But Republican lawmakers in some states think the new rules — part of the GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump — don’t go far enough.

Indiana is leading that charge, with a new law that requires applicants to prove they’ve been working or participating in a similar activity for three consecutive months to get benefits.

Meanwhile, residents in many other states will have to show they’ve been working just one month, the least cumbersome option under Trump’s signature tax-and-domestic-spending law. It instructs states to decide whether to require one, two, or three months of work history.

As in Indiana, Republican Idaho lawmakers approved a three-month requirement, and the state’s governor signed the bill into law on April 10.

The efforts, along with similar moves in Arizona, Missouri, and Kentucky, are aimed at restricting flexibility to implement the federal law at the state level.

“Normally, you would not see state legislators weighing in on these decisions,” said Lucy Dagneau, a senior official with the American Cancer Society’s advocacy arm.

The nonpartisan Congressional Budget Office estimated 18.5 million adults will be subject to the new rules, which will be enforced across 42 states and the District of Columbia. In Indiana, work rules will target about 33% of the state’s Medicaid population. The rules generally wouldn’t apply to children, people 65 or older, or people with disabilities or serious health issues.

Typically, state administrators — not lawmakers — detail how they plan to comply with new federal standards, and they often look to federal regulators for guidance. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving state lawmakers to intervene.

Gov. Mike Braun, a Republican, signed the Indiana bill into law on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under the federal law.

Republican state Sen. Chris Garten introduced a bill in January, saying it was needed to “align” state law with the new federal Medicaid rules. He also pitched the bill as a way to crack down on “waste, fraud, and abuse” in public programs.

When ineligible people get enrolled, it robs “the truly vulnerable Hoosier who actually needs the help,” Garten said during a January committee hearing.

Democratic state Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the necessity of the legislation. Qaddoura asked Indiana Family and Social Services Administration Secretary Mitch Roob to provide an estimate of the number of ineligible people who enrolled in Medicaid in the state.

“I think very few,” Roob replied. “It’ll never be none.”

After hearing Roob’s answer, Qaddoura said there is no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud, and abuse as justification to deny health benefits and food aid to vulnerable Hoosiers.

Garten later called Qaddoura’s accusation a “fundamental mischaracterization” of the bill.

Republicans have said imposing these limits protects the Medicaid program’s longevity.

“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains sustainable.”

Indiana’s Medicaid enrollment is expected to decrease because of Garten’s legislation, according to an analysis from Indiana’s nonpartisan Legislative Services Agency.

Medicaid helps keep people healthy, so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization focusing on health, housing, and food insecurity.

Mueller worries that people will struggle to prove their work history, especially those with nontraditional jobs.

“If the point is to get people engaged, the one month would do it,” Mueller said.

Ultimately, he fears the law will harm Hoosiers with the greatest need for assistance. “They’re going to get tripped up by the bureaucratic hurdles.”

An analysis by the Center on Budget and Policy Priorities predicted that work rules will and that how states choose to implement the rules will “significantly affect the number of people who lose coverage.” State policy decisions will determine just “how intense the burden is,” the left-leaning think tank found, and opting for a shorter look-back period “will enable more people to enroll.”

Lawmakers in multiple states considered limits. And the same right-leaning lobbying group, the Foundation for Government Accountability, testified in favor of these measures in Arizona, Indiana, and Missouri.

In Missouri, FGA lobbyist James Harris said the measure intends to “move people from dependency and give them back that dignity and pride of work.”

Missouri state Rep. Darin Chappell proposed requiring a three-month look-back period like the measure in Indiana. But the latest version of the bill he sponsored would require applicants to show they were working for only one month before enrolling.

Chappell, a Republican, said his initiative would encourage a “working mindset.”

Anna Meyer, owner of a small bakery in Columbia, Missouri, said the implication is that she and others on Medicaid are lazy. “I have been working since I was 15 years old,” she said. “I’m 43 now.”

Meyer, who voiced her opposition, said she previously had problems submitting information to the state Medicaid agency. She fears new reporting requirements will put her and others at risk of losing coverage, even if they meet the work rule.

She has fibromyalgia, a chronic condition that increases overall sensitivity to pain. She also has food allergies. Medicaid helps pay for medications and doctor visits that keep her healthy and allow her to keep working.

“I work very hard,” Meyer said.

In St. Louis, Jessica Norton, an OB-GYN, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to remain insured even though Missouri extends a full year of Medicaid coverage to eligible women after they give birth. Some of her patients are inexplicably kicked off that coverage by the time of their checkups six weeks after birth. She fears red tape from the new work requirements will make it harder to hang on to insurance, even though pregnant women and new mothers are supposed to be exempt.

Norton criticized lawmakers for the message this policy sends to vulnerable patients. They are saying, “Oh, actually, health care is a privilege, and you have to earn it,” she said.

of adults ages 19 to 64 on Medicaid already work, according to Â鶹ŮÓÅ. The reason many of the remaining adults on Medicaid are not working is that they are retired, serving as a caregiver, or too sick, Â鶹ŮÓÅ has found.

Some states are not only setting the strictest requirements but also blocking out the optional leniency built into the federal rules.

For example, states may adopt additional exemptions from work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with medical conditions that prevent them from working.

Missouri lawmakers are seeking a constitutional amendment to bar their state from offering such optional exemptions. But patient advocates warn these limits would harm the state’s vulnerable residents when they need coverage the most, particularly Missouri’s rural cancer patients.

Often, rural Missouri patients must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist for the American Cancer Society’s advocacy arm, testified at the January hearing. Recognizing this, the federal law provides certain exemptions for this kind of scenario.

But this short-term hardship exemption would be off the table in Missouri.

Time is “very important in the life of a cancer patient or a cancer survivor,” Kalmer said.

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 .

USE OUR CONTENT

This story can be republished for free (details).

According to new data from the Centers for Disease Control and Prevention, there were 3.6 million births in 2025, a from 2024. The fertility rate dropped to 53.1 births per 1,000 women ages 15 to 44, down 23% since 2007.

The Trump administration has said it wants to reverse this trend. President Donald Trump has called for “a new baby boom,” and aides have solicited proposals from outside advocates and policy groups ranging from baby bonuses to expanded fertility planning. The administration is also the federal government’s only dedicated family planning program: Title X.

For more than five decades, Title X has been geared — with bipartisan support — toward giving low-income women access to contraception, screening for sexually transmitted infections, and reproductive health care regardless of ability to pay. At its peak, the served more than 5 million patients a year. Title X clients have reported the program as their sole source of health care in a given year.

In early April, the Department of Health and Human Services for Title X grants for fiscal year 2027, which begins in October. The 67-page Notice of Funding Opportunity included only one mention of contraception — describing it as overprescribed, associated with negative side effects, and part of a broader “overreliance on pharmaceutical and surgical treatments.”

The grant notification reshapes the program from its traditional public health intervention efforts to focus on fertility, family formation, and reproductive health conditions such as polycystic ovary syndrome, endometriosis, low testosterone, and erectile dysfunction.

While Title X will continue to help women “achieve healthy pregnancies,” the grant document does not explicitly reference preventing unintended pregnancies — a long-standing goal of the program.

Jessica Marcella, who oversaw the Title X program as a senior official in the Biden administration, said the new funding notice amounts to a wholesale redefinition of family planning.

“What we’re seeing is trying to use our nation’s family planning as a Trojan horse for an entirely different agenda,” Marcella said, noting that Trump eliminating Title X altogether.

Birth Rates and Fertility Trends

The administration is overhauling Title X in the context of declining birth rates. But researchers who study fertility trends say the decline is driven by forces that have little to do with contraception access and that restricting it is unlikely to produce more births.

The most important factors, according to demographer Alison Gemmill of UCLA, are timing-related. “Childbearing is increasingly delayed as part of a broader shift toward later adult milestones, including stable employment, leaving the parental home, and marriage,” she said.

Most American women, she said, still complete their childbearing years with an average of two children, suggesting a shift toward smaller families rather than an increase in childlessness.

“Having children has become more contingent and more planned,” she said.

Much of the decline since 2007 reflects women postponing births rather than forgoing them.

“The average number of babies women are having in their whole lives has not fallen. It’s still more than 2.0 for women aged 45,” said Philip Cohen, a professor of sociology at the University of Maryland.

Phillip Levine, an economist at Wellesley College, said the birth rate has declined due to shifts in how women approach work, leisure, and parenting. “Efforts to reverse those patterns would be more successful if they can make childbearing more desirable, not make it harder to prevent a pregnancy,” he said.

Asked about the role of contraception in reducing maternal mortality and how the new funding notice advances that goal, HHS press secretary Emily Hilliard said in a statement: “Applicants for the 2027 Title X funding cycle will be expected to align with the administration’s stated priorities in the released Notice of Funding Opportunity. HHS, under the leadership of Secretary Kennedy and President Trump, will continue to support policies that support life, family well-being, maternal health, and address the chronic disease epidemic. HHS remains focused on improving maternal outcomes and ensuring programs are administered consistent with applicable law.”

Marcella said the new funding notice is the product of two converging forces: the Make America Healthy Again movement, with its skepticism of conventional medicine and emphasis on lifestyle and behavioral interventions, and a pronatalist agenda that seeks to boost birth rates by steering policy toward family formation.

The document’s language reflects both: It repeatedly invokes “optimal health” and “chronic disease” while sidelining the contraceptive services that have defined Title X for .

Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association, which represents health professionals focused on family planning, said tying Title X to birth-rate goals replaces individual decision-making with a government objective. The program “is designed to facilitate access to family planning services, including services to achieve and prevent pregnancy,” she said.

Title X’s New Focus

The administration’s changes have been welcomed on the right.

Emma Waters, a senior policy analyst at the conservative Heritage Foundation, who has advocated for what she calls “restorative reproductive medicine,” said the new funding notice reflects overdue attention to neglected aspects of women’s health.

“I was particularly encouraged to see language that spoke to the delays in diagnosis for conditions like endometriosis, the need for women to practically understand how their cycle and fertility works, and to ensure that real root-cause was promoted through Title X,” Waters said.

She described the notice as an expansion, not a narrowing, of the program’s mission: “I see this iteration of Title X as the fulfillment of its purpose. The goal was never just ‘more contraception’ but a wholesale empowerment of women to govern their own fertility.”

Waters also argued that untreated reproductive health problems may contribute to lower birth rates.

“One of the interesting aspects of this debate, and one that is often overlooked, is the degree to which painful and unaddressed reproductive health problems may suppress or create ambivalence around a woman’s desire to have kids,” she said, pointing to endometriosis.

An estimated of reproductive age have endometriosis, and of those, . Scientifically speaking, the relationship is an association, not a proven cause. Women aren’t screened for endometriosis if they don’t have symptoms, and the condition may be more prevalent than is recognized. Researchers still do not fully understand why some women with endometriosis struggle to conceive while others do not, and treating the disease does not reliably restore fertility.

Infertility rates in the U.S., meanwhile, have not risen. An found them essentially flat between 1995 and 2019, even as the national birth rate fell sharply — a divergence that points away from untreated reproductive disease as an explanation.

Meanwhile, in February, the American College of Obstetricians and Gynecologists enabling earlier diagnosis of endometriosis without surgery, a step toward addressing the delays Waters described. But the first-line treatment ACOG recommends is hormonal therapy, part of the same category of care the funding notice dismisses as part of an “overreliance on pharmaceutical and surgical treatments.” The effect, reproductive health experts say, is a contradiction: Title X is now prioritizing diagnosis of endometriosis while deemphasizing the drugs clinicians use to treat it.

Treatments that have been shown to improve fertility in women with endometriosis, such as laparoscopic surgery and in vitro fertilization, are . When President Richard Nixon signed Title X into law in 1970, as a way to expand access to family planning services — helping women determine the number and spacing of their children by making contraception and related preventive care more widely available, particularly for those who could not afford it. , not Title X, is the primary government health insurance program covering health care for low-income women, but, like many commercial insurance plans, it .

Many of the conditions prioritized in the funding notice deserve attention, said Liz Romer, a former chief clinical adviser for the HHS Office of Population Affairs who helped write updated guidelines for the family planning program. But they fall outside the scope of what Title X can realistically provide.

“There’s not even enough funding to support the core premise of contraception,” Romer said. “And so, if you want to expand Title X funding, you can expand the scope, but you can’t move away from the foundation.”

The emergence of an anticontraception ideology within federal health policy is striking, she said, given how broadly the public supports access to birth control. Eight in 10 women of childbearing age surveyed by Â鶹ŮÓÅ in 2024 reported having in the previous 12 months.

Laura Lindberg, director of the Concentration in Sexual and Reproductive Health, Rights and Justice at Rutgers School of Public Health, said, “If contraception is sidelined in Title X, it won’t just change language on paper but will show up as fewer options and more barriers for patients.” Funding could move away from providers who offer a full range of contraceptive care, she added, “toward organizations that are ideologically opposed to contraception and don’t deliver the same standard of health care services.”

The Stakes Are High

The United States already has one of the highest maternal mortality rates among wealthy nations — as of 2024. According to the CDC, in the U.S. may be preventable. Medical research shows that pregnancy carries substantially higher risks of blood clots, stroke, and cardiovascular complications than hormonal contraception.

And since the Supreme Court’s Dobbs decision in 2022, which overturned the constitutional right to abortion established by Roe v. Wade, access to abortion has been significantly curtailed across much of the country. While national abortion numbers have risen, driven largely by telehealth and interstate access, research shows births have increased in states with bans, with an estimated , disproportionately among young women and women of color.

Dr. Christine Dehlendorf, who directs the Person-Centered Reproductive Health Program at the University of California-San Francisco, said “there is absolutely no evidence for any positive outcome of restricting access to contraception.” Restrictions would instead increase demand for abortion care and make it harder for women to prevent high-risk pregnancies.

Since Trump returned to office, more than a dozen Title X grantees have had their grants frozen, forcing some health centers to stop delivering services, lay off staff, or close. During the first Trump administration, regulatory changes led to a decline in Title X participation from more than . The program grew slowly under the Biden administration, reaching about 3 million clients, before the current round of disruptions began.

The second Trump administration’s overhaul of the program, Marcella said, “directly undermines the public health intent of our nation’s family planning program and will potentially exclude millions of individuals from getting the care they have relied on for decades. It’s bad policy.”

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 .

USE OUR CONTENT

This story can be republished for free (details).

It started building over the summer, fed by news of across Southern California, Trump administration plans to with Immigration and Customs Enforcement, and the passage of state and federal restrictions on immigrant Medicaid eligibility. Then in November, the federal government released a new that, if enacted, could block certain immigrants from obtaining permanent legal residency if they or family members have used public benefits, including Medicaid.

Many of González’ clients and their children, often U.S. citizens, still qualify for California’s Medicaid program, known as Medi-Cal, which provides health coverage to over 14 million residents with low incomes or disabilities. But increasingly, they don’t want to enroll or renew their coverage, she said.

“Many people don’t want to apply,” she said. “There are people who say they don’t even want to go outside and water their plants.”

An analysis by Â鶹ŮÓÅ Health News found that, from June to December, the latest month for which figures are available, almost 100,000 immigrants without legal status left Medi-Cal, representing about a quarter of all disenrollments in that time frame, even though this group makes up only about 11% of Medi-Cal enrollees.

It marks a reversal in a steady rise in enrollment among immigrants without legal status in California. Until July, sign-ups among this group had risen every month since the state opened Medi-Cal to all low-income residents regardless of immigration status in January 2024.

Tessa Outhyse, a spokesperson for the California Department of Health Care Services, which oversees Medi-Cal, said the enrollment declines can be mostly attributed to the fact that the government restarted eligibility checks that were suspended during the covid-19 pandemic. Indeed, overall Medi-Cal enrollment peaked in May 2023, and has since declined by about 1.6 million.

But two researchers, Leonardo Cuello at Georgetown University’s Center for Children and Families and Susan Babey at the UCLA Center for Health Policy Research, pointed out that California and most other states had fully resumed eligibility checks . In other words, that wouldn’t explain why enrollment has fallen precipitously in the last 12 months or so.

What has changed, Cuello said, is that the federal government passed the One Big Beautiful Bill Act, and executive orders added more changes that are propelling disenrollment.

Surveys Offer Clues

found immigrant adults nationally, especially parents, to be increasingly avoiding government programs that help pay for food, housing, or health care, to avoid drawing attention to their or a family member’s immigration status. That included lawfully present residents and naturalized citizens. Parental avoidance of these programs is particularly concerning, Cuello said, because about 1 in 4 children in the U.S. have an immigrant parent, even though most of those children were born in the U.S.

Cuello suspects that may help explain a nationwide enrollment drop of almost 3% in Medicaid and the Children’s Health Insurance Program during the first 10 months of last year, including a 5.6% drop in enrollment among California children, according to .

During the first Trump administration, the president broadened public charge criteria to allow consideration of Medicaid use and food and housing assistance. That led many citizen children and other household members to they were eligible for. Some the programs even after several courts blocked implementation and Democratic President Joe Biden rescinded the rule.

“It caused a high level of confusion,” said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, which represents about 70 health centers in the Los Angeles area. “Community health center staff are still working to undo the effects of the first rule.”

Projected Savings

Currently, only people reliant on cash assistance programs or long-term, government-funded institutionalized care may be considered a public charge risk when applying for a visa to enter the country or to become a legal permanent resident. But under the Trump administration’s proposed rule, Medicaid and other noncash programs could be used to determine whether an immigrant is likely to become dependent on the government. Immigration officers would also have more discretion to label people a public charge.

The Department of Homeland Security’s proposal says the changes are needed because the existing rules hamper the agency’s ability to make decisions about an immigrant’s risk of becoming reliant on government resources. A public comment period for the proposal ended in December.

DHS did not respond to a request about when it plans to make a final decision on the rule. The change would “align with long-standing policy that aliens in the United States should be self-reliant and government benefits should not incentivize immigration,” the proposal states.

The agency projected the change could save federal and state governments almost $9 billion annually from people disenrolling from or forgoing enrollment in public benefit programs.

A of the proposed rule estimated it could result in 1.3 to 4 million people disenrolling from Medicaid or CHIP, including as many as 1.8 million citizen children.

“It’s clearly being weaponized to create fear and anxiety,” said Benyamin Chao, supervising health and public benefits policy manager at the California Immigrant Policy Center. He called the proposal part of an “assault on lawfully present immigrants and U.S. citizens who are family members, and just the general community.”

Public charge fears are expected to decrease enrollment also in anti-hunger programs, such as the Supplemental Nutrition Assistance Program, known in California as CalFresh. Mark Lowry, who heads the Orange County Food Bank, said that that — along with disenrollment related to the One Big Beautiful Bill Act — could overwhelm food pantries, since federal nutrition programs account for the vast majority of food aid.

“There’s no way that the emergency food system has the capacity or resources to address those needs,” he said.

Health Care Needs

Fear of Medi-Cal enrollment doesn’t extend to all immigrants. Juana Zaragoza manages a program in Oxnard that helps mostly Indigenous Mexican farmworkers sign up for Medi-Cal. Overall enrollment and reenrollment has remained steady over the past few months, she said. Neither she nor the community members she serves know much about the public charge proposal, she added.

Often, any concerns they have are outweighed by an immediate need for health care.

“We encounter a lot of people who are balancing: what benefits me now and what benefits me later,” she said. “Some just want to cover their needs in the moment.”

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 .

USE OUR CONTENT

This story can be republished for free (details).

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.

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 .

USE OUR CONTENT

This story can be republished for free (details).

“La primera vez, el teléfono suena sin parar. La siguiente, te manda al buzón de voz y se corta la llamada”, dijo la mujer de 48 años, que vive en Delaware. “A veces te contesta alguien que dice que no es la persona indicada. Te transfieren y se corta. A veces contestan y no hay nadie en la línea”.

Pasó meses tratando de averiguar si su cobertura de Medicaid había sido renovada. Hasta finales de marzo, todavía no le había llegado la renovación anual para el programa estatal y federal que ofrece seguro de salud a personas con bajos ingresos y con discapacidades.

Crouch, quien sufrió un aneurisma cerebral debilitante hace una década, también tiene Medicare, que cubre a personas de 65 años o más, o a aquellas con discapacidades. Medicaid pagaba sus deducibles mensuales de Medicare de $200, pero en los últimos tres meses ha tenido que cubrirlos ella misma, lo que ha afectado el ingreso fijo de su familia, contó.

Los problemas de Crouch con el centro de llamadas de Medicaid en Delaware no son un caso aislado. Las agencias estatales de Medicaid pueden tener dificultades para mantener suficiente personal que ayude a las personas a inscribirse en los beneficios y atender llamadas de afiliados con preguntas.

La falta de estos trabajadores puede impedir que las personas usen plenamente sus beneficios, dijeron investigadores de políticas de salud.

Ahora, la ley One Big Beautiful Bill Act de los republicanos aprobada por el Congreso, que el presidente Donald Trump firmó el verano pasado, pronto exigirá más al personal de las agencias estatales en los lugares donde los legisladores ampliaron Medicaid a más adultos con bajos ingresos, que son casi todos los estados y el Distrito de Columbia.

Según la ley, que se espera reduzca el gasto de Medicaid en casi $1.000 millones en los próximos ocho años, estos trabajadores deberán no solo determinar si millones de afiliados cumplen con los nuevos requisitos laborales del programa, sino también verificar con mayor frecuencia que califican: cada seis meses en lugar de una vez al año.

Â鶹ŮÓÅ Health News contactó a agencias que deberán implementar estas reglas de trabajo, y muchas dijeron que necesitarán más personal.

Estas exigencias pondrán más presión sobre una fuerza laboral ya sobrecargada, lo que podría dificultar que afiliados como Crouch reciban servicios básicos de atención al cliente. Y muchos podrían perder acceso a beneficios a los que tienen derecho por ley, según afirmaron defensores del consumidor e investigadores de políticas de salud, algunos con experiencia directa trabajando en agencias estatales.

Los estados ya están “teniendo grandes dificultades”, dijo Jennifer Wagner, directora de elegibilidad e inscripción de Medicaid en el Center on Budget and Policy Priorities y ex subdirectora del Departamento de Servicios Humanos de Illinois. “Habrá desafíos adicionales importantes por culpa de estos cambios”.

Largos tiempos de espera para recibir ayuda

Los republicanos sostienen que los cambios en Medicaid, que entrarán en vigencia el 1 de enero de 2027 en la mayoría de los estados, incentivarán a los afiliados a conseguir empleo. Investigaciones sobre otros programas con requisitos laborales en Medicaid han encontrado poca evidencia de que aumenten el empleo.

La Oficina de Presupuesto del Congreso (CBO, por sus siglas en inglés) provocarán que más personas pierdan la cobertura de salud para 2034: indicó que más de 5 millones de personas podrían verse afectadas.

Muchos estados no tienen suficiente personal para procesar solicitudes o renovaciones de Medicaid con rapidez, dijeron defensores.

Los Centros de Servicios de Medicare y Medicaid (CMS, por siglas en inglés) supervisan si los estados pueden procesar el tipo más común de solicitud de beneficios dentro de un plazo de 45 días.

En diciembre, alrededor del 30% de todas las solicitudes de Medicaid y del Programa de Seguro de Salud Infantil (CHIP, por sus siglas en inglés) en Washington, D.C., y Georgia en procesarse. Más de una cuarta parte tardó ese tiempo en Wyoming. En Maine, una de cada 5 solicitudes no cumplió ese plazo.

Los CMS comenzaron a compartir públicamente datos de los centros de llamadas de Medicaid en 2023, lo que mostró un sistema bajo presión, según investigadores y defensores.

En Hawaii, las personas esperaron más de tres horas al teléfono en diciembre. En Oklahoma, casi una hora, y en Nevada, más de una hora.

En 2023, las agencias estatales de Medicaid comenzaron a verificar que todavía calificaban a los afiliados que habían sido protegidos para que no perdieran su cobertura durante la pandemia de covid. Ese proceso no funcionó bien en muchos estados, y más de .

Investigadores y defensores dicen que implementar las nuevas reglas será un reto mayor. Las reglas laborales requerirán cambios amplios en los sistemas informáticos y capacitación para los trabajadores que verifican la elegibilidad en un plazo ajustado.

“Es un nivel mucho mayor de complejidad administrativa”, señaló Sophia Tripoli, directora de políticas en Families USA, una organización de defensa de salud del consumidor.

Después de meses intentando hablar con alguien, Crouch dijo que finalmente obtuvo respuestas sobre sus beneficios de Medicaid luego de escribir a la oficina de la representante federal Sarah McBride (demócrata de Delaware). La oficina contactó a la agencia estatal de Medicaid, que finalmente la llamó con una actualización, dijo.

Crouch en realidad no calificaba para Medicaid. Dijo que eso nunca había surgido en dos años de interacciones con el estado.

“No tiene ningún sentido que el estado no se haya dado cuenta antes”, dijo.

La agencia de Medicaid de Delaware no respondió a solicitudes de comentarios sobre su caso.

Estados con poco personal para Medicaid

A fines de marzo, algunos estados dijeron a Â鶹ŮÓÅ Health News, que necesitarán más personal para implementar las reglas laborales de manera efectiva.

Idaho informó que tiene 40 vacantes para trabajadores de elegibilidad. Nueva York estimó que necesitará 80 nuevos empleados para manejar el trabajo administrativo adicional, con un costo de $6,2 millones. Pennsylvania tiene casi 400 puestos vacantes en oficinas de servicios humanos de los condados. La agencia de Medicaid de Indiana tiene 94 vacantes. Maine quiere contratar 90 trabajadores adicionales, y Massachusetts busca sumar 70 más. Montana llenó 39 de los 59 puestos que dice que necesitará.

La agencia de servicios sociales de Missouri ha reducido personal y tiene 1.000 trabajadores de primera línea menos que hace aproximadamente una década, esto con más del doble de afiliados en Medicaid y en el Programa de Asistencia Nutricional Suplementaria (SNAP, por sus siglas en inglés), según comentarios de su directora, Jessica Bax,

“El departamento pensó que habría una mejora en la eficiencia gracias a las actualizaciones del sistema de elegibilidad”, dijo Bax. “Muchas de esas mejoras no se concretaron”.

Los estados podrían tener dificultades para encontrar personas interesadas en estos trabajos, que requieren meses de capacitación, pueden ser emocionalmente exigentes y generalmente ofrecen salarios bajos, afirmó Tricia Brooks, investigadora del Centro para Niños y Familias de la Universidad de Georgetown.

“Reciben muchos reclamos y gritos”, dijo Brooks, quien antes dirigió el programa de atención al cliente de Medicaid y CHIP en New Hampshire. “Las personas están frustradas. Lloran. Están preocupadas. Están perdiendo acceso a la atención médica, y no es un trabajo fácil cuando es difícil ayudar”.

Los estados están pagando millones de dólares a contratistas del gobierno para ayudar a cumplir con la nueva ley federal.

Maximus, un contratista de servicios gubernamentales, brinda apoyo en elegibilidad, como la gestión de centros de llamadas, en 17 estados que ampliaron Medicaid y atiende a casi 3 de cada 5 personas inscritas en el programa a nivel nacional, según la empresa.

Durante una llamada de resultados en febrero, la empresa dijo que puede cobrar según el número de gestiones que realiza para los afiliados, independientemente de cuántas personas estén inscritas en el programa en un estado.

Maximus no tiene “un enfoque único” para los servicios que ofrece ni para cómo cobra por ellos, dijo su vocera Marci Goldstein a Â鶹ŮÓÅ Health News.

La empresa, que reportó ingresos de $1.760 millones en 2025 en el área que incluye trabajo relacionado con Medicaid, espera que esos ingresos sigan creciendo, incluso si menos personas permanecen en el programa, “debido a las gestiones adicionales que serán necesarias”, señaló David Mutryn, director financiero y tesorero de Maximus.

Perder la cobertura de Medicaid no es solo una molestia, ya que muchas personas inscritas probablemente no ganan lo suficiente para pagar atención médica por su cuenta y pueden no calificar para ayuda financiera bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), dijo Elizabeth Edwards, abogada del National Health Law Program.

Las personas podrían no poder pagar medicamentos o recibir atención esencial, lo que podría tener impactos “devastadores” en la salud, dijo.

“Lo que está en juego son las vidas de las personas”, concluyó.

Los corresponsales de Â鶹ŮÓÅ Health News Katheryn Houghton y Samantha Liss contribuyeron con este artículo.

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 .

USE OUR CONTENT

This story can be republished for free (details).

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.”

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 .

USE OUR CONTENT

This story can be republished for free (details).

Researchers say the children at about a mile away pay the price. They discovered the students there and at other elementary schools near major pollution sites in Pennsylvania had than other children in the state.

Residents and environmental advocates saw reason for hope and relief in the form of a designed to tamp down on coke oven plant pollution. But even before it took effect, President Donald Trump granted in the U.S. — including the one in Clairton — a from the standards.

Trump and Republicans have sought to align themselves with the Make America Healthy Again movement’s populist ideals, such as improving Americans’ food choices and reducing corporate harm to the environment. But the administration is ratcheting up its attacks on the very environmental protections that MAHA followers hold dear.

Taken together, these anti-environmental initiatives will lead to more pollution-related illnesses and higher health care spending, health researchers say. They could also have political ramifications, eroding MAHA’s support for GOP candidates in the November midterm elections if followers believe the party is more beholden to industry than to the movement’s agenda.

, including about a quarter of Republicans, support rolling back environmental regulations, according to a poll by the Energy Policy Institute at the University of Chicago and The Associated Press-NORC Center for Public Affairs Research.

Some MAHA supporters believe voters will support Republicans because the Trump administration is delivering on other goals important to the movement.

“MAHA has a pretty diverse set of policy goals, ranging from medical freedom to food and the environment,” said David Mansdoerfer, who served in Health and Human Services leadership during Trump’s first term. “In totality, the Trump administration has strongly delivered on much of the MAHA agenda.”

While MAHA voters have been upset at some of the administration’s actions that promote industry, it’s hard to know how that may play out in the midterms, said Christopher Bosso, a professor of public policy and politics at Northeastern University. Many were disillusioned by a Trump they viewed as promoting glyphosate, which HHS Secretary Robert F. Kennedy Jr. has .

“The glyphosate thing really ticks off a lot of them; they’re really upset,” Bosso said. “Kennedy said it was poison. If it is a poison, why aren’t we regulating it? That’s where the tension plays out.”

The situation with the Clairton coke plant and the others granted exemptions from regulations underscores the potential public health risks. Six of the 11 factories had “high priority” violations of the Clean Air Act as of last May, according to a Â鶹ŮÓÅ Health News analysis. Five coke oven plants logged major violations every quarter for at least three years straight.

“Poisoning continues to some of the most vulnerable residents of Allegheny County,” , who had lived in nearby Glassport, Pennsylvania, said at a about the coke plant.

Environmental Protection Agency spokesperson Brigit Hirsch said the president gave companies extra time because the technology needed to meet a new standard isn't ready yet.

“Forcing plants to comply before the tools exist doesn't make the air cleaner, it just shuts down facilities and kills jobs with nothing to show for it,” Hirsch said.

But environmental groups disagree that the plants were unable to comply at a reasonable cost, and they say the exemption from the EPA requirements shows the Trump administration is prioritizing the coal industry at the expense of public health.

“The Trump administration’s relentless actions to dismantle lifesaving environmental protections are a gut punch to the administration’s own promise to Make America Healthy Again,” said Cathleen Kelly, a senior fellow at the Center for American Progress, a liberal think tank.

Hard Times in Clairton

Sprawled across , the Clairton plant operates ovens in which coal is heated to as much as 2,000 degrees Fahrenheit to make up to 4.3 million tons annually of the carbon-rich fuel known as coke. The product is used in blast furnaces to produce iron.

It’s a dirty operation. The process leads to hazardous emissions of that the Centers for Disease Control and Prevention says can lead to anemia and leukemia, as well as , which can trigger severe asthma.

The Clairton operation has had repeated problems with its emissions and operations, including and of toxic chemicals. The plant has received more than from the Allegheny County Health Department since 2022, stemming largely from a fire in 2018 that led to high emissions, and violated the Clean Air Act in each of the last , with the last compliance monitoring in July 2025, according to the EPA.

Nippon Steel Corp. last year acquired U.S. Steel, which now operates as a subsidiary. The company didn’t respond to an email seeking comment. U.S. Steel said it spends $100 million annually on environmental compliance at Clairton.

“Environmental stewardship is a core value at U. S. Steel, and we remain committed to the safety of our communities,” spokesperson Andrew Fulton said in a written statement.

Clairton was once bustling with movie theaters, a mix of grocery stores, and riverside parks, with a dance pavilion and . But the decline of steel hit hard. The town’s population dwindled from more than in the mid-20th century to as of 2024. until they were razed and replaced with signs saying to keep out. The 1978 movie , which depicts a hardscrabble industrial town, is partly set there. Today, about 33% of residents live in poverty.

While the plant brings jobs and revenue, residents of the town and the surrounding areas have long complained about health problems they attribute to its emissions.

“My parents are gone. My mom had cancer, my dad,” , a Clairton resident, said at a 2025 County Council meeting. “I lost a lot of loved ones and seen other ones pass because of this mill.”

Pediatric allergist looked into asthma rates among 1,200 children who attended school near major pollution sites in the area — including students at Clairton Elementary School. They had nearly triple the national rate of asthma, with the highest rate among African American youth, according to she led.

“We were shocked,” she said. “It was double or triple what we expected. The people are proud of their industrial background. We need steel, but they’re not running a good enough operation.”

A found children with asthma living near the coke plant had an 80% higher chance of missing school when sulfur dioxide pollution was elevated.

Allegheny County, which includes Clairton and Pittsburgh, is home to a number of industrial plants, and to increased deaths, chronic heart disease, and adverse birth outcomes. It was ranked in the top 1% of counties in the nation for cancer risk from stationary industrial air pollutants in a 2018 .

Clairton has an age-adjusted cancer death rate of 170 per 100,000 people, higher than the broader county’s rate of 150 deaths per 100,000 people, based on a Â鶹ŮÓÅ Health News analysis of .

The American Lung Association in 2025 gave the county an F rating for its particle pollution levels. PennEnvironment, an environmental group that was party to a settlement with U.S. Steel involving the Clairton plant, says the coke operation caused of toxic releases in 2021, which amounted to 60% of all such releases in the county that year.

From 2020 through 2025, the Clairton plant racked up more in fines from Clean Air Act penalties than any other coke oven facility nationwide, costing U.S. Steel over $10 million, according to EPA facility reports.

“We are deeply concerned with exemptions, which allow air toxics to affect public health,” Allegheny County Health Department spokesperson Ronnie Das said in a statement.

The Clairton plant provides and hundreds of millions of dollars in tax revenue to the area. The jobs help generate nearly $3 billion in annual economic output, according to estimates from the Pennsylvania Manufacturers’ Association.

Some community members and advocacy groups hoped air quality would improve after the coke plant was sold. has pledged to upgrade facilities in the Monongahela River Valley.

Politics, Waivers, and Environmental Concerns

Under the Biden-era rule, coke plants were supposed to start meeting from the lids and doors of ovens that heat coal. They would also have had to monitor for benzene at their property lines and take steps to lower emissions of the carcinogen if they exceeded certain levels. Compliance deadlines were set for July 2025.

The Trump administration, which has sought to revive the coal industry, intervened. Last year, it , including coke plants such as Clairton’s, to seek from issued in 2024 by the EPA.

Then Trump in November went further, granting all coke plants a two-year compliance break.

The reprieve was necessary, the EPA spokesperson Hirsch said, because the requirements would have meant extra costs for the industry when standards already in effect work “extremely well” at reducing pollution.

Hirsch also said the agency under Trump is protecting the environment, pointing to action the administration has taken to called PFAS, prevent lead poisoning, strengthen chemical safety, and protect Americans’ food and water supply.

“We are building a future where the next generation of Americans is the healthiest in our nation's history, and they inherit the cleanest air, land and water in the world,” Hirsch said.

However, the administration has taken several steps that environmental advocates say weaken health protections.

The president's executive order on glyphosate, an herbicide the World Health Organization has linked to cancer, which touched off a furor among MAHA enthusiasts who said they felt betrayed. The EPA has decided to stop considering the of reducing pollution when making policy decisions, instead focusing on the cost to industry of complying with rules. The agency also rescinded the legal and scientific basis that had long established as dangerous to public health.

The actions have rankled some MAHA enthusiasts who counted on the administration to tackle chronic disease, especially among children. A petition to Trump on with more than 15,000 signatures called for the removal of EPA Administrator Lee Zeldin, it said supported corporations over MAHA goals.

Some MAHA enthusiasts have sounded off on social media.

“No one should believe that MAHA is being upheld at the EPA at this point,” , a leader of American Regeneration, which focuses on a conservation approach to farming, said Feb. 8 on X.

, host of a , also aired her concerns on X, saying “there is something really freaking spooky going on at the EPA and I refuse to let the American people be gaslit into thinking they’re upholding the MAHA agenda.”

“A significant number of people who supported Trump are worried these rollbacks are going to hurt their health,” said , a Democratic strategist and the founder of the communications firm Third Degree Strategies. “The MAHA voters, especially women, are very sensitive to this. Republicans have put themselves in a bind.”

MAHA supporters shouldn’t be surprised by a Trump administration that doesn’t prioritize environmental protections over industry, because the president has always championed fossil fuels, said Kyle Kondik, managing editor of Sabato’s Crystal Ball, a nonpartisan election forecasting newsletter published by the University of Virginia Center for Politics.

The coke plant exemptions have disappointed some community members, environmental groups, and regulators concerned about public health and emissions.

Nearly 300,000 people live within 3 miles of the 11 active coke plants across the U.S., according to EPA data compiled by the Environmental Defense Fund.

Weakening environmental rules has helped boost Trump with the U.S. coal industry. In February, mining industry executives and lobbyists gathered at the White House, .

Coal miners, including some in white hard hats bedecked with American flags, with a bronze-colored trophy emblazoned “The Undisputed Champion of Beautiful Clean Coal.”

At the event, Trump praised their work. “We love clean, beautiful coal,” he said.

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 .

USE OUR CONTENT

This story can be republished for free (details).

In a humbling exercise, employees were waiting to test whether their entry badges still worked at the Department of Health and Human Services — or whether they’d be walked back out by security because they were among the 10,000 unlucky ones whose jobs had suddenly been eliminated.

I thought back to that day recently as I researched andÌýreported onÌýa significant, under-the-radar proposal from the Office of Personnel Management, which oversees federal workers.Ìý

According to aÌýÌýin December, OPM isÌýseekingÌýpersonally identifiable medical and pharmaceutical claims information on federal employees and retirees, as well as their family members, who are enrolled in the Federal Employees Health Benefits or Postal Service Health Benefits programs. Just over 8 million Americans get coverage through such plans.

Right now, 65 insurance companiesÌýmaintainÌýdata the agency wants, including information on prescriptions, diagnoses, and treatments. That would put a tremendous amount of personal information about federal employees in the hands of an administration that has earned a reputation for takingÌýÌýagainst some workers andÌýsharing sensitive dataÌýacross agencies as part of its immigration and fraud crackdowns.ÌýÌý

My colleague Maia Rosenfeld and I wanted to know what lawyers and ethicists who work on health policy issues think about this proposal.ÌýÌý

On the one hand, sources toldÌýus,Ìýthis sort of detailed data could be used by the federal government to improve the largest employer-sponsored health insurance system in the country.Ìý

But doubts about the Trump administration’s motives percolated through every conversation we had.Ìý

“The concern here is the more information they have, theyÌýcould use it to discipline or target people who are not cooperating politically,” Sharona Hoffman, a health law ethicist at Case Western Reserve University, told me.ÌýÌý

And, though the notice states that insurers are legallyÌýpermittedÌýtoÌýdiscloseÌý“protected health information” to the agency for “oversight,” Hoffman and others raised questions about OPM’s access to such a sweeping database of medical records under federal health privacy laws.ÌýÌý

Insurance companies — several of which declined to comment — would have to provide monthly reports to OPM with data on their members. One insurer, CVS Health, said in a public comment that insurers would be breaking the law by providing the information for OPM’s “vague and broad general purposes.” The association thatÌýrepresentsÌýmany of those companies also has voiced objections to the proposal, which has not yet beenÌýfinalized.ÌýÌý

OPM spokespeople did not respond to our repeated requests for comment.

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 .

USE OUR CONTENT

This story can be republished for free (details).

At the Trump administration’s request, a federal judge in Louisiana this week agreed to delay a ruling affecting the continued availability of the abortion drug mifepristone. That angered anti-abortion groups that want the drug, if not banned, at least more strictly controlled. But the administration clearly wants to avoid big abortion fights in the run-up to November’s midterm elections.

Meanwhile, the administration’s proposed budget for fiscal year 2027 calls for more than $15 billion in cuts to programs at the Department of Health and Human Services. It’s a significant number, but less drastic than cuts it proposed for fiscal 2026.

This week’s panelists are Julie Rovner of Â鶹ŮÓÅ Health News, Lauren Weber of The Washington Post, Alice Miranda Ollstein of Politico, and Maya Goldman of Axios.

Panelists

Among the takeaways from this week’s episode:

• The Trump administration says it is conducting a thorough scientific review of the abortion pill mifepristone at the Food and Drug Administration. Yet advocates on both sides of the abortion debate think the administration is just trying to buy time to avoid a controversial decision about medication abortion before November’s midterm elections.
• It’s budget time on Capitol Hill. With the unveiling of the president’s spending plan for fiscal 2027, Cabinet secretaries will make their annual tour of congressional committee hearings. HHS Secretary Robert F. Kennedy Jr., whose Hill appearances have been few during his tenure, is scheduled to testify before six separate House and Senate committees before the end of the month.
• Back at HHS, Kennedy appears to be trying to reconstitute the Advisory Committee on Immunization Practices in a way that will enable him to restock it with vaccine skeptics without running afoul of a March court ruling that he violated federal procedures with his replacements last year.
• Continuing his efforts to promote his Make America Healthy Again agenda, Kennedy announced this week that he will launch his own biweekly podcast. He also announced efforts to combat microplastics in the water supply and to get hospitals to stop serving ultraprocessed food to patients.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Atlantic’s “,” by Katherine J. Wu.

Maya Goldman: Â鶹ŮÓÅ Health News’ “Trump’s Personnel Agency Is Asking for Federal Workers’ Medical Records,” by Amanda Seitz and Maia Rosenfeld.

Lauren Weber: CNN’s “,” by Holly Yan.

Alice Miranda Ollstein: Politico’s “,” by Simon J. Levien.

Also mentioned in this week’s podcast:

• JAMA Internal Medicine’s “,” by Lauren J. Ralph, C. Finley Baba, Katherine Ehrenreich, et al.
• Â鶹ŮÓÅ Health News’ “Immigrant Seniors Lose Medicare Coverage Despite Paying for It,” by Vanessa G. Sánchez, El Tímpano.
• The New York Times’ “,” by Ellen Barry.
• Stateline’s “,” by Nada Hassanein.
• The Washington Post’s “,” by Lena H. Sun.

[Editor’s note:ÌýThis transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]Ìý

Julie Rovner:ÌýHello, from Â鶹ŮÓÅ Health News and WAMU Public Radio in Washington, D.C. Welcome toÌýWhat the Health?ÌýI’mÌýJulie Rovner, chief Washington correspondent for Â鶹ŮÓÅ Health News, andÌýI’mÌýjoined by some of the best and smartest health reporters covering Washington.ÌýWe’reÌýtaping this week on Thursday,ÌýApril 9, at 9:30Ìýa.m.ÌýAs always, news happens fast, and things might have changed by the time you hear this. So here we go.Ìý

Today, we are joined via video conference by Lauren WeberÌýofÌýThe Washington Post.Ìý

Lauren Weber:ÌýHello,Ìýhello.Ìý

Rovner:ÌýAlice MirandaÌýOllsteinÌýof Politico.Ìý

Alice MirandaÌýOllstein:ÌýHi,Ìýeverybody.Ìý

Rovner:ÌýAnd my fellow Michigan Wolverine this national championship week,ÌýMaya Goldman of Axios.ÌýGo,ÌýBlue!Ìý

Maya Goldman:ÌýGo,ÌýBlue.Ìý

Rovner:ÌýNo interview this week, but plenty of news.ÌýSoÌýlet’sÌýget rightÌýtoÌýit.ÌýWe’reÌýgoing to start with reproductive health. On Tuesday, a federal judge in Louisiana ruled for the Trump administration and against anti-abortion forces in a lawsuit over the availability of the abortion pillÌýmifepristone.ÌýWait, what? Please explain,ÌýAlice,Ìýhow the administration and anti-abortion groups ended up on opposite sides of an abortion pill lawsuit.Ìý

Ollstein:ÌýYeah.ÌýSoÌýthis has been building for a while, and it is not the only lawsuit of its kind out there. There are several.ÌýAÌýbunch of different state attorneys general,Ìýwho are very conservative and anti-abortion, have been suing the FDAÌýin an attempt toÌýeither completely getÌýrid of the availabilityÌýof the abortion pillÌýmifepristoneÌýor reimpose previous restrictions on it.ÌýSo right now, at least according to federal rules, not according to every state’sÌýrules,Ìýyou can get it via telehealth.ÌýYou can get it delivered byÌýmail. You can pick it up at a retailÌýpharmacy. YouÌýdon’tÌýhave to get it in person handed to you from a doctor like you used to.ÌýSoÌýthese lawsuits areÌýattemptingÌýto bring back those restrictions or get the kind of national ban that a lot of groups want.ÌýAndÌýsoÌýyou haveÌýother onesÌýpending:ÌýFlorida, Texas,ÌýMissouri,Ìýyou have a bunch of ones.ÌýSoÌýthis is the Louisiana version. And the Trump administration,Ìýit’sÌýimportant to note, they are not defending the FDA or the abortion pill on the merits. They are saying,ÌýweÌýdon’tÌýwant this lawsuit and this court to force us to do something.ÌýWe want to go through our own careful process and do our own internal review of the safety of mifepristone, and then we may decide to impose restrictions. ButÌýthey’reÌýasking courts to give them the time and space to complete that process and saying, you know,ÌýThisÌýis our power we should have in the executive branch. And so,Ìýin this case, the judge,Ìýin ruling for the Trump administration,Ìýbasically justÌýhit pause. ThisÌýdoesn’tÌýget rid of the case. It just putsÌýa stay on it for now, andÌýthat’sÌýimportant.ÌýIn some of these other cases, the Trump administration has asked the courts to throw out the case, but that was not the situation here.ÌýSoÌýthisÌýdoesn’tÌýmean that abortion pills are going to be available forever. ThisÌýdoesn’tÌýmeanÌýnothing’sÌýgoing to happen,ÌýandÌýthey’reÌýgoing to be banned. This just means, you know,Ìýwe’reÌýkicking the can down the road.ÌýÌý

Rovner:ÌýI was saying,Ìýjust to be clear. I mean, we know that this FDA quote-unquoteÌý“study”Ìý—Ìýwhether it is or isn’t going onÌý—Ìýis part of, kind of,Ìýa delaying tactic by the administration, because they don’t want to really make abortion a big front-and-center issue in the midterms.ÌýSoÌýthey’reÌýtrying toÌýsort of runÌýthe clock out here. Is that notÌýsort of theÌýinterpretationÌýthat’sÌýgoing on right now?ÌýÌý

Ollstein:ÌýThat’sÌýwhat people on both sides assume is going on.ÌýIt’sÌýreally been fascinating how everyone is being kept in the dark aboutÌýwhat’sÌýhappening inside the FDAÌý—Ìýand if this review is even happening, ifÌýit’sÌýreal, ifÌýit’sÌýin good faith, what is it based on? AndÌýsoÌýit’sÌýbecome this sort of Rorschach test,Ìýwhere people on the left are saying, you know,ÌýThey’reÌýlaying the groundwork to do a national ban. This is justÌýpoliticalÌýcover. They just want to wait until after the midterms, and thenÌýthey’reÌýgoing to go for it. And people on the right are saying, you know,ÌýTheÌýadministration is cowardly, and theyÌýaren’tÌýreally doing anything, andÌýthey’reÌýjust trying to get us to shut up and be patient. WeÌýdon’tÌýknow if either of those interpretations orÌýneither ofÌýthemÌýare true.ÌýÌý

Rovner:ÌýLauren,ÌýyouÌýwant to add something?Ìý

Weber:ÌýI just think it’sÌýpretty clearÌýthis is also just on aÌý[Health and Human Services Secretary Robert F.]ÌýKennedyÌý[Jr.]Ìýpriority.ÌýI mean,Ìýlet’sÌýgo back. The manÌý…Ìýcomes from oneÌýofÌýthe top Democratic political families originally. You know,Ìýthere’sÌýobviously been a lot of chatter around his anti-abortion beliefs. Now, obviously,Ìýhe’sÌýon a Republican ticket. I think some of that plays into this as well. And he already has his hand on the stove on so many otherÌýhot issuesÌýthat,Ìý[if]ÌýI had to guess,ÌýIÌýdon’tÌýthink thatÌýthey’reÌýtrying to rock the boat on this one.Ìý…ÌýI think, some background context too, to some ofÌýwhat’sÌýgoing on.ÌýÌý

Rovner:ÌýWe’llÌýget to some of those hotter issues. But,Ìýmeanwhile, the Journal of the American Medical AssociationÌý[Internal Medicine]Ìýhas aÌýÌýsuggesting that medication abortion is so safe that it could be provided over the counterÌý—Ìýthat’sÌýwithout any consultation with a medical professional, either in person or online. ThisÌýdoesn’tÌýfeel likeÌýit’sÌýgoing to happen anytime soon, though, right? WhileÌýwe’reÌýstill debating the existence of medication abortion in general.Ìý

Ollstein:ÌýThat’sÌýright. I mean, there are a lot of people whoÌýcan’tÌýget this medication prescribed by a valid doctor right now, let alone over the counter. I will say it is common in a lot of parts of the world to get it over the counter,ÌýwhereasÌýin the United States, the most common way to have a medication abortion is with a two-pill combination,ÌýmifepristoneÌýand misoprostol. In a lot of parts of the world, people just use misoprostol alone, and it isÌýeffectiveÌýand it isÌýlargely safe.ÌýIt’sÌýslightly less safe than using both pills together. AndÌýsoÌýI thinkÌýthere’sÌýa lot of international data out there, and people point to that and advocate for this. And I will say there are activist groups in the United States who are setting up networks, underground networks, to get these pills to people with no doctor’s involvement. And so that is already going on. I think that a lot of people would prefer to get it from a doctor if they could.ÌýBut because of bans and restrictions, theyÌýcan’t. AndÌýsoÌýpeople are turning to these activist groups.Ìý

Rovner:ÌýI will point out, as a person who covered the entirety of the fight to have emergency contraceptionÌý—Ìýwhich is not the abortion pillÌý—Ìýmade over theÌýcounter,Ìýit took like, 15 years. It shortened myÌýlifeÌýcovering that story. Lauren, did youÌýwant to add something?ÌýÌý

Weber:ÌýYeah, I just wanted to say I find itÌýreally interesting.ÌýObviously, reproductive issues end up taking 15 years, as you pointed out, to make it over the counter.ÌýBut there are a lot of things that are considered potentially more dangerous that you canÌýorder upÌýinÌýa pretty basic telehealth visit or even just buy in not-so-sketchy ways that the administration is also even looking to deregulate.ÌýSoÌýI think the differencesÌýofÌýaccessÌýofÌýthis compared to other less studied, potentially more unsafe medication is quite striking.Ìý

Goldman:ÌýPart ofÌý[President Donald]ÌýTrump’sÌý“GreatÌýHealthcareÌýPlan”Ìýis making more medications available over the counter.ÌýSoÌýthis is certainly something that they have said they want to do, in general.ÌýThis is a political nightmare, though, to do that for abortion.Ìý

Ollstein:ÌýYeah,Ìýand people have been pointing to this and a lot of other policies for a while to argue about something they call abortion exceptionalism, in which people apply a different standard to anything related to abortion, a different safety standard, a different standard of scrutiny than they do to medications for lots of other purposes.ÌýAndÌýyou’veÌýseen that, and that comes up in lawsuits and political arguments about this. And I think,Ìýyou know, people can point to this as another example.Ìý

Rovner:ÌýSo last week, weÌýtalked about the federal family planning programÌýTitleÌýX, which finally got funded after months of delays. But Alice, you warned us that the administration was planning to make someÌýbig changesÌýto the program, and now those have finally been announced. Tell us what the plan is for a program that’s provided birth control and other types of primary and preventive care since the early 1970s.Ìý

Ollstein:ÌýWell, the changes haveÌýsort ofÌýbeen announced. They’veÌýmore been teased. What we are still waiting for is an actual rule,Ìýlike we saw in the first Trump administration, that would impose conditions on the program. AndÌýsoÌýwhat we saw recently, it was part of a wonky document called aÌý“Notice of Funding Opportunity,”Ìýor NOFO, for those in the D.C.Ìýlingo. AndÌýbasicallyÌýit was signaling that when groups reapplyÌý—Ìýthey just got this year’s money,Ìýbut when they reapply for next year’s moneyÌý—Ìýit sets upÌýsort of newÌýpriorities and a new focus for the entire program. And what was really striking to me is, youÌýknow,Ìýthis is a family planning program. It was created in the 1970s and it is primarily about delivering contraception to people who can’t afford it around the country, providing it to millions of peopleÌýwhoÌýdepend on this program, and the wordÌý“contraception”Ìýdid not appear in the entire 70-page document other than an assertion that it is overprescribed and has bad side effects. And instead, they signaled that they want to shift the program to focus on, quote,Ìý“family formation.”ÌýSoÌýthis is really striking to me.ÌýI think weÌýsaw some signs that something like this was coming. You know, about a year ago, there was someÌýTitleÌýXÌýmoney approved to focus on helping people struggling with infertility.ÌýBut that wasÌýsort of justÌýa subset of the program, and now it looks like they want to make that, you know, an overriding focus of the program.ÌýSoÌýI think when the actual rule to this effect drops, and weÌýdon’tÌýknow when that will beÌý—Ìýwill they wait till after the midtermsÌýto, you know, avoid blowback? Who knows? I think there will certainly be lawsuits then.ÌýBut I think right now, this is just sort of a sign of where they want to go in the future.ÌýAndÌýit’sÌýimportant to note that it came very quickly on the heels of a big backlash from the anti-abortion movement over the approval of this year’s funding going out toÌýall ofÌýthe clinics that got it before, including Planned ParenthoodÌýclinics.ÌýTheÌýanti-abortion groups were agitating for Planned Parenthood to be cut off at once, you know, not in the future,Ìýright now.Ìý

Rovner:ÌýJust to remind people that the ban on Planned ParenthoodÌýfunding fromÌýlast year was for Medicaid, not for theÌýTitleÌýXÌýprogram.Ìý

Ollstein:ÌýRight.ÌýÌý

Rovner:ÌýAnd that’s why Planned Parenthood got money.Ìý

Ollstein:ÌýYes, and Planned Parenthood is not allowed to use any Medicaid orÌýTitleÌýXÌýmoneyÌýfor abortions, but the anti-abortion groups say it functions like a backdoor subsidy, and so they wanted it to beÌýcutÌýoff.ÌýSoÌýthey were very pissed that this money went out to Planned Parenthood. And so very quickly after,Ìýthe administration put out this document, saying,ÌýLook, we are taking things in another direction, and it is not the direction of Planned Parenthood.Ìý

Rovner:ÌýLauren,ÌýyouÌýwant to add something?Ìý

Weber:ÌýOh, I just wanted to say Alice has really been owning the beat on all theÌýTitleÌýXÌýcoverage, soÌý…Ìý

Rovner:ÌýAbsolutely.ÌýÌý

Weber:Ìý…Ìýglad weÌýare able toÌýhave her explain it to us.ÌýButÌýjust wanted to throw outÌýaÌýkudos for breaking all the news on that front.ÌýÌý

Goldman:ÌýYeah, great coverage.Ìý

Rovner:ÌýYes.ÌýVery happyÌýto have youÌýforÌýthis. Turning to the budget, which is normally the major activity for CongressÌýin the spring, we finally got President Trump’s spending blueprint last week. It does propose cuts to discretionary spending at the Department of Health and Human Services to the tune of aboutÌý$15 billion,Ìýbut those cuts are far less deep than those proposed last year.ÌýAnd,Ìýas we have noted, Congress didn’tÌýactually cutÌýthe HHS budget last year by much at all.ÌýAnd many programs, like the National Institutes of Health,Ìýactually gotÌýsmall increases. Is this budget a reflection of the fact that the administration is recognizing that cuts toÌýHealth andÌýHumanÌýServices programsÌýaren’tÌýactually popularÌýwith the public or with Congress, for that matter, going into a midterm election?Ìý

Weber:ÌýI thinkÌýit’sÌýthat last little piece you mentioned there, Julie. I thinkÌýit’sÌýtheÌý“going into the midterm election.”ÌýI think youÌýhit the nail on the headÌýthere. Cuts are also not good economically for many Republicans.ÌýYou know, we saw Katie Britt be one of theÌý— theÌýAlabama Republican senatorÌý—Ìýbe one of the most outspoken senators in general about some of the cuts that were floated for the budget for HHS last year.ÌýSoÌýI think whatÌýyou’reÌýhinting at, and whatÌýwe’reÌýgetting at, is thatÌýit’sÌýnot politicallyÌýpopular,Ìýit can be economically problematic, on top of the scientific advances that are not found.ÌýSoÌýI suspect you are rightÌýonÌýthat.Ìý

Ollstein:ÌýThe administration knows that this isÌý“hopes and dreams”Ìýand will not become reality. It did not become reality last year. It almost never becomes reality. And I think you can see the sort of acknowledgement that this is about sending a message more than actually making policy in things likeÌýTitleÌýX, because at the sameÌýtime they put out this guidance from HHS about the future ofÌýTitleÌýX, moving away from contraception,Ìýin theÌýpresident’s budget heÌýproposed completely getting rid ofÌýTitleÌýX, completely defunding it, which he has in the past as well. And so why would they put out guidance for a program thatÌýdoesn’tÌýexist?Ìý

Goldman:ÌýI think,Ìýalso, this is the second budget thatÌýthey’reÌýputting out in this administration, right? So now they are just a little more used toÌýwhat’sÌýgoing on, and they have more of their feet under them.Ìý

Weber:ÌýAsÌýa preview for listeners,Ìýtoo,ÌýI’mÌýsure we will have Kennedy asked about this budget when he appears in a series of so many hearings next week and the week after. And there were a lot of fireworks last year with him and various members of Congress about the budget.ÌýSoÌýI am sure that we will hear a lot more on this front in theÌýweeks to come.Ìý

Rovner:ÌýYeah, I would say that’s one thing that the budget process does, is when theÌýpresident finally puts out a budget, the CabinetÌýsecretaries travel to all of the various committees on Capitol Hill to, quote,Ìý“defend theÌýpresident’s budget,”Ìýwhich is sometimes or,ÌýI guess in the case of Kennedy, one of the few chances that they get to actually have him in person to ask him questions. But in the meantime, you know, we have the budget, then we have the president himself, who at an Easter lunch last weekÌý—Ìýthat was supposed to be private, but ended up beingÌýlive-streamedÌý—Ìýsaid, and I quote,Ìý“It’s not possible for us to take care of dayÌýcare, Medicare, Medicaid, all these individual things.” The president went on to say that states should take over all that social spending, and the only thing the federal government should fund is, quote,Ìý“military protection.”ÌýDidÌýI justÌýhearÌýa thousandÌýDemocratic campaign ads bloom?Ìý

Goldman:ÌýI think thisÌýis a prime example of when you should take Trump seriously, butÌýnot literally. IÌýdon’tÌýthink thatÌýthere’sÌýany world, at least in theÌýforeseeable future, where the federal governmentÌýisn’tÌýfunding Medicare.ÌýBut,Ìýyou know, you certainlyÌýhave toÌýwatch atÌýthe margins.ÌýIt’sÌýlike,Ìýit’sÌýnot a secret that this is something thatÌýthey’reÌýinterested in cutting backÌýspending on.ÌýIt’sÌýsuper politically difficult to do that, and they know that, and that’s part of why, whichÌýI’mÌýsureÌýwe’llÌýtalk about in a little bit,Ìýthey bumped up the payment rate for 2027 to Medicare Advantage plans.ÌýÌý

Rovner:ÌýWhich we will get to.Ìý

Goldman:ÌýYeah, so I mean,Ìýit’sÌýcertainly an eye-opening statement, and you should remember it. But IÌýdon’tÌýthink thatÌýwe’reÌýin immediate jeopardy here.Ìý

Rovner:ÌýThis is theÌýpresident who ran in 2024,Ìýyou know, saying that he was going to protect Medicare and Medicaid. I mean,Ìýit’sÌýbeen, you know, against some of the recommendations of his own administration. I was justÌýsort of shockedÌýto see these words come out of his mouth. Lauren,Ìýyou wantedÌýto sayÌýsomething?ÌýÌý

Weber:ÌýI mean,Ìýit’sÌýnotÌýthat surprising, though. I mean, look at what theÌýOneÌýBigÌýBeautiful BillÌý[Act]Ìýdid to Medicaid.ÌýHe’sÌýalready pushed through massive Medicaid cuts, which areÌýessentially beingÌýoffloaded to the states.ÌýSo, I mean, I think this ideology has alreadyÌýborneÌýout and will continue to bear out, and obviouslyÌýit’sÌýhappening amid the backdrop of a war. So that plays into, obviously, the commentary as well.ÌýÌý

Rovner:ÌýWell, meanwhile,ÌýRepublicans are still talking about doing another budget reconciliation bill, the 2.0 version of last year’sÌýBigÌýBeautifulÌýBill, except this time it’s essentially just to fund the military andÌýICEÌý[Immigration and Customs Enforcement]ÌýandÌýborderÌýcontrol, because Democrats won’t vote for those things, at least they won’t vote for additional military spending.ÌýWhat are the prospects for that toÌýactually happen?ÌýAnd would Republicans really be able to do it if those programs are paid for with more cuts to Medicare and/or Medicaid, as someÌýhave suggested?Ìý

Goldman:ÌýYou know, my co-worker Peter Sullivan wrote about this last week, and there was a lot ofÌýblowbackÌýfrom politicos, from advocates, from, you know,Ìýkind of acrossÌýthe spectrum of groups there. I think that it would be extremely politically unpopular, especially going into the midterms, to use healthÌýcare as an offset. But I would say that Republicans areÌýpretty goodÌýat rhetoric, right?ÌýThat’sÌýone of the things thatÌýthey’reÌýknown for right now, andÌýthere’sÌýalways a way to spin it.Ìý

Rovner:ÌýAlice and I spoke to a group earlier this week, and I went out on a limb and predicted that IÌýdidn’tÌýthink Republicans could get the votes for another big budget reconciliation this year. I mean, look at how close it was last year. The idea of cutting any deeper seems to me unlikely, just given the margins that they have.Ìý

Goldman:ÌýAndÌýI think thatÌýis something that youÌýdo inÌýbetween election years.ÌýThat’sÌýnot something you do in anÌýelection year.Ìý

Rovner:ÌýThat’sÌýtrue, yesÌý…Ìýyou do tend to see these bigger bills in the odd-numbered years rather than the even-numbered years, but …Ìý

Ollstein:ÌýAndÌýI thinkÌýit’sÌýimportant to remember that the reason Republicans are in this bind and that they feel like theyÌýhave toÌýkeep reconciliation nearly focused on funding immigration enforcement is because Democrats refuse to fund immigration enforcement.ÌýAndÌýsoÌýthey feel pressured to put all their effort and political capital towards that, andÌýdon’tÌýwant to mess that up by adding a bunch of otherÌýhealthÌýcare things that could cause fights and loseÌýthemÌývotes.ÌýÌý

Goldman:ÌýThe moneyÌýhas got toÌýcome from somewhere.Ìý

Rovner:ÌýAndÌýhealthÌýcare is where all the money is.ÌýSpeaking of Medicare and Medicaid,Ìýwhere most of the money is,Ìýthere is news on those fronts,Ìýtoo.ÌýMaya, as you hinted on Medicare, the administration is out with its payment rule for private Medicare Advantage plans for next year. And remember,Ìýwe talked about how HHS was going to really go after overbilling in Medicare Advantage and cut reimbursement dramatically?ÌýWell, you can forget all that. The final rule will provide plans with a 2.48% pay bump next year.ÌýThat’sÌýcompared to the less than 1% increase in the proposed rule.ÌýThat’sÌýa difference of aboutÌý$13 billion.ÌýThe final rule alsoÌýeliminatedÌýmany of the safeguards that were intended to prevent overbilling. What happened to the crackdown on Medicare Advantage?ÌýAre theirÌýlobbyists really that good?Ìý

Goldman:ÌýTheir lobbyists areÌýpretty good. This was a year where there wereÌý—ÌýI think CMSÌý[the Centers for Medicare & Medicaid Services]Ìýsaid there were a record number of public comments on their proposed rate, flat rate increase, flat rate update. But I thinkÌýit’sÌýalso not that surprising. Historically, the final rate announcement for Medicare Advantage isÌýalmost alwaysÌýa little higher than the proposed because they incorporateÌýadditionalÌýdata from the end of the previous year thatÌýwasn’tÌýavailable when first rate is proposed, theÌýinitialÌýrate isÌýproposed.ÌýButÌýcertainlyÌýthey backed away fromÌýa big changeÌýto risk adjustment, or,Ìýlike, the way to adjust payment based on how sick aÌýplan’sÌýenrollees are. You get more payÌý…ÌýÌý

Rovner:ÌýBecauseÌýthat’s where the overbilling was happening,Ìýthat we’d seen a lot of these wonderful stories that plans were basically, you know, inventing diagnoses for patients who didn’t necessarily have them or didn’t have a severeÌýillness, andÌýusing that to get additional payments.Ìý

Goldman:ÌýRight.ÌýAnd they did move forward with a plan to prevent diagnoses that are not linked to informationÌýthat’sÌýin a patient’s medical chart from being used for risk adjustment. But a lot of plansÌýhadÌýsaid, like,ÌýYeah, this is,Ìýthat’sÌýthe right thing to do, andÌýit’sÌýnot going to be that impactful for us. You know, overall, this is a win for health insurance. I think one thing to note is that Chris Klomp, the director of Medicare, said,ÌýWe’reÌýstill really focused on trying to right-size this program.ÌýThat’sÌýstill a priority for us as anÌýadministration, but we also want to safeguard it. AndÌýsoÌýI think insurersÌýare notÌýoff the hook entirely.ÌýThere’sÌýstill going to be a lot of scrutiny, but their lobbyists areÌýpretty good. And you know, no one wants to be seen as the candidate that cuts Medicare.Ìý

Rovner:ÌýAnd we haveÌýseen this before, that when Congress cutsÌý“overfunding”Ìýfor Medicare Advantage, the plans,Ìýseeing that theyÌýcan’tÌýmake its big profits,Ìýdrop out or they cut back on those extra benefits. And the beneficiaries complain because they’re losing their plans, or they’re losing their extra benefits, and they don’t really want to do that in an election year either, because there are a lot of people, many millions of people, who vote who are on these plans. So,Ìýin some ways, the plans have the administration over a political barrel, in addition to how good their lobbyists are.ÌýÌý

Well, apparently, oneÌýgroup that HHS is still cracking down on are legal immigrants with Medicare. Most of the publicity around the health cuts in last year’s budget bill focused on the cuts to Medicaid.ÌýButÌýwe at Â鶹ŮÓÅ Health News have a story this weekÌýabout legal immigrantsÌýwho’veÌýpaid into the Medicare system with their payroll taxes for years and are now being cut off from their Medicare coverage. This isÌýapparently theÌýfirst time an entire category of beneficiariesÌýareÌýhaving their Medicare taken away.ÌýI’mÌýsurprised thereÌýhasn’tÌýbeen more attention to this, orÌýifÌýit’sÌýjust tooÌýmuchÌýall happening at once.Ìý

Ollstein:ÌýI mean,Ìýthere’sÌýa lot happening at once, and even just in the space of immigrants’Ìýaccess to health care, there is so much happening at once. AndÌýsoÌýthis is obviously havingÌýa huge impactÌýon a lot of people, but so are 100 other things. And I think, you know, the zone has been flooded as promised. And really, state officials who are also dealing withÌýa thousandÌýother things, Medicaid cuts, you know, theseÌýfederal changes,Ìýwork requirements,Ìýare grappling with thisÌýas well.Ìý

Rovner:ÌýLauren,Ìýyou wantedÌýto add something?Ìý

Weber:ÌýYeah. I mean, I thought it was, there was a striking quote in the story from MichaelÌýCannon, whoÌýbasically said,ÌýTheÌýreason thisÌýisn’tÌýresonating is because thisÌýwon’tÌýupset the Republican base. And I thinkÌýthat’sÌýa striking quote to beÌýconsidered.Ìý

Rovner:ÌýMichaelÌýCannon, libertarian health policy expert,ÌýjustÌýkind of anÌýobserver to this one. ButÌýyeah, I thinkÌýthat’sÌýtrue. I mean, or at least the perception is that these are not Republican voters, although, you know, asÌýwe’ve seen, you know, Congress has tried to take aim at people they think aren’t their voters, and it’s turned out that those are their voters.ÌýSoÌýwe will see how this all plays out.ÌýÌý

Well,Ìýat the same time thatÌýthis is all going on, the folks over at the newsletterÌý“HealthcareÌýDive”Ìýare reporting that the Centers for MedicareÌý&ÌýMedicaid Services are trying to embark on all these new initiatives on fraud,Ìýand work requirements,Ìýand artificial intelligence with a diminished workforce.ÌýWhile CMS lost far fewer workers in theÌýDOGE [Department of Government Efficiency]Ìýcuts last year than many other of the HHS agenciesÌý—Ìýit was in the hundreds rather than theÌýthousandsÌý—ÌýCMS has long been understaffed,Ìýgiven the fact that it manages programs that provide health insurance to more than 160 million Americans through not just Medicare andÌýMedicaid, but also the Children’s Health Insurance Program and the Affordable Care Act. I know last week, FDAÌýCommissioner MartyÌýMakaryÌýsaid he wants to hire more workers to replace the 3,000 who wereÌýRIF’edÌýor took early retirement there at the FDA.ÌýAnd CMS does have lots of job openingsÌýbeing advertised.ÌýButÌýit’sÌýhard to see how replacing trained and experienced workers with untrained, inexperienced onesÌýareÌýgoing to improve efficiency, right?Ìý

Goldman:ÌýTangentially, I was talking to a health insurance executive yesterday who was saying that his team is so much bigger than CMS, and they cover a fraction of the market, and they’re often the ones coming to CMS and proposing ideas and working with CMS on it. IÌýdon’t,ÌýI think thatÌýis a dynamic that far predates this administration, butÌý…Ìý

Rovner:ÌýOh, absolutely.Ìý

Goldman:ÌýButÌýit’sÌýcertainly interesting. AndÌý…ÌýCMS hasÌývery ambitiousÌýplans, and not that many people to carry them out. But, you know, I think one thing that I also want to note is that when I talk to trade associations and stakeholders about thisÌýCMS, they are generally like, pretty support-Ìý…Ìýlike,Ìýthey say that they think they’re being heard, and they think that CMS and the career staff are doing, you know, the same kind of caliber of work that they’ve been doing, which I think is notable.Ìý

Rovner:ÌýAnd as we have mentioned many times, you know, Dr.Ìý[Mehmet]ÌýOz, the head of CMS, is very serious about his job and doing a lot ofÌýreally interestingÌýthings.ÌýIt’sÌýjust,Ìýit’sÌýhard, you know, in the federal government, if youÌýdon’tÌýhave the resources that you want toÌý…Ìýif youÌýdon’tÌýhave the resources to match your ambitions.ÌýLet’sÌýput it that way.ÌýÌý

Well, meanwhile, on the Medicaid front,Ìýwe’reÌýalready seeing states cutting back, and some of the results of those cutbacks.ÌýÌýonÌýhow psychiatric units are at risk of being shut down due to the Medicaid cuts, since they often serve a disproportionate number of low-income peopleÌýand alsoÌýtend to lose money.ÌýAndÌýThe New York Times has aÌýÌýof an Idaho Medicaid cutback of a program that had provided home visits to people living in the community with severe mental illness, until those people who lost the services began to die or to end up back in more expensive institutional care. Now the state has resumedÌýfundingÌýtheÌýprogram, butÌýobviously will end up having to cut someplace else instead. I know when Republicans in Congress passed the cuts last year, they said that people on Medicaid who were not the able-bodied working-age populationsÌýwouldn’tÌýsee their services cut. ButÌýthat’sÌýnot how this is playing out, right?ÌýÌý

Weber:ÌýI justÌýthink the story by Ellen Barry, who you should always readÌýonÌýmental health issues inÌýThe New York Times,Ìý“,”Ìýis such anÌýillustrative example of unintended consequences from these cuts.ÌýAnd the reason thatÌýthey’reÌýbeing reversedÌý—Ìýby Republican legislators, no lessÌý—Ìýin Idaho, is becauseÌýit’sÌýmore expensive to have cut the money from it than it is efficient. I mean, what they found was, isÌýthat after they cut the money to the schizophrenia program, they saw this massive uptick in law enforcement cases and hospitalizations, uninsured hospitalizations,Ìýthat this avoided. And I thinkÌýit’sÌýa real canary in the coalÌýmineÌýsituation, becauseÌýwe’reÌýonly starting to see these states cut these things off. And this wasÌýa pretty immediateÌýmultiple-death consequence. And I thinkÌýwe’reÌýgoing to see a lot of stories like this, of a variety of programs that we allÌýdon’tÌýeven have any idea thatÌýexistÌýin the safety net across the country thatÌýareÌýbeingÌýchipped away at.ÌýÌý

Rovner:ÌýWell, turning toÌýother news from the Department of Health and Human Services,Ìýwe’reÌýgetting some more competition here atÌýWhatÌýthe Health?ÌýHealthÌýsecretary Kennedy has announcedÌýhe’llÌýbe unveiling his own podcast,ÌýcalledÌýThe Secretary KennedyÌýPodcast, next week. He promises to,Ìýaccording to the trailer posted online on Wednesday, quote,Ìý“name the names of the forces that obstruct the paths to public health.”ÌýOKÌýthen,Ìýwe look forward to listening.ÌýÌý

Meanwhile, in actual secretarial work, theÌýsecretary this week also unveiled changes to the charter of the Advisory Committee onÌý[Immunization]ÌýPractices after a federal judge last month invalidated both the replacement members that he’d appointed lastÌýyearÌýand the changes made to theÌýfederally recommended vaccine schedule.ÌýSoÌýwhat’sÌýgoing to happen hereÌýnow?ÌýWill this get around the judge’s ruling by watering down theÌýexpertiseÌýthat members of this advisory committee are supposed to have in vaccines? And why hasn’t the administrationÌýappealedÌýthe judge’sÌýruling yet?Ìý

Goldman:ÌýYou know, I don’t have actual answers to this, but I do wonder and speculate that this is going to end up being some kind of legal whack-a-mole situation where theÌýsecretary and HHSÌýsays,ÌýOK, you don’t like it that way?ÌýWe’llÌýdo it this way, and thenÌýthey’llÌýdo it another way, and advocates will sue, andÌýwe’llÌýsee how this plays out going forward in the courts.ÌýI think thisÌýis not the end of the story.ÌýEven though the judge’s decision was a big win for vaccine advocates,Ìýit’sÌýjustÌýwe’reÌýin the midpoint, if that.Ìý

Rovner:ÌýAnd Lauren, speaking of vaccines, your colleague LenaÌýH. Sun hasÌýÌýon HHS and vaccine policy.Ìý

Weber:ÌýYeah, LenaÌýSun is always delivering.ÌýShe found out that the acting director of the CDCÌý[Centers for Disease Control and Prevention]Ìýat the time delayed publication of a report showing that the covid-19 vaccine[s]Ìýcut the likelihood of emergency department visits and hospitalizations for healthy adults last winter by about half. So even though Kennedy is not talking more about vaccines, it appears that, based on this reporting,Ìýthat some of his underlings are not necessarily touting the benefits ofÌývaccine, so to speak.ÌýAnd I’m very curious, going back to Kennedy’s podcast, I found the rollout of that so interesting because the teaserÌýwas veryÌýleaning intoÌýthe KennedyÌýthat got elected, you know, someone who speaks about, you know, dark truths that are hidden from the public,Ìýand so on. And then the press team had these statements of,Ìýlike,ÌýKennedy will investigate the affordability of healthÌýcosts and foodÌýand nutrition.ÌýAnd I think this dichotomy of who Kennedy is and who theÌýWhite House and the press secretary and HHS want Kennedy to be before the midterms really could come to a head in this podcast.ÌýSoÌýI think we will all be listening to hear how that goes.Ìý

Rovner:ÌýYeah, we keep hearing aboutÌýhow theÌýsecretary is being, you know,Ìýsort of putÌýon a leash, if you will. And, you know, told to downplay some of his anti-vaccine views and things like this. And that seems quiteÌýat oddsÌýwith him having his own podcast. Alice,Ìýdo you wantÌýto …?Ìý

Weber:ÌýI guess, it depends onÌýwho’sÌýediting the podcast and who they have on.ÌýI’mÌýjust veryÌý…Ìýyou could even tell from the trailer to how his press secretary presented it, there was an interesting differential in framing, and I am curious how that plays out as we seeÌýguests on it.Ìý

Ollstein:ÌýI mean,Ìýit’sÌýalso worth noting that this is an administration of podcasters. I mean, you haveÌýKashÌýPatel,Ìýyou have so many of these folks who have a history of podcasting,Ìýclearly have a passion for it, justÌýcan’tÌýlet it go while working aÌýfull-time, high-pressureÌýgovernment job.ÌýÌý

Rovner:ÌýWe shall see.ÌýMeanwhile, HHS, together with the Environmental Protection Agency, is wagingÌýwarÌýon microplastics, thoseÌýnearly tooÌýimpossibleÌýtoÌýdetect bits of plastic that are getting into our lungs and stomachs and body tissues throughÌýair and waterÌýand food. The plan here seems to be to find ways to detect exactly how much microplastics we are all getting in our water and what the health impacts might be, since weÌýdon’tÌýhave enough information to regulate them yet.ÌýI would think this would be one of those things thatÌýpleasesÌýboth MAHAÌý[Make America Healthy Again]Ìýand the science community, right? Or is it just,Ìýas one MAHAÌýsupporterÌýcalled it,Ìýtheater?Ìý

Goldman:ÌýI think thisÌýisÌýa great exampleÌýof the,Ìýyou know, part of theÌýreason whyÌýMAHAÌýis so interesting to such a wide swath of people.ÌýLike,Ìýthere’sÌýa lot of legitimate concern, not that other concernsÌýaren’tÌýnecessarily legitimate, butÌýthere’sÌýa lot of concern over,Ìýfrom the scientific community, over microplastics.ÌýI’mÌýhonestly surprised thatÌýwe’reÌýthis far into the administration with this announcement. I would have thought that thisÌýisÌýsomething they would have done sooner, but they obviously had other prioritiesÌýas well.Ìý

Rovner:ÌýWell. Finally, this week, speaking of other priorities, HHS Secretary Kennedy and CMS Administrator Dr.ÌýOz are declaring war on junk food in hospitals. Again, this seems like a popular andÌýfairly harmlessÌýcrusade;ÌýhospitalsÌýshouldn’tÌýbe serving their patientsÌýultraprocessedÌýfood.ÌýExcept,Ìýalmost as soon as the announcement came out, I saw tons of pushback online from doctors and nurses who worried about patients for whom sugary food or drinks are actually medically indicated, or who,Ìýbecause of medications they’re taking, or illnesses they have, can only eat, or will only eat, highly palatable, often processed food. Nothing in healthÌýcare is as simple as it seems, right?ÌýÌý

Weber:ÌýI thinkÌýwhat’sÌýalso interesting is one of my favorite examples in the memo they put out was they hope that every hospital, as an example, could serve quinoa and salmon. And IÌýjust amÌýcurious to see how fast that gets implemented. AndÌýit’sÌýa veryÌývalidÌý—Ìýa lot of people complain about hospital food.ÌýIt’sÌýa very valid thing to push for better food. But I also question, as I understandÌýit,Ìýthis seems more like a carrot than a stick when it comes to the regulation they put out.Ìý

Rovner:ÌýAs it were.Ìý

Weber:ÌýAs it were.ÌýAndÌýsoÌýI’mÌýcurious to see how it gets implemented. That said, there are hospitals that have taken it upon themselvesÌý—Ìýthe NorthwellÌý[Health]Ìýexample in New York is a good exampleÌý—Ìýto really improve their hospital food. And frankly,Ìýit’sÌýa money maker. If your food’s better, people come to your hospital, especiallyÌýinÌýan urban area where there is hospital competition.ÌýSoÌýyou know, like most MAHAÌýtopics, there’s a lot of interesting points in there, and then there’s a lot of what’sÌýthe realityÌýand what’Ìýactually goingÌýto happen. AndÌýsoÌýI’Ìývery curious to see how this continues to play.Ìý

Rovner:ÌýIÌýdidÌýa bigÌýstory,Ìýlike,Ìý10 years ago on a hospital chain that had its ownÌýgardens,ÌýthatÌýliterally grewÌýits own healthy food.ÌýSoÌýthis is not completely new but,Ìýagain, interesting.Ìý

All right, that is this week’s news. NowÌýit’sÌýtime for ourÌýextra-creditÌýsegment.ÌýThat’sÌýwhere we each recognize a story we read thisÌýweekÌýwe think you should read,Ìýtoo.ÌýDon’tÌýworry if you miss it. We will post the links in our show notes on your phone or other mobile device. Alice, why don’t you start us off this week?Ìý

Ollstein:ÌýIÌýhave a piece from my co-worker SimonÌý[J.]ÌýLevien, and it is calledÌý“.”ÌýThis is aboutÌýthousands of doctors around the country who are from other countries that are placed on, you know, a list by the Trump administration of places where they want to scrutinize and limit the number of immigrants coming from there. And so these are people who are already here, already practicing, have poured years into their training, have been living here, and,Ìýin some cases, are the only folks willing to work in certain areas that have a lot of medical shortages, and they just can’t practice because their paperwork isn’t getting processed in time. AndÌýsoÌýthey’reÌýsort of inÌýthis scary limbo, andÌýthat’sÌýputting these hospitals and clinics that they work in in aÌýreally toughÌýbind. AndÌýsoÌýthey’reÌýhammering the Trump administration to give them answers about what their fate is. You know,Ìýthey’reÌýnot trying to deport them yet, butÌýthey’reÌýnot allowing them to continue working either.ÌýÌý

Rovner:ÌýFor anÌýadministration that’s been pushingÌýreally hardÌýto improve rural health care, this does not seem to be a way to improve rural health care.ÌýMaya.Ìý

Goldman:ÌýMy extra credit this week is calledÌý“Trump’s Personnel Agency Is Asking for Federal Workers’ Medical Records.”ÌýIt’sÌýa greatÌýÂ鶹ŮÓÅÌýHealthÌýNewsÌýscoopÌýfrom Amanda Seitz andÌýMaia Rosenfeld. It’s a really great example of the administration, you know, sort of moving in silence,ÌýdoingÌýthese small regulatory announcements that could haveÌýbigÌýimpact.ÌýBasically, theÌýOffice of Personnel Management is asking for personally identifiable medical information from health insurers, and its reasoning is to analyze costs and improve the health system, but they could getÌývery detailedÌýmedical information from federal employees, including things like, did they get an abortion? Are they undergoing gender-affirming care? And,Ìýobviously,Ìýthere is a strongÌýconcern thatÌýthat could be used against them.ÌýÌý

Rovner:ÌýYeahÌý…Ìýthis was quite a scoop. Really,ÌýreallyÌýinterestingÌýstory. Lauren.Ìý

Weber:ÌýMineÌýwasÌýa pretty alarmingÌýstory by Holly Yan at CNN:Ìý“.”ÌýAnd basically there’s this type of drug test that the scientists have found is not that effective, and it’s led to things like bird poop being scraped off a man’s car appearing on a drug test as cocaine, a great-grandmother’s medication testing positive for cocaine, and a toddler’s ashes registering as meth orÌýecstasy, and horrible legal and other consequences of thisÌýkind of misdiagnosis in the field. And the reason these drug tests are often done is becauseÌýthey’reÌýcheaper.ÌýThere’sÌýa more expensive, moreÌýaccurateÌýversion, but these are cheaper.ÌýThey’reÌýdone in the field.ÌýBut the potential side effects and horrible, wrongly accused effects are quite large, and soÌýColorado has passed this law to try and move away from this. AndÌýit’sÌýcurious to see if otherÌýstates will follow suit.Ìý

Rovner:ÌýYeah, this was something I knew nothing about until I read this story. My extra credit this week is fromÌýThe Atlantic byÌýKatherineÌý[J.] Wu,ÌýandÌýit’sÌýcalledÌý“.” And it’s about how some of the very top career officials from the NIHÌý[National Institutes of Health],Ìýthe CDC,Ìýand other agencies have, after having been put on leave more than a year ago, finally been reassigned toÌýfar-flungÌýoutposts of the Indian Health Service in the western United States. They got news of their proposed reassignments with little description of their new roles and only a couple of weeks to decide whether to move across the country or face termination. Now,Ìýif these officials’Ìýskills matched those needed by the Indian Health Service, this all might make some sense.ÌýBut whatÌýthe IHSÌýmostÌýneedsÌýare active clinicians:Ìýdoctors and nurses and social workers and lab technicians.ÌýAnd those who are now being reassigned are largely managers, includingÌý—Ìýand here I’m reading from the story,ÌýquoteÌý— “the directors of several NIH institutes, leaders of several CDC centers, aÌýtop-rankingÌýofficial from the FDA tobacco-productsÌýcenter, a bioethicist, a human-resources manager, a communications director,Ìýand a technology-information officer.”ÌýTheÌýNative populations who areÌýostensibly beingÌýhelped hereÌýaren’tÌývery happyÌýabout this, either. Former Biden administration Interior Secretary Deb Haaland, a Native AmericanÌýwho’sÌýnow running for governor in New Mexico, called the reassignment proposals, quote,Ìý“shameful”ÌýandÌý“disrespectful.”ÌýAlso, and this is myÌýaddition, not a very efficient use of human capital.Ìý

OK, that’s this week’s show.ÌýThanksÌýthis week to our fill-in editor,ÌýMary-EllenÌýDeily, and our producer-engineer,ÌýFrancis Ying.ÌýA reminder:ÌýWhat the Health?Ìýis now available on WAMU platforms, the NPR app, and wherever you get your podcasts — as well as, of course,Ìýkffhealthnews.org. Also,Ìýas always, you can emailÌýusÌýyour comments or questions.ÌýWe’reÌýat whatthehealth@kff.org.ÌýOr you can find me on XÌý, or on BlueskyÌý.ÌýWhere doÌýyou guysÌýhangÌýthese days? Maya.Ìý

Goldman:ÌýI am on LinkedIn under my first and last name,Ìý, and onÌýXÌýatÌý.Ìý

Rovner:ÌýAlice.Ìý

Ollstein:ÌýI’mÌýonÌýBlueskyÌýÌýand onÌýXÌý.Ìý

Rovner:ÌýLauren.Ìý

Weber:ÌýStillÌý@LaurenWeberHPÌýonÌýbothÌýÌýandÌý.Ìý

Rovner:ÌýWe will be back in your feed next week.ÌýUntil then, be healthy.

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From Â鶹ŮÓÅ Health News” on , , , , , or wherever you listen to podcasts.

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 .

USE OUR CONTENT

This story can be republished for free (details).

“The first time, it’ll ring interminably. Next time, it’ll go to a voicemail that just hangs up on you,” said the 48-year-old, who lives in Delaware. “Sometimes you’ll get a person who says they’re not the right one. They transfer you, and it hangs up. Sometimes, it picks up and there’s just nobody on the line.”

She spent months trying to figure out whether her Medicaid coverage had been renewed. As of late March, she hadn’t been reapproved for the year for the state-federal program, which provides health insurance for people with low incomes and disabilities.

Crouch, who suffered a debilitating brain aneurysm a decade ago, also has Medicare, which covers people who are 65 or older or have disabilities. Medicaid had been paying her monthly Medicare deductibles of $200, but she’d been on the hook for them for the past three months, straining her family’s fixed income, she said.

Crouch’s challenges with Delaware’s Medicaid call center aren’t unique. State Medicaid agencies can struggle to keep enough staff to help people sign up for benefits and field calls from enrollees with questions. A shortage of such workers can keep people from fully using their benefits, health policy researchers said.

Now, congressional Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will soon demand more from staff at state agencies in places where lawmakers expanded Medicaid to more low-income adults — nearly all states and the District of Columbia.

Under the law, which is expected to reduce Medicaid spending by almost $1 trillion over the next eight years, these staffers will have to not only determine whether millions of enrollees meet the program’s new work requirements but also verify more frequently that they qualify for the program — every six months instead of yearly.

Â鶹ŮÓÅ Health News reached out to agencies that will need to stand up the work rules, and many said they’ll need additional staff.

The mandates will put extra strain on an already-stressed workforce, potentially making it harder for enrollees like Crouch to get basic customer service. And many could lose access to benefits they’re legally entitled to, said consumer advocates and health policy researchers, some of them with direct experience working at state agencies.

States are already “struggling significantly,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities and a former associate director of the Illinois Department of Human Services. “There will be significant additional challenges caused by these changes.”

Long Wait Times for Help

Republicans argue the Medicaid changes, which will take effect Jan. 1, 2027, in most states, will encourage enrollees to find jobs. Research on other Medicaid work requirement programs has found little evidence they increase employment.

The Congressional Budget Office would cause more people to lose health coverage by 2034 than any other part of the GOP budget law. It said last year more than 5 million people could be affected.

Many states don’t have the staff to process Medicaid applications or renewals quickly, said consumer advocates and researchers.

The Centers for Medicare & Medicaid Services tracks whether states can handle the most common type of benefit application within a 45-day window.

In December, about 30% of all Medicaid and Children’s Health Insurance Program, or CHIP, applications in Washington, D.C., and Georgia to process. More than a quarter took that long in Wyoming. In Maine, 1 in 5 applications missed that deadline.

CMS began publicly sharing state Medicaid call center data in 2023, revealing a taxed system, researchers and consumer advocates said.

In Hawaii, people waited on the phone for more than three hours in December. They waited for nearly an hour in Oklahoma, and more than an hour in Nevada.

In 2023, state Medicaid agencies began making sure enrollees who were protected from being dropped from the program during the covid pandemic still qualified for coverage. That Medicaid unwinding process didn’t go well in many states, and lost their benefits.

Health policy researchers and consumer advocates say rolling out the new Medicaid rules will be a bigger challenge. The Medicaid work rules will require extensive IT system changes and training for workers verifying eligibility on a tight timeline.

“It is a much larger scale of administrative complexity,” said Sophia Tripoli, senior director of policy at Families USA, a health care consumer advocacy organization.

After months of trying to get someone on the phone, Crouch said, she finally got answers to questions about her Medicaid benefits after writing to the office of U.S. Rep. Sarah McBride (D-Del.). McBride’s office contacted the state’s Medicaid agency, which eventually called with an update, Crouch said.

Crouch didn’t qualify for Medicaid after all. She said that had never come up in two years of interactions with the state.

“It makes absolutely no sense” that the state never realized she shouldn’t have been on the program, Crouch said.

Delaware’s Medicaid agency didn’t respond to requests for comment on Crouch’s situation.

States Short-Staffed for Medicaid

Some states told Â鶹ŮÓÅ Health News in late March that they’ll need more staff to roll out the work rules effectively.

Idaho said it has 40 eligibility worker vacancies. New York estimated it will need 80 new employees to handle the additional administrative work, at a cost of $6.2 million. Pennsylvania said it has nearly 400 open positions in county human services offices in the state. Indiana’s Medicaid agency has 94 open positions. Maine wants to hire 90 additional staffers, and Massachusetts wants to hire 70 more.

As of early March, Montana had filled 39 of 59 positions state officials projected it would need. The state still plans to roll out the rules early, starting July 1, despite its long struggle with system backlogs that applicants said have delayed benefits.

Missouri’s social services agency has been cutting staff and has 1,000 fewer front-line workers than it did roughly a decade ago — with more than double the number of enrollees in Medicaid and the Supplemental Nutrition Assistance Program, or SNAP, according to comments Jessica Bax, the agency director, made in November.

“The department thought that there would be a gain in efficiency due to eligibility system upgrades,” Bax said. “Many of those did not come to fruition.”

States could have a hard time finding people interested in taking those jobs, which require months-long training, can be emotionally challenging, and generally offer low pay, said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families.

“They get yelled at a lot,” said Brooks, who formerly ran New Hampshire’s Medicaid and CHIP customer service program. “People are frustrated. They’re crying. They’re concerned. They’re losing access to health care, and so sometimes it’s not an easy job to take if it’s hard to help someone.”

States are paying government contractors millions of dollars to help them comply with the new federal law.

Maximus, a government services contractor, provides eligibility support, such as running call centers, in 17 states that expanded Medicaid and interacts with nearly 3 in 5 people enrolled in the program nationally, according to the company.

During a February earnings call, company leadership said Maximus can charge based on the number of transactions it completes for enrollees, independent of how many people are enrolled in a state’s Medicaid program.

Maximus has “no one-size-fits-all approach” to the services it offers or the way it charges for those services, spokesperson Marci Goldstein told Â鶹ŮÓÅ Health News.

The company, which reported bringing in $1.76 billion in 2025 from the part of its business that includes Medicaid work, expects that revenue to continue to grow, even as people fall off the Medicaid rolls, “because of the additional transactions that will need to take place,” David Mutryn, Maximus’ chief financial officer and treasurer, said during the earnings call.

Losing Medicaid health coverage isn’t just an inconvenience, since many people enrolled in the program probably don’t make enough money to pay for health care on their own and may not qualify for financial help for Affordable Care Act coverage, said Elizabeth Edwards, a senior attorney with the National Health Law Program.

People could be unable to afford medications or get essential care, which could lead to “devastating” health impacts, she said.

“The human stakes of this are people’s lives,” she said.

Â鶹ŮÓÅ Health News correspondents Katheryn Houghton and Samantha Liss contributed to this report.

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 .

USE OUR CONTENT

This story can be republished for free (details).