely on ChatGPT for mental health support.

Polling suggests these AI chatbots may be even more popular among young adults. A Â鶹ŮÓÅ poll found about 3 in 10 respondents ages 18 to 29 for mental or emotional health advice in the past year. Uninsured adults were about twice as likely as insured adults to report using AI tools. And nearly 60% of adult respondents who used a chatbot for mental health didn’t follow up with a flesh-and-blood professional.

The App Will Put You on the Couch

A burgeoning industry of apps offers AI therapists with human-like, often unrealistically attractive avatars serving as a sounding board for those experiencing anxiety, depression, and other conditions.

Â鶹ŮÓÅ Health News identified some 45 AI therapy apps in Apple’s App Store in March. While many charge steep prices for their services — one listed an annual plan for $690 — they’re still generally cheaper than talk therapy, which can cost hundreds of dollars an hour without insurance coverage.

On the App Store, “therapy” is often used as a marketing term, with small print noting the apps cannot diagnose or treat disease. One app, branded as OhSofia! AI Therapy Chat, had downloads in the six figures, said OhSofia! founder Anton Ilin in December.

“People are looking for therapy,” Ilin said. On one hand, the product’s name ; on the other, it warns in that it “does not provide medical advice, diagnosis, treatment, or crisis intervention and is not a substitute for professional healthcare services.” Executives don’t think that’s confusing, since there are disclaimers in the app.

The apps promise big results without backup. its users “immediate help during panic attacks.” it was “proven effective by researchers” and that it offers 2.3 times faster relief for anxiety and stress. (It doesn’t say what it’s faster than.)

There are few legislative or regulatory guardrails around how developers refer to their products — or even whether the products are safe or effective, said Vaile Wright, senior director of the office of health care innovation at the American Psychological Association. Even federal patient privacy protections don’t apply, she said.

“Therapy is not a legally protected term,” Wright said. “So, basically, anybody can say that they give therapy.”

Many of the apps “overrepresent themselves,” said John Torous, a psychiatrist and clinical informaticist at Beth Israel Deaconess Medical Center. “Deceiving people that they have received treatment when they really have not has many negative consequences,” including delaying actual care, he said.

States such as Nevada, Illinois, and California are trying to sort out the regulatory disarray, enacting laws forbidding apps from describing their chatbots as AI therapists.

“It’s a profession. People go to school. They get licensed to do it,” said Jovan Jackson, a Nevada legislator, who co-authored an enacted bill banning apps from referring to themselves as mental health professionals.

Underlying the hype, outside researchers and company representatives themselves have told the FDA and Congress that there’s little evidence supporting the efficacy of these products. What studies there are — and some companion-focused chatbots are “consistently poor” at managing crises.

“When it comes to chatbots, we don’t have any good evidence it works,” said Charlotte Blease, a professor at Sweden’s Uppsala University who specializes in trial design for digital health products.

The lack of “good quality” clinical trials stems from the FDA’s failure to provide recommendations about how to test the products, she said. “FDA is offering no rigorous advice on what the standards should be.”

Department of Health and Human Services spokesperson Emily Hilliard said, in response, that “patient safety is the FDA’s highest priority” and that AI-based products are subject to agency regulations requiring the demonstration of “reasonable assurance of safety and effectiveness before they can be marketed in the U.S.”

The Silver-Tongued Apps

Preston Roche, a psychiatry resident who’s , gets lots of questions about whether AI is a good therapist. After trying ChatGPT himself, he said he was “impressed” initially that it was able to use techniques to help him put negative thoughts “on trial.”

But Roche said after seeing posts on social media discussing people developing psychosis or being encouraged to make harmful decisions, he became disillusioned. The bots, he concluded, are sycophantic.

“When I look globally at the responsibilities of a therapist, it just completely fell on its face,” he said.

This sycophancy — the tendency of apps based on large language models to empathize, flatter, or delude their human conversation partner — is inherent to the app design, experts in digital health say.

“The models were developed to answer a question or prompt that you ask and to give you what you’re looking for,” said Insel, the former NIMH director, “and they’re really good at basically affirming what you feel and providing psychological support, like a good friend.”

That’s not what a good therapist does, though. “The point of psychotherapy is mostly to make you address the things that you have been avoiding,” he said.

While polling suggests many users are satisfied with what they’re getting out of ChatGPT and other apps, there have been about the service or encouragement to self-harm.

And or have been filed against OpenAI after ChatGPT users died by suicide or became hospitalized. In most of those cases, the plaintiffs allege they began using the apps for one purpose — like schoolwork — before confiding in them. These cases are being .

Google and the startup Character.ai — which has been funded by Google and has created “avatars” that adopt specific personas, like athletes, celebrities, study buddies, or therapists — are settling other wrongful-death lawsuits, .

OpenAI’s CEO, Sam Altman, has said up to may talk about suicide on ChatGPT.

“We have seen a problem where people that are in fragile psychiatric situations using a model like 4o can get into a worse one,” Altman said in a public question-and-answer session reported by , referring to a particular model of ChatGPT introduced in 2024. “I don’t think this is the last time we’ll face challenges like this with a model.”

An OpenAI spokesperson did not respond to requests for comment.

The company has said it on safeguards, such as referring users to 988, the national suicide hotline. However, the lawsuits against OpenAI argue existing safeguards aren’t good enough, and some research shows the problems are . OpenAI its own data suggesting the opposite.

OpenAI is , offering, early in one case, a variety of defenses ranging from denying that its product caused self-harm to alleging that the defendant misused the product by inducing it to discuss suicide. It has also said it’s working to .

Smaller apps also rely on OpenAI or other AI models to power their products, executives told Â鶹ŮÓÅ Health News. In interviews, startup founders and other experts said they worry that if a company simply imports those models into its own service, it might duplicate whatever safety flaws exist in the original product.

Data Risks

Â鶹ŮÓÅ Health News’ review of the App Store found listed age protections are minimal: Fifteen of the nearly four dozen apps say they could be downloaded by 4-year-old users; an additional 11 say they could be downloaded by those 12 and up.

Privacy standards are opaque. On the App Store, several apps are described as neither tracking personally identifiable data nor sharing it with advertisers — but on their company websites, privacy policies contained contrary descriptions, discussing the use of such data and their disclosure of information to advertisers, like AdMob.

In response to a request for comment, Apple spokesperson Adam Dema to the company’s App Store policies, which bar apps from using health data for advertising and require them to display information about how they use data in general. Dema did not respond to a request for further comment about how Apple enforces these policies.

Researchers and policy advocates said that sharing psychiatric data with social media firms means patients could be profiled. They could be targeted by dodgy treatment firms or charged different prices for goods based on their health.

Â鶹ŮÓÅ Health News contacted several app makers about these discrepancies; two that responded said their privacy policies had been put together in error and pledged to change them to reflect their stances against advertising. (A third, the team at OhSofia!, said simply that they don’t do advertising, though their app’s notes users “may opt out of marketing communications.”)

One executive told Â鶹ŮÓÅ Health News there’s business pressure to maintain access to the data.

“My general feeling is a subscription model is much, much better than any sort of advertising,” said Tim Rubin, the founder of Wellness AI, adding that he’d change the description in his app’s privacy policy.

One investor advised him not to swear off advertising, he said. “They’re like, essentially, that’s the most valuable thing about having an app like this, that data.”

“I think we’re still at the beginning of what’s going to be a revolution in how people seek psychological support and, even in some cases, therapy,” Insel said. “And my concern is that there’s just no framework for any of this.”

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La situación comenzó a agravarse durante el verano, impulsada por las noticias sobre en todo el sur de California, los planes de la administración Trump de compartir con el Servicio de Inmigración y Control de Aduanas (ICE) y la aprobación de restricciones estatales y federales sobre el derecho de los inmigrantes a acceder a Medicaid.

Luego, en noviembre, el gobierno federal publicó una nueva propuesta sobre la que, de aprobarse, podría impedir que determinados inmigrantes obtuvieran la residencia legal permanente si ellos o sus familiares han utilizado beneficios públicos, incluido Medicaid.

Muchos de los pacientes de González y sus hijos, que a menudo son ciudadanos estadounidenses, todavía califican para el programa Medicaid de California, conocido como Medi-Cal, que brinda cobertura de salud a más de 14 millones de residentes con bajos ingresos o discapacidades. Pero, cada vez más, esas personas prefieren no inscribirse ni renovar su cobertura.

“Muchos no quieren solicitar la cobertura”, afirmó González. “Hay quienes dicen que ni siquiera se atreven a salir a regar sus plantas”.

Datos de Medi-Cal sugieren que lo que algunos defensores de inmigrantes llaman una “pandemia de miedo” ha comenzado a reducir la inscripción en el programa de Medicaid más grande del país. Un análisis de Â鶹ŮÓÅ Health News encontró que, de junio a diciembre, el mes más reciente para el que hay datos disponibles, casi 100.000 inmigrantes sin estatus legal salieron del programa. Representan alrededor de una cuarta parte de todas las bajas de Medi-Cal, aunque este grupo constituye aproximadamente solo el 11% de los inscritos.

Esto marca un cambio de rumbo respecto del aumento constante en la inscripción de inmigrantes sin estatus legal en el estado. Hasta julio, las inscripciones de este sector habían aumentado cada mes desde que, en enero de 2024, el estado abrió Medi-Cal a todos los residentes de bajos ingresos sin que importara su estatus migratorio.

Tessa Outhyse, vocera del Departamento de Servicios de Atención Médica (DHCS), que supervisa Medi-Cal, afirmó que no hay evidencia de que los inmigrantes se estén dando de baja del programa en mayor proporción que otros grupos. En general, la inscripción en Medi-Cal ha disminuido en alrededor de 1,6 millones desde su punto más alto en mayo de 2023.

Outhyse atribuyó la caída a la reanudación de las verificaciones anuales de elegibilidad, que se suspendieron durante la pandemia de covid-19. California es uno de los 14 estados que, junto con Washington, D.C., financian cobertura de salud para, al menos, algunos inmigrantes que no califican para Medicaid o el Programa de Seguro de Salud para Niños bajo las reglas federales.

Pero dos investigadores, Leonardo Cuello, del Centro para Niños y Familias de la Universidad Georgetown, y Susan Babey, del , cuestionaron esa explicación. Señalaron que California y la mayoría de los otros estados ya habían reanudado completamente las verificaciones de elegibilidad .

Sin embargo, Tony Cava, vocero del DHCS, aseguró que esas revisiones continuaron reduciendo la inscripción hasta 2025.

Cuello agregó que los cambios federales aprobados por los republicanos en la ley One Big Beautiful Bill Act, que se espera provoquen más bajas, no entran en vigor hasta dentro de algunos meses.

“Tenemos muchos factores importantes que aún no han ocurrido y que provocarán la pérdida de cobertura”, explicó Cuello. “Pero la pérdida de cobertura que está ocurriendo ahora parece estar en gran medida relacionada con el miedo de los inmigrantes”.

Encuestas dan algunas pistas

Una encontró que, en todo el país, los adultos inmigrantes, especialmente los que son padres, están evitando cada vez más incluirse en programas gubernamentales que ayudan a pagar alimentos, vivienda o atención médica para no llamar la atención sobre su estatus migratorio o el de algún familiar. Esto incluye a residentes con estatus  y a ciudadanos naturalizados.

Cuello dijo que la tendencia a evitar estos programas por parte de los padres es especialmente preocupante porque aproximadamente 1 de cada 4 niños en EE.UU. tiene al menos un padre inmigrante. Aunque la mayoría de esos niños haya nacido en el país.

También opina que esa decisión de las familias puede explicar una disminución nacional de casi 3% en la inscripción en Medicaid y el Programa de Seguro de Salud para Niños durante los primeros 10 meses del año pasado, incluida una caída de 5,6% en la inscripción de niños en California, según datos recopilados por .

Los patrones de inscripción durante la primera administración Trump también ofrecen pistas. Por ejemplo, el presidente amplió los criterios de carga pública para incluir el uso de Medicaid y asistencia para alimentos y vivienda. Esto llevó a muchas familias inmigrantes, incluidos niños ciudadanos y personas no afectadas por la regla, a para los que eran elegibles. Algunos incluso después de que varios tribunales bloquearon su implementación y el presidente demócrata Joe Biden revocó la regla.

“La medida generó un alto nivel de confusión”, señaló Louise McCarthy, presidenta y directora ejecutiva de la Asociación de Clínicas Comunitarias del condado de Los Ángeles, que representa a unos 70 centros de salud en la zona. “El personal de los centros de salud comunitarios aún está trabajando para revertir los efectos de la primera regla”.

Ahorros estimados

Actualmente, solo las personas que dependen de programas de asistencia en efectivo o de atención institucional a largo plazo financiada por el gobierno pueden ser consideradas un riesgo de carga pública cuando solicitan una visa para entrar al país o gestionan la residencia permanente legal.

Pero bajo la propuesta de la administración Trump, Medicaid y otros programas sin entrega directa de dinero, así como el uso de beneficios por parte de familiares, podrían usarse para evaluar si es posible que una persona termine dependiendo del estado. Los oficiales de inmigración también tendrían mayor autoridad para decidir cuáles factores convierten a alguien en carga pública.

La propuesta del Departamento de Seguridad Nacional (DHS) indica que los cambios son necesarios porque las reglas actuales limitan la capacidad de la agencia para evaluar el riesgo de que un inmigrante dependa de recursos gubernamentales. El período de comentarios públicos terminó en diciembre.

El DHS no respondió a una pregunta respecto de cuándo tomará una decisión final sobre la norma. La propuesta indica que “estaría en línea con una política de larga data: según la cual los extranjeros en Estados Unidos deben ser autosuficientes y los beneficios estatales no deben incentivar la inmigración”.

La agencia calculó que esa modificación podría ahorrar a los gobiernos federal y estatales casi $9 mil millones al año gracias a personas que se den de baja o decidan no inscribirse en programas públicos.

En una carta en apoyo a esa iniciativa, el , una organización conservadora que promueve restricciones migratorias, describió la regla actual de carga pública como demasiado limitada y dijo que impide a los funcionarios de inmigración considerar “toda la información relevante”.

“El concepto de negar la entrada a personas que probablemente dependerán de la asistencia gubernamental no es nuevo”, escribió Elizabeth Jacobs, directora de asuntos regulatorios del grupo, en una publicación de diciembre.

La propuesta federal también admite que estas modificaciones podrían  provocar una pérdida de ingresos para economías estatales y locales, incluidos proveedores de salud como hospitales, supermercados, agricultores y arrendadores que participan en programas de vivienda financiados por el gobierno federal.

Un estimó que la norma que impulsa el gobierno podría llevar a que entre 1,3 y 4 millones de personas abandonen Medicaid o el Programa de Seguro de Salud para Niños, incluidos hasta 1,8 millones de niños ciudadanos.

“Claramente se está usando para generar miedo y ansiedad”, dijo Benyamin Chao, gerente supervisor de políticas de salud y beneficios públicos del California Immigrant Policy Center. El funcionario calificó la iniciativa como parte de un “ataque a inmigrantes con residencia legal, a ciudadanos estadounidenses que son familiares, y a la comunidad en general”.

Es posible que el temor a la carga pública también haga que menos personas participen en iniciativas contra el hambre, como el Programa de Asistencia Nutricional Suplementaria, conocido en California como CalFresh. Mark Lowry, director del Banco de Alimentos del condado de Orange, dijo que esto — junto con las bajas relacionadas con la ley One Big Beautiful Bill Act — podría saturar los bancos de alimentos, ya que los programas federales de nutrición representan la mayor parte de la ayuda alimentaria.

“No hay forma de que el sistema de alimentos de emergencia tenga la capacidad ni los recursos para cubrir esas necesidades”, dijo.

Necesidades de atención médica

El temor a inscribirse en Medi-Cal no afecta a todos los inmigrantes. Juana Zaragoza dirige un programa en Oxnard que ayuda principalmente a trabajadores agrícolas indígenas de México a anotarse en Medi-Cal. Allí, la inscripción y reinscripción se han mantenido estables en los últimos meses. Ni ella ni las comunidades a las que atiende conocen mucho sobre la propuesta de carga pública, explicó.

A menudo, las preocupaciones se ven superadas por la necesidad inmediata de atención médica.

“Nos encontramos con muchas personas que están evaluando qué los beneficia ahora y qué los beneficiará después”, dijo. “Algunos solo quieren cubrir sus necesidades en el momento”.

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El gobierno federal no lleva un registro de cuántos niños han ingresado a este sistema como consecuencia de operativos de control migratorio, lo que dificulta saber con qué frecuencia ocurre.

En Oregon, hasta febrero, dos niños habían sido ubicados en hogares temporales luego de ser separados de sus padres en casos de detención migratoria, según Jake Sunderland, vocero del Departamento de Servicios Humanos del estado.

“Antes del otoño de 2025, esto nunca había ocurrido”, aseguró.

Hasta mediados de febrero, casi por el Servicio de Inmigración y Control de Aduanas (ICE, por sus siglas en inglés).

El récord de 73.000 personas detenidas en enero representó un comparado con el año anterior. Según una , hasta agosto de 2025, padres de 11.000 niños con ciudadanía estadounidense habían sido detenidos desde el inicio del mandato de Trump.

El medio NOTUS que por lo menos 32 niños de padres detenidos o deportados habían sido colocados en hogares temporales en siete estados.

Sandy Santana, director ejecutivo de Children’s Rights, una organización de defensa legal, dijo que sospechan que el número real es mucho mayor.

“Ese número nos parece realmente muy bajo”, dijo.

La separación de sus padres es profundamente traumática para los niños y suele provocar , incluido el trastorno de estrés postraumático. El estrés prolongado e intenso también puede causar infecciones más frecuentes en los niños y problemas en el desarrollo. Ese “estrés tóxico” también se asocia con daños en áreas del cerebro responsables del aprendizaje y la memoria, , una organización sin fines de lucro dedicada a la información en salud que incluye a Â鶹ŮÓÅ Health News.

Durante el primer mandato de Trump, . y modificaron algunas leyes para permitir que tutores recibieran derechos parentales temporales en casos relacionados con migración. Ahora, tras el regreso de Trump al poder el año pasado, el aumento en los controles migratorios está impulsando una nueva ola de respuestas estatales.

En Nueva Jersey, legisladores están considerando un proyecto para modificar estatal que permite que los padres designen tutores temporales para casos de muerte o incapacidad. La nueva versión agregaría como otra razón válida la separación por control migratorio federal.

El año pasado, Nevada y California aprobaron leyes para proteger a las familias separadas por acciones de control migratorio. La ley de California, llamada Ley del Plan de Preparación Familiar (), permite que los padres designen tutores y compartan derechos de custodia, en lugar de que sus derechos se suspendan mientras están detenidos. Si son liberados y pueden reunirse con sus hijos, recuperan sus derechos parentales completos.

Existen importantes obstáculos legales para la reunificación familiar una vez que un niño entra bajo custodia estatal, explicó Juan Guzman, director del tribunal de menores y tutela en Alliance for Children’s Rights, una organización de defensa legal en Los Ángeles.

Si el niño es colocado en cuidado temporal y ni el padre ni la madre pueden participar en los procesos judiciales requeridos porque están detenidos o han sido deportados, es menos probable que puedan volver a reunirse con su hijo, afirmó Guzman.

Se estima que que son ciudadanos estadounidenses viven con un padre u otro familiar que no tiene estatus migratorio legal, según investigaciones de Brookings Institution, un centro de estudios en Washington, D.C. Dentro de ese grupo, 2,6 millones de niños tienen a ambos padres sin estatus legal.

Santana dijo que es probable que el número de casos de separación familiar aumente a medida que el gobierno de Trump avance con su campaña migratoria. Por lo tanto, más niños corren el riesgo de terminar en el sistema de cuidado temporal.

Las exigen que la agencia se esfuerce en facilitar la participación de los padres detenidos en los procedimientos de los tribunales de familia, de bienestar infantil o de tutela, pero Santana indicó que no está claro que el ICE esté cumpliendo con estas normas.

Los funcionarios de ICE no respondieron a las solicitudes de comentarios para este artículo.

Antes de que cambiara la ley de California, la única razón por la que un padre podía compartir derechos de custodia con otro tutor era si tenía una enfermedad terminal, contó Guzman.

Ahora, si los padres preparan un plan con anticipación y designan a alguien de confianza que pueda hacerse cargo de sus hijos si llegara a ser necesario, la agencia estatal de bienestar infantil puede iniciar el proceso para entregar a los niños a esa persona sin tener que abrir un caso formal de cuidado temporal, agregó.

Si bien el año pasado los legisladores de Nevada ampliaron una ley de tutela existente para incluir la aplicación de las leyes de inmigración, la medida exige a los padres dar el paso adicional de presentar documentación notariada ante la oficina del Secretario de Estado, señaló Cristian González-Pérez, abogado de Make the Road Nevada, una organización sin fines de lucro que brinda recursos a las comunidades inmigrantes.

González-Pérez señaló que algunos inmigrantes dudan en completar formularios gubernamentales por temor a que el ICE pueda acceder a esa información y los persiga. Él les asegura a los miembros de la comunidad que los formularios estatales son confidenciales y solo pueden ser consultados por hospitales y tribunales.

El gobierno de Trump ha tomado para acceder a información sensible a través de los Centros de Servicios de Medicare y Medicaid, el Servicio de Impuestos Internos (IRS), el Programa de Asistencia Nutricional Suplementaria (SNAP), el Departamento de Vivienda y Desarrollo Urbano y otras entidades.

González-Pérez y Guzmán consideran que muchos padres inmigrantes no conocen sus derechos. Designar un tutor temporal y crear un plan familiar es una forma de no sentirse impotentes, afirmó González-Pérez.

“La gente no quiere hablar de esa cuestión”, reflexionó Guzman. “Que un padre tenga que hablar con un niño sobre la posibilidad de separarse da miedo. No es algo que nadie quiera hacer”, concluyó.

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The federal government doesn’t track how many children have entered foster care because of immigration enforcement actions, leaving it unclear how often it happens. In Oregon, as of February two children had been placed in foster care after being separated from their parents in immigration detention cases, according to Jake Sunderland, a spokesperson for the Oregon Department of Human Services.

“Before fall 2025, this simply had never happened before,” Sunderland said.

As of mid-February, nearly by Immigration and Customs Enforcement. The record 73,000 people in detention in January represented an compared with one year before. According to , parents of 11,000 children who are U.S. citizens were detained from the beginning of Trump’s term through August.

The news outlet NOTUS that at least 32 children of detained or deported parents had been placed in foster care in seven states.

Sandy Santana, executive director of Children’s Rights, a legal advocacy organization, said he thinks the actual number is much higher.

“That, to us, seems really, really low,” he said.

Separation from a parent is deeply traumatic for children and can lead to , including post-traumatic stress disorder. Prolonged, intense stress can lead to more-frequent infections in children and developmental issues. That “toxic stress” is also associated with responsible for learning and memory, according to Â鶹ŮÓÅ.

, and amended existing laws during Trump’s first term to allow guardians to be granted temporary parental rights for immigration enforcement reasons. Now the enforcement surge that began after Trump returned to office last year has prompted a new wave of state responses.

In New Jersey, lawmakers are considering to amend a state law that allows parents to nominate standby, or temporary, guardians in the cases of death, incapacity, or debilitation. The bill would add separation due to federal immigration enforcement as another allowable reason.

Nevada and California passed laws last year to protect families separated by immigration enforcement actions. California’s law, called the , allows parents to nominate guardians and share custodial rights, instead of having them suspended, while they’re detained. They regain their full parental rights if they are released and are able to reunite with their children.

There are significant legal barriers to reunification once a child is placed in state custody, said Juan Guzman, director of children’s court and guardianship at the Alliance for Children’s Rights, a legal advocacy organization in Los Angeles.

If a parent’s child is placed in foster care and the parent cannot participate in required court proceedings because they are in detention or have been deported, it’s less likely they will be able to reunite with their child, Guzman said.

are U.S. citizens who live with a parent or family member who does not have legal immigration status, according to research from the Brookings Institution, a Washington, D.C.-based think tank. Within that group, 2.6 million children have two parents lacking legal status.

Santana said he expects the number of family separation cases to grow as the Trump administration continues its immigration enforcement campaign, putting more children at risk of being placed in foster care.

the agency to make efforts to facilitate detained parents’ participation in family court, child welfare, or guardianship proceedings, but Santana said it’s uncertain whether ICE is complying with those rules.

ICE officials did not respond to requests for comment for this report.

Before the change in California’s law, the only way a parent could share custodial rights with another guardian was if the parent was terminally ill, Guzman said.

If parents create a preparedness plan and identify an individual to assume guardianship of their children, the state child welfare agency can begin the process of placing the children with that individual without opening a formal foster care case, he added.

While Nevada lawmakers expanded an existing guardianship law last year to include immigration enforcement, the measure requires the parents to take the additional step of filing notarized paperwork with the secretary of state’s office, said Cristian Gonzalez-Perez, an attorney at Make the Road Nevada, a nonprofit that provides resources to immigrant communities.

Gonzalez-Perez said some immigrants are still hesitant to fill out government forms, out of fear that ICE might access their information and target them. He reassures community members that the state forms are secure and can be accessed only by hospitals and courts.

The Trump administration has taken through the Centers for Medicare & Medicaid Services, the IRS, the Supplemental Nutrition Assistance Program, the Department of Housing and Urban Development, and other entities.

Gonzalez-Perez and Guzman said that not enough immigrant parents know their rights. Nominating a temporary guardian and creating a plan for their families is one way they can prevent feelings of helplessness, Gonzalez-Perez said.

“Folks don’t want to talk about it, right?” Guzman said. “The parent having to speak to a child about the possibility of separation, it’s scary. It’s not something anybody wants to do.”

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An elementary school teacher chose a low-price health insurance plan but soon realized she wasn’t clear about what it would mean for her family’s finances.

“Once I got the insurance card, I compared our old plan to our new plan, and that’s when I really got worried, because I didn’t really understand what a deductible was. It got me thinking, how do I use this insurance?”

— Madison Burgess, 31, of San Diego

When enhanced federal subsidies expired at the end of 2025, a lot of people buying their own health insurance on the state and federal exchanges saw their expected monthly rates jump. To keep costs down, many switched to a high-deductible health plan. These plans offer lower monthly payments, but in exchange patients can face steep out-of-pocket costs when they need care.

The plans are pretty common. In 2023, 30% of people who got insurance through their employer had a high-deductible plan, up from only 4% in 2006.

Madison Burgess, a teacher in San Diego, gets health insurance through her teaching job. But when she investigated adding her husband to her plan, it was just too expensive, so she started shopping on the exchange for a cheaper option for him.

The longer she scrolled through the plan options, the more overwhelming it felt. Insurance jargon made it hard to tell what her family would owe if her husband got sick.

“I didn’t know what a deductible was, so I just went with what was cheap, and now I have regret,” she said.

In exchange for that lower monthly premium payment, her husband’s coverage won’t kick in for most care until they’ve paid $5,800 in medical bills. Burgess didn’t know that the deductible must be met before insurance picks up part of the tab.

Deductible:

The amount you as the patient have to pay before insurance picks up part of the tab

Premium:

The monthly bill for your policy, paid to the insurance company

How do you prepare for thousands of dollars in upfront costs? One option is a health savings account, or HSA, which lets you save pretax money and is now available to people enrolled in lower-tier state and federal exchange plans, including bronze and catastrophic coverage. These plans generally have the lowest premiums on the exchange but the highest out-of-pocket costs when you need care.

Burgess had chosen a bronze plan and didn’t know HSAs were an option.

“I’ve never thought about having to put money away for a deductible,” she said.

Burgess and others are often more worried about socking away money for unexpected car and house repairs or vet bills.

If, like Burgess, you chose cheaper health coverage for this year only to discover you’re on the hook for meeting a high deductible, these tips can help you prepare.

1. You might qualify for an HSA and not know it.

If you’re enrolled in a bronze or catastrophic plan, you qualify to open a health savings account. Think of it as a medical piggy bank with tax perks. You put in pretax money, which lowers your taxable income. The money grows tax-free, and when you spend it on , those transactions are also tax-free. That’s what people call a “triple tax advantage.”

These accounts build a cushion for future health costs, such as doctor visits, prescriptions, and even products like over-the-counter medicine, tampons, and sunscreen.

The money typically can’t be used for monthly premiums, but the account is yours to use for qualified medical expenses for yourself, your spouse, or your dependents anytime in the future. The money in the account is yours, even if you change jobs or health plans.

An HSA is not the same as a flexible spending account, or FSA. FSAs are tax-advantaged too but are offered only through employers. The money expires annually and you lose any remaining money when you leave that job.

2. HSA-curious? Here’s how to open one.

You open a health savings account through a bank or other financial institution. The institution will issue you a debit card so you can make purchases from the HSA.

You can at any point during the year as long as you’re covered by an eligible plan. You can choose where to open the account, but be sure to check for any fees financial institutions charge and shop around.

If you get insurance through your job, your employer may require you to use a specific IRS-approved company.

Many people decide they can’t afford to contribute to an HSA. For some households, the desire to set aside money for medical expenses competes with the need to pay rent and buy groceries.

But there’s a detail that can make it feel more manageable. Contributions don’t have to be large. Just a few dollars a month can get you started.

There is, however, a limit. The IRS sets an annual cap on how much you’re allowed to contribute to an HSA. In 2026, an individual is limited to $4,400, or $8,750 for a family plan. Under that ceiling, the amount is up to you.

3. Preventive services should be covered at no cost to you.

All plans sold on marketplaces must cover at no cost to the patient as long as the care is provided in-network. Those services include routine immunizations and cancer screenings.

Beyond preventive care, understanding what different services cost can help you decide which type of medical appointment works best for your health needs and your wallet. For example, some plans charge less for a telehealth visit than to see your primary care doctor in person.

Check out your for more details.

4. Seek care early in the year.

Most deductibles reset on Jan. 1. Scheduling appointments or surgeries early in the year can be strategic if you discover a condition that requires ongoing care. If you can afford it, meeting your deductible sooner can make the rest of the year significantly cheaper, said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

5. Consider paying cash instead of spending down your deductible.

Some hospitals, clinics, or other providers offer cheaper prices if you pay cash. You have the and explanation of how much a health service would cost if you paid out-of-pocket. Ask for the estimate before you get care. Then, compare that price with what your insurance company tells you it would cost if you used your insurance. If you decide to go with a cash payment, you’ll need to pay while you’re still at the doctor’s office, before charges get submitted to your insurance company.

Paying cash may save you money, but the amount you pay generally won’t count toward your deductible or out-of-pocket maximum.

“If you don’t think you’re ever going to hit your deductible — you’re that young invincible, and your deductible is $10,000 — negotiate the cash price,” Donovan said.

6. On an ACA plan? Update your income and use an HSA to avoid a tax surprise.

If you’re on an ACA plan and you’re eligible for subsidies, be aware: If your and you don’t update your marketplace application, you could owe thousands of dollars at tax time. The . Report raises, new jobs, or side gigs as they happen. If your income goes up, stashing money in an HSA can help because the money you put in the account doesn’t count toward your taxable income.

As soon as you report an increase in your income, that could mean higher premiums (if you no longer qualify for the same subsidy), but experts say it’s better to pay now than owe a big bill that you have to pay all at once.

“One of the biggest problems I see is someone is newly unemployed and they sign up for coverage, they say that they’re not making any money, and then eventually they get a job and don’t report it, and then they have this huge tax bill at the end,” Donovan said.

She advises updating your marketplace profile as soon as your income changes, which could newly qualify you for Medicaid or a plan that contributes more toward your medical bills.

Taylor Cook contributed to this report.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and Â鶹ŮÓÅ Health News.

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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Vestida con ropa de senderismo y collares de cuentas, Carranza, de 67 años, se movía entre árboles y niños en una mañana soleada de diciembre. “Agárrate de esa rama”, dijo en español. “¡Tú puedes, mi amor!”.

Carranza, profesional especializada en desarrollo infantil que creció columpiándose entre árboles y nadando en ríos en El Salvador, dijo que se siente como en casa en el bosque del preescolar al aire libre que cofundó. Ha trabajado con niños y adolescentes como cuidadora y educadora durante más de tres décadas, el tiempo suficiente para saber cuándo intervenir y cuándo dar un paso atrás para que sus estudiantes encuentren su propio equilibrio.

Cuando pasó a trabajar medio tiempo el año pasado, Carranza contaba con recibir Medicare y cheques del Seguro Social, beneficios otorgados a trabajadores estadounidenses e inmigrantes con presencia legal cuando se retiran, si de historial laboral y edad, o si tienen alguna discapacidad.

Carranza ha aportado decenas de miles de dólares a Medicare y al Seguro Social durante 24 años, según su registro de ingresos de la Administración del Seguro Social, revisado por El Tímpano y Â鶹ŮÓÅ Health News. Pero Carranza es una de un estimado de 100.000 inmigrantes con papeles que pronto quedarán excluidos de Medicare.

La ley One Big Beautiful Bill Act del Partido Republicano, firmada en julio pasado por el presidente Donald Trump, prohíbe que ciertas categorías de inmigrantes con presencia legal — incluidos beneficiarios del estatus de protección temporal (TPS), refugiados, solicitantes de asilo, sobrevivientes de violencia doméstica, víctimas de trata y personas con visas de trabajo — accedan a Medicare.

Quienes ya están en el programa, como Carranza, serán dados de baja antes del 4 de enero, una medida de legisladores republicanos para reducir el gasto de Medicare, ya que, junto con Trump, han argumentado que el dinero de los contribuyentes no debe usarse para pagar la atención médica de inmigrantes sin autorización.

“Los demócratas quieren que los inmigrantes ilegales, muchos de ellos CRIMINALES VIOLENTOS, reciban atención médica GRATIS”, dos meses después de firmar la ley. “¡No podemos permitir que esto suceda!”

Sin embargo, las categorías de inmigrantes que ahora perderán cobertura sí tienen estatus legal. Ni la Casa Blanca ni el Departamento de Salud y Servicios Humanos (HHS) respondieron a una pregunta sobre si era justo sacar de Medicare a residentes legales.

Los inmigrantes sin estatus legal ya no eran elegibles para Medicare ni para la mayoría de los beneficios públicos financiados por el gobierno federal.

Carranza teme que también pueda perder el permiso legal para vivir en Estados Unidos si la administración Trump pone fin al TPS para salvadoreños, como intentó hacer durante .

Si eso ocurre, Carranza perdería su residencia legal y podría estar en riesgo de pasar tiempo en un centro de detención migratorio o ser deportada.

“Esto es como una película de terror, una pesadilla completa”, dijo Carranza. “No es así como imaginé envejecer”.

“Bajo ataque constante”

Carranza dejó El Salvador en 1991 durante una guerra civil brutal, dejando atrás a tres hijos pequeños, para ganar dinero y enviarlo a su familia. Permaneció en el país después de que venciera su visa hasta 2001, cuando calificó para el TPS, luego de dos terremotos que azotaron El Salvador, y desplazando a 1,3 millones.

El TPS fue aprobado por el Congreso y promulgado en 1990 por el presidente republicano George H.W. Bush.

Este estatus permite que personas como Carranza, provenientes de ciertos países afectados por conflictos armados, guerras civiles o desastres climáticos, vivan y trabajen en Estados Unidos, si regresar a su país representa un riesgo.

Carranza se perdió la graduación de jardín de infantes de su hija menor y su primera medalla en atletismo. Trabajó turnos nocturnos cuidando recién nacidos y luego como maestra sustituta en escuelas públicas del Área de la Bahía de San Francisco para pagar la educación de sus hijos en El Salvador, así como sus propios estudios en el City College of San Francisco, donde obtuvo un título en desarrollo infantil.

También cuidó a decenas de niños de 3, 4 y 5 años que miraban con asombro mientras descubrían pequeños tesoros en el bosque de secuoyas del parque de Oakland donde cofundó Escuelita del Bosque, un preescolar de inmersión en español que enseña al aire libre.

Se suponía que la recompensa sería una jubilación tranquila. Pero el Congreso limitó la elegibilidad de Medicare a ciudadanos, residentes permanentes legales, nacionales cubanos y haitianos, y personas amparadas por los Compacts of Free Association, acuerdos entre Estados Unidos y naciones insulares del Pacífico.

La medida siguió a los intentos de Trump de excluir a algunos inmigrantes con presencia legal de Medicaid, de los subsidios en el mercado de seguros de salud y de servicios de apoyo social, como asistencia alimentaria, ayuda para vivienda y visitas médicas en centros de salud financiados por el gobierno federal. En total, se proyectaba que 1,4 millones de inmigrantes con presencia legal perderían el seguro de salud, según Â鶹ŮÓÅ, una organización sin fines de lucro de información de salud que incluye a Â鶹ŮÓÅ Health News.

Taylor Haulsee, vocero del presidente de la Cámara de Representantes, Mike Johnson, no respondió a solicitudes de comentarios.

Michael Cannon, director de estudios de política de salud en el Cato Institute, un centro de tendencia libertaria, dijo que los republicanos querían implementar recortes de impuestos y eliminar el seguro de salud para inmigrantes porque no afectaría a su base.

“No quieren convertir a Estados Unidos en un imán de asistencia social”, opinó. “Y les molesta que el gobierno les haga pagar por un estado de bienestar”.

Aunque no hay datos sobre inmigrantes con presencia legal, los inmigrantes sin papeles aportaron y $25,7 mil millones al Seguro Social en 2022, según el Institute on Taxation and Economic Policy.

La Oficina de Presupuesto del Congreso estimó que solo las restricciones a Medicare reducirían el gasto federal en para 2034.

Expertos en salud dicen que eliminar la cobertura para inmigrantes con estatus legal .

“En realidad, esta es la primera vez que el Congreso le quita Medicare a algún grupo”, dijo Drishti Pillai, directora de políticas de salud para inmigrantes en Â鶹ŮÓÅ. “Este cambio está afectando a inmigrantes con presencia legal en Estados Unidos, muchos de los cuales ya han trabajado y contribuido al sistema durante décadas”.

A medida que adultos mayores como Carranza pierdan su cobertura de Medicare, los médicos anticipan que retrasarán su atención, lo que llevará a un aumento de pacientes gravemente enfermos, especialmente en salas de emergencia.

Los adultos mayores pueden enfermarse de forma repentina y rápida, y son más vulnerables a enfermedades cardiovasculares como afecciones del corazón y presión arterial alta, especialmente si posponen la atención de rutina, dijo Theresa Cheng, médica de emergencias en Zuckerberg San Francisco General Hospital y profesora clínica adjunta de medicina de emergencias en la Universidad de California-San Francisco.

“Es bastante fácil que sufran un deterioro crítico de su salud”, dijo Cheng.

Carranza hace senderismo y se considera saludable, pero reconoce que está envejeciendo y comenzando a tener dificultades para seguir el ritmo de los niños en el bosque.

A finales del año pasado le diagnosticaron hipertensión, y en enero despertó con una presión en el pecho y fue a un centro de urgencias porque su presión había subido a niveles peligrosos. Unas semanas después, tropezó mientras caminaba y se cayó. Al día siguiente despertó con el pie hinchado. En el hospital local, un médico le dijo que tenía artritis.

Dijo que fueron momentos preocupantes, pero estaba agradecida de pagar solo $10 por la visita a urgencias y $5 por ver a su médico de atención primaria. Sin embargo, eso cambiará cuando pierda Medicare a principios del próximo año.

El estrés de saber que perderá su seguro de salud y posiblemente su estatus legal, mientras agentes federales detienen a inmigrantes como ella en todo el país, ha afectado su salud mental, contó. Está buscando terapia y servicios de acupuntura para tratar su insomnio y ansiedad, y la sensación de estar “bajo un ataque constante”.

Sin un lugar a donde ir

En California, hogar del mayor número de , Carranza podría haberse inscrito en un seguro patrocinado por el estado, pero este año la inscripción para adultos de 19 años o más que tienen TPS, están en el país sin autorización o son solicitantes de asilo. Otros estados con gobernadores demócratas como también han reducido sus programas de salud para inmigrantes por presiones presupuestarias.

En enero, el gobernador de California, Gavin Newsom, propuso un presupuesto estatal que no compensaría los recortes federales de atención médica para unos 200.000 inmigrantes con presencia legal, señalando el costo anual de $1.1 mil millones y déficits presupuestarios estatales.

“Dadas estas presiones fiscales, la administración no puede compensar este cambio en la política federal”, dijo H.D. Palmer, vocero del Departamento de Finanzas de California.

Pero algunos legisladores demócratas y defensores de los consumidores dicen que el estado debería intervenir. La asambleísta Mia Bonta, quien preside el Comité de Salud de la Asamblea, dijo que está trabajando en una solución presupuestaria legislativa para incluir en Medi-Cal — la versión estatal de Medicaid — a los inmigrantes que perderán su cobertura, incluidos los adultos mayores.

La demócrata de East Bay está especialmente preocupada por personas como Carranza, “que han vivido aquí durante décadas y han contribuido a esta economía, que han aportado a nuestro tejido cultural y a nuestras comunidades, que han formado familias y vidas y que ahora quieren tener la posibilidad de retirarse con dignidad y vivir con dignidad y tener la atención médica que necesitan”.

Una señal del futuro

En abril pasado, Carranza vislumbró lo que podría significar perder su cobertura de salud y beneficios de jubilación, después de que la Administración del Seguro Social le enviara una carta informándole que ya no calificaba para beneficios de jubilación porque no tenía presencia legal en el país, aunque sí la tenía. Luego Medicare dejó de pagar a su plan de salud, que como resultado la dio de baja.

Como beneficiaria de TPS con permiso de trabajo, sabía que se trataba de un error. Aun así, sin su cheque, Carranza no tuvo dinero para pagar la renta durante un mes. Compensó ese pago cuidando a los hijos de sus arrendadores. En mayo pasado, la oficina de la representante federal Lateefah Simon (demócrata de Oakland) ayudó a Carranza a recuperar sus beneficios de jubilación, pero tomó meses recuperar su seguro de salud.

La experiencia la dejó afectada.

“Es como recibir una bofetada en la cara después de más de 30 años trabajando para el sistema aquí”, dijo Carranza. “Y a cambio, esto es lo que tenemos ahora”.

Por las noches permanece despierta imaginando el futuro: aquí, donde ha pasado la mitad de su vida, sin seguro de salud y posiblemente sin beneficios del Seguro Social; o en El Salvador, donde están dos de sus tres hijos. Su hija, residente permanente que vive en Texas, espera convertirse en ciudadana para poder solicitar la residencia permanente para Carranza, pero el proceso puede tardar años.

También está la posibilidad que más teme: la detención indefinida o la deportación.

En una mañana reciente en su estudio en el sótano en Oakland, Carranza sacó una caja del fondo de su clóset. Dentro había una pila alta de tarjetas de identificación que incluían licencias de conducir antiguas, su tarjeta del Seguro Social y decenas de permisos de trabajo emitidos por el gobierno federal.

“Mi vida está en esta caja”, dijo.

Este artículo fue producido en colaboración con , una organización cívico-mediática que sirve y cubre a las comunidades inmigrantes latinas y mayas del Área de la Bahía.

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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Dressed in hiking gear and beaded necklaces, Carranza, 67, maneuvered between trees and children on a sunny morning in December. “Hold on to that branch,” she said in Spanish. “You can do it, my love!”

Carranza, a child development professional who grew up swinging through trees and swimming in rivers in El Salvador, said she feels at home in the forest at the outdoor preschool she co-founded. She has worked with children and teens as a caregiver and educator for more than three decades, long enough to know when to lean in and when to step back to let her students find their own footing.

When she transitioned to working part-time last year, Carranza counted on getting Medicare and Social Security checks — benefits given to American workers and lawfully present immigrants when they retire, work history and age or disability requirements. She’s contributed tens of thousands of dollars into Medicare and Social Security over 24 years, according to her Social Security Administration earnings record, reviewed by El Tímpano and Â鶹ŮÓÅ Health News. But Carranza and an estimated immigrants will soon be cut out of Medicare.

The GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump, barred certain categories of lawfully present immigrants — including temporary protected status holders, refugees, asylum-seekers, survivors of domestic violence, trafficking victims, and people with work visas — from Medicare.

Those already in the program, like Carranza, will be disenrolled by Jan. 4 — a move by Republican lawmakers to rein in Medicare spending, as they and Trump have argued that taxpayer dollars should not be used to pay for the health care of immigrants in the U.S. without authorization.

“The Democrats want Illegal Aliens, many of them VIOLENT CRIMINALS, to receive FREE Healthcare,” Trump two months after he signed the bill into law. “We cannot let this happen!”

However, the categories of immigrants now losing coverage do have legal status. Neither the White House nor the Department of Health and Human Services responded to a question about whether it was fair to disenroll legal residents from Medicare.

Immigrants without legal status were already ineligible for Medicare or most other federally funded public benefits.

Carranza is worried that she could also lose legal permission to live in the United States if the Trump administration ends temporary protected status for Salvadorans, as it sought to do during .

If that happened, Carranza would lose legal residency, risking time in an immigration detention center or deportation.

“This is like a horror movie, a complete nightmare,” Carranza said. “This is not how I imagined getting old.”

‘Under Constant Attack’

Carranza left El Salvador in 1991 during a brutal civil war, leaving behind three young children, to earn money to send home to her family. She overstayed her visa until 2001, when she qualified for temporary protected status, after two earthquakes struck El Salvador, and displacing 1.3 million.

Temporary protected status, or TPS, was passed by Congress and signed into law by Republican President George H.W. Bush in 1990.

It allows people such as Carranza, from select nations undergoing armed conflict, civil war, and climate disasters, to live and work in the United States if being in their home country poses a risk.

Carranza missed her youngest daughter’s graduation from kindergarten and first medal-winning performance in track. She worked overnight shifts babysitting newborns and later substitute-taught in public schools in the San Francisco Bay Area to pay for her children’s schooling in El Salvador, and for her own classes at City College of San Francisco, where she earned a degree in child development.

And she cared for dozens of 3-, 4-, and 5-year-olds who gazed in awe as they uncovered little treasures buried in the redwood forest of the Oakland park where she co-founded Escuelita del Bosque, a Spanish immersion preschool that teaches children outdoors.

The trade-off was supposed to be a peaceful retirement. But Congress narrowed Medicare eligibility to citizens, lawful permanent residents, Cuban and Haitian nationals, and people covered under the Compacts of Free Association, agreements between the United States and Pacific island nations.

The move followed Trump’s efforts to bar some lawfully present immigrants from Medicaid, marketplace insurance subsidies, and social support services, such as food assistance, housing subsidies, and medical visits in federally funded health centers. Altogether, 1.4 million lawfully present immigrants were projected to lose health insurance, according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

A spokesperson for House Speaker Mike Johnson, Taylor Haulsee, did not respond to requests for comment.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said Republicans wanted to enact tax cuts and eliminate health insurance for immigrants because it wouldn’t upset their base.

“They don’t want to turn the United States into a welfare magnet,” he said. “And they resent the government for making them pay for a welfare state.”

While data on lawfully present immigrants is not available, immigrants without legal status and $25.7 billion into Social Security in 2022, according to the Institute on Taxation and Economic Policy. The Congressional Budget Office estimated that the Medicare restrictions alone would reduce federal spending by 2034.

Health experts say eliminating coverage for immigrants with legal status .

“This is actually the first time that Congress has taken away Medicare from any group,” said Drishti Pillai, director of immigrant health policy at Â鶹ŮÓÅ. “This change is impacting immigrants who have lawful presence in the U.S., and many of whom have already worked and paid into the system for decades.”

As older adults like Carranza lose their Medicare coverage, clinicians anticipate that they will delay their care, leading to an increase in severely ill patients, especially in hospital emergency rooms.

Seniors can become sick suddenly and quickly, and they are more vulnerable to cardiovascular diseases such as heart disease and high blood pressure, especially if they put off routine care, said Theresa Cheng, an emergency physician at Zuckerberg San Francisco General Hospital and assistant clinical professor of emergency medicine at the University of California-San Francisco.

“It’s quite easy for them to fall off the cliff,” Cheng said.

Carranza hikes and considers herself healthy, but she acknowledges that she is aging and starting to struggle to keep up with the kids in the forest.

Late last year she was diagnosed with high blood pressure, and in January she woke up with a tight chest and went to urgent care because it had spiked to dangerous levels. A few weeks later, she tripped on a curb while walking and fell to the ground. She woke up the next day with a swollen foot. A doctor at the local hospital told her she had arthritis.

These were scary moments, she said, but she was grateful to have to pay only $10 for the urgent care visit and $5 to see her primary care doctor. However, that will change when she loses Medicare by early next year.

The stress of knowing she will lose health insurance coverage, and potentially her legal status, all while masked federal agents are detaining immigrants like her across the country, has taken a toll on her mental health, she said. She is searching for a therapist and acupuncture services to treat her insomnia and anxiety — and the feeling that she is “under constant attack.”

Nowhere To Turn

In California, home to the largest number of , Carranza could have enrolled in state-sponsored insurance, but this year the state for adults 19 and older who are a TPS holder, in the U.S. without authorization, or an asylum-seeker. Other states with Democratic governors such as have also scaled back their health programs for immigrants amid budget pressures.

In January, California Gov. Gavin Newsom proposed a state budget that would not backfill federal health care cuts to about 200,000 lawfully present immigrants, noting the $1.1 billion annual price tag and state budget shortfalls.

“Given these fiscal pressures, the administration cannot backfill for this change in federal policy,” California Department of Finance spokesperson H.D. Palmer said.

But some Democratic lawmakers and consumer advocates say the state should step in. State Assembly member Mia Bonta, who chairs the Assembly’s health committee, said she is working on a legislative budget solution to bring immigrants who will lose health coverage, including older adults, into Medi-Cal, the state’s version of Medicaid.

The East Bay Democrat is especially concerned for people like Carranza, “who have lived here for decades and contributed into this economy, who have given into our cultural fabric and into our communities and who built families and lives and who are now wanting to be able to retire with dignity and live with dignity and have the health care that they need.”

A Sign of the Future

Last April, Carranza got a glimpse of what losing her health coverage and retirement benefits could look like, after the Social Security Administration sent her a letter informing her that she no longer qualified for retirement benefits because she was not lawfully present in the U.S. — even though she was. Then Medicare stopped payments to her health plan, which disenrolled her as a result.

As a TPS holder with a work permit, she knew a mistake had been made. Yet, without her check, Carranza didn’t have money to pay her rent for a month. She worked off her rent by babysitting her landlords’ children. Last May, the office of U.S. Rep. Lateefah Simon, an Oakland Democrat, helped Carranza recover her retirement benefits, but it took months for her to get her health insurance back.

The experience left her reeling.

“It’s like getting slapped on the face after more than 30 years working for the system here,” Carranza said. “And in return, this is what we have now.”

She lies awake at night imagining the future: here, where she’s spent half her life, without health insurance and possibly Social Security benefits; or in El Salvador, where two of her three children remain. Her daughter, a green-card holder who lives in Texas, hopes to become a citizen so she can petition for permanent residency for Carranza, but the process can take years. Then there’s the possibility she fears most: indefinite detention or deportation.

On a recent morning in her basement studio in Oakland, Carranza pulled a box from the back of her closet. In it was a thick stack of identification cards that included old driver’s licenses, her Social Security card, and dozens of work IDs issued by the federal government.

“My life is in that box,” she said.

This article was produced in collaboration with , a civic media organization serving and covering the Bay Area’s Latino and Mayan immigrant communities.

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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This story can be republished for free (details).

Ollie’s parents, who adopted her in 2020, tried to sign her up for a clinical trial using — which genetically reprograms a patient’s white blood cells to help them fight cancer — at UNC Health in Chapel Hill, North Carolina, an hour-and-a-half drive from their home in Eden.

Her mother, Britany Super, described it as Ollie’s “last option.”

But in early March, Super recalled, UNC Health’s financial office told them the bad news: The state’s new insurance for kids in foster care wasn’t going to pay for the treatment.

In December, Ollie became one of hundreds of thousands of kids nationwide enrolled in a special kind of public health insurance for people served by the foster care system. That insurance, known as a specialized managed care plan, is part of Medicaid, the federal-state program that covers health costs for people with low incomes or disabilities.

North Carolina is one of 14 states with such specialized foster care plans, according to the National Academy for State Health Policy. The plans differ by state, but each is meant to expand coverage for children in the foster care system — and for kids who were adopted out of it, such as Ollie and her siblings.

Yet, as in other states that have struggled when adding such plans, North Carolina families have faced hurdles obtaining care. Thousands of doctors whose services were covered under Medicaid were not included in the specialized plan — which is costing the state $3.1 billion over four years — when it rolled out on Dec. 1. That left guardians and parents of kids adopted out of the system scrambling to figure out whether they would have to find new health care providers or new insurance.

In North Carolina, the insurance plan’s stumbles have added another layer of complication around health care issues. The state — like many others — is already over expected Medicaid cuts in the wake of congressional Republicans’ One Big Beautiful Bill Act. A separate Medicaid funding shortfall also prompted a push to cut care providers’ reimbursement rates.

Texas, which established its plan 18 years ago, that its foster families also had a hard time finding doctors on the insurance. In Florida, researchers for the state reported as early as 2016 that there was .

Illinois’ plan by the Centers for Medicare & Medicaid Services over a lack of access to care. Research concluded that California’s plan children with adequate mental health services. Georgia’s access problems alarmed state officials enough to calling for children to be removed from the plan and put back on other Medicaid plans.

But such specialized plans for kids in foster care continue to gain traction. Four states have started their own plans in the past five years, said , the senior director of children and family health at the National Academy for State Health Policy, and she said it’s likely more will adopt them soon.

showing how these programs are faring, Medicaid policy analysts said. It’s therefore difficult to know why they’ve run into rollout problems or whether they’ve improved access to care. That makes the plans risky, said , a research professor at Georgetown University’s Center for Children and Families.

“The states that are going in this direction, unless they have data to support it, are experimenting,” Schneider said. “They’re putting all their eggs in one basket, so they need to pay close attention.”

Rough Rollout

North Carolina’s specialized insurance plan for foster kids experienced problems the day it rolled out.

The state automatically enrolled Ollie and about 32,000 other people in , called . North Carolina officials had said the program would improve health care access for foster children, who often have medically complex needs and move frequently.

But foster families quickly began hearing that their health care providers were not taking the insurance, according to several families who recounted their experiences fighting to get their children’s procedures covered under the plan.

UNC Health, a state-run health system that is , with nearly 4,400 physicians, initially, which is why it told Super that Ollie’s CAR T-cell treatment wouldn’t be covered.

After more than two months of limbo for families, UNC Health ultimately in mid-March with Blue Cross Blue Shield of North Carolina, which runs the plan.

But some North Carolina doctors still don’t accept Healthy Blue insurance.

, interim deputy secretary for North Carolina’s Medicaid program, said her office to expand its network, even though it already has what she called an “adequate” number of providers. North Carolina’s health department and Blue Cross Blue Shield did not answer Â鶹ŮÓÅ Health News’ questions about how many providers are covered by the new insurance.

“We welcome qualified providers who want to join,” said Blue Cross Blue Shield of North Carolina spokesperson Sara Lang.

Other problems . As thousands of health care records move over to a statewide database managed by Healthy Blue, children’s doctors are struggling to track their patients’ medical histories, said foster care advocates and pediatricians. Parents reported problems seeing health records, finding themselves locked out of online portals. Others couldn’t access prescriptions. Surgeries got delayed. Appointments were canceled.

“Network management for any plan is an ongoing process,” Lang said.

All this meant added red tape and heartache for the caregivers of children like Ollie with complex medical needs — those the .

Gearing Up

Cancer has been part of Ollie’s life since she was 2. She was in the process of getting adopted out of foster care when she began chemotherapy and radiation treatments, then received two stem cell transplants, Super recalled.

Surgeons installed temporary tubes in a vein near her heart and a feeding tube in her abdomen. Her hair fell out as the treatment intensified, and a thin layer of skin peeled off, forcing her new family to wear surgical gowns and gloves when they wanted to be close.

“She doesn’t remember life outside of going to doctors and being in a hospital,” Super said.

Ollie still has a port in her chest ready for whenever she needs intravenous medicine, and her monthly doctor appointments are about to become weekly. During an emergency room visit in mid-March, doctors told Super her daughter’s cancer had spread. Ollie will need more chemotherapy before her body is ready for the more advanced treatment.

But the Supers, thrown into uncertainty for more than two months, still feel some relief. They’re preparing for back-and-forth drives for the CAR T-cell therapy treatments in Chapel Hill. And they’re grateful, even if it means Ollie will spend at least five more weeks in and out of a hospital.

Reliable health insurance will be vital for Ollie, and Healthy Blue leaders said they are talking with doctors, parents, and others to make sure the plan is working. Her procedures carry multimillion-dollar price tags, her mother said, but having her bills seamlessly covered allows the family to focus on Ollie’s treatment.

“The biggest challenges for her will be in the first few months of the study,” said Super, who knows the therapy’s side effects include fever, fatigue, and confusion. “But I’m hoping that after that, the CAR T-cells will do their job and fight the cancer and she can continue to have a playful, active life.”

That means, they hope, the girl could be at home more often with her five siblings and the three family dogs, including Remy, a border collie mix who is Ollie’s favorite.

Super relishes those precious moments for her daughter — “being a kid and doing kid things.”

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