The Hospital Preparedness Program was created more than two decades ago in response to the Sept. 11, 2001, terrorist attacks on New York City’s World Trade Center and the Pentagon, and the deadly anthrax attacks that began days later. The fund has provided nearly $2.2 billion to states, territories, major cities, and other entities over the past 17 years to ready health care systems for the next pandemic, cyberattack, or mass-casualty event.

Recently, that money has been used to combat the bird flu that has sickened at least 70 people in the United States, killed at least one, and remains a threat. The funds also have been used to respond to crises such as hurricanes, tornadoes, mass shootings, floods, and heat waves.

But the budget request sent to Congress by Trump’s budget director, Russell Vought, proposes eliminating the program, saying the effort “has been wasteful and unfocused” and that cutting it would allow states and cities to “properly” fund their own preparedness plans. Any action is currently stalled by the government shutdown, which stems from a partisan dispute over expiring health care subsidies that affect many of the 24 million Americans who buy coverage from Affordable Care Act marketplaces.

Red and blue states say the hospital preparedness funds are essential and could not be readily replaced with local funds. It’s an example of how the White House’s efforts to reduce its role in responding to public health and natural disasters have imperiled state and municipal reliance on federal resources to meet community needs.

The program “is the main source of government funding for disaster preparedness among hospitals, EMS providers, and other parts of the health care system,” Texas Department of State Health Services spokesperson Chris Van Deusen said.

Texas received more than $20 million from the Hospital Preparedness Program this year, and Van Deusen said it’s unlikely the state could backfill any federal funding gap in the short term since the budget has been finalized through August 2027.

The funds help Texas’ health providers create disaster plans and test hospitals’ ability to boost their capacity in an emergency, he said, while enabling the distribution of medical resources and patient loads so hospitals aren’t overwhelmed during disasters. The program, along with state funding, supports the state’s Emergency Medical Task Force, which responded to deadly floods this year and the Uvalde school shooting in 2022, among many other emergencies.

Georgia, which received $13.5 million this year, “continues to monitor and plan for potential changes to future federal funding while ensuring health care preparedness efforts across Georgia remain strong and sustainable,” said public health spokesperson Eric Jens.

A California health official called the money vital to ensuring local health care systems can respond to emergencies beyond their usual capacity. The program is the only federal funding devoted to health care system preparedness for such catastrophes, said Department of Public Health spokesperson Robert Barsanti.

“Without this funding, California risks losing critical infrastructure for emergency response, weakening its ability to protect lives, maintain continuity of care, and meet federal preparedness benchmarks,” Barsanti said.

As the most populous state, California receives the most money — nearly $29 million this year — as it struggles with a massive budget deficit and fights a running rhetorical battle with Trump administration officials. The funds go to the state’s public health department; the California Emergency Medical Services Authority, which coordinates the state’s emergency medical system; health care associations; and about 60 local entities. Los Angeles County, with more than a quarter of the state’s population, received an additional $11 million, and the University of California system got $1.2 million.

Neither the White House, the Administration for Strategic Preparedness and Response, which administers the program under the U.S. Department of Health and Human Services, nor the Office of Management and Budget responded to repeated requests for comment about the May proposal to cut the Hospital Preparedness Program.

The Administration for Strategic Preparedness and Response has seen an 81% reduction in employees over the past year, The New York Times reported. It’s by far the largest workforce reduction at HHS and part of the wider culling of federal workers under Trump.

Already, HHS has delayed the distribution of this year’s Hospital Preparedness Program funds by nearly three months. The funds were supposed to be available to states for use starting in July, but the bulk of the money was not released until late September. Health officials in the waning days of the Biden administration had wanted to quickly distribute the funds for the nation’s response to the H5N1 bird flu.

The months-long delay “is yet another example of how changes and uncertainty at the federal level threaten critical public health programs in New York state,” said Department of Health spokesperson Cadence Acquaviva. Despite health officials’ best efforts, “delays or elimination of funding places New Yorkers at significant risk in the event of a disaster or emergency,” Acquaviva said.

New York state received nearly $14 million, and New York City more than $9 million.

Illinois Department of Public Health spokesperson Jim Leach said the medical system needs the federal funds to prepare for natural and human-caused disasters of every sort, “regardless of the ebb and flow of any single disease.”

Illinois and Chicago received a combined $15 million from the preparedness program.

During emergencies, the state’s federally funded crisis response program “turns hundreds of Illinois hospitals, EMS, and other health care facilities into a single, coordinated system,” Leach said, adding it saves both lives and taxpayer dollars. “If there is a natural disaster or an infectious disease outbreak, a state would not be able to react quickly enough without the HPP funds.”

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

USE OUR CONTENT

This story can be republished for free (details).

He hasn’t forgotten the pile of hospital bills that awaited him after he had a seizure while tending to customers in his Austin, Texas, barbershop four years ago. Once doctors hurriedly removed the dangerous tumor growing on his brain, a weeklong hospital stay, months of therapy, and nearly $250,000 worth of medical expenses followed.

The coverage he has purchased for years through the Affordable Care Act marketplace covered most of those bills.

“That saved my ass,” said Cleveland, who owns three barbershops across the city.

Even with Cleveland’s monthly premiums expected to soar next year — from $560 to about $682 — he will still sign up for a plan that requires him to shell out $70 if he sees a doctor and 50% of the cost for any emergency room visits. Still, Cleveland is most worried about some of his employees, who might risk going without insurance once they see the high prices.

Small-business owners are among those who stand to lose the most should Congress let the additional, generous federal subsidies put in place during the covid-19 pandemic lapse. The looming change threatens not only their own coverage but also that of their employees, who often depend on marketplace coverage.

Whether to extend the enhanced ACA subsidies that cost taxpayers billions of dollars yearly poses a serious political conundrum for Republicans. After years of unified opposition to Obamacare, the party now faces pressure from one of its most loyal constituencies, small-business owners, who will bear the brunt of rising premiums if the subsidies disappear.

Most of the roughly 20 employees who work on Justin Miller’s 113-year-old family fruit farm in rural Northern California purchase coverage through the Obamacare marketplace.

He’s agonizing over what it could mean if health insurance through the marketplace becomes unaffordable for his employees. He fears they might consider leaving his farm for a job that comes with health coverage.

“Being a small-business owner, especially in a field like ours, where it is tough work and we really understand how hard everybody works, we have to look everybody in the eyes every day,” Miller said. “Knowing that they’re going to have to pay $4,000 or $5,000 more a year to stay on their insurance is a tough pill to swallow.”

Miller says he already pays a minimum wage of $22.50 and provides sick leave, vacation, retirement, and employee housing benefits.

Adding health insurance for his employees, he said, would be too costly to keep his farm in business.

GOP Pollsters Issue ACA Caution

About half of the 24 million people enrolled in Obamacare coverage are, or are employed by, small-business owners — a group that is more likely to vote Republican and overwhelmingly backed President Donald Trump in last year’s election. Farmers, dentists, real estate agents, and chiropractors are among the professions most represented among enrollees.

Even Trump’s own pollsters have found deep support for the Obamacare subsidies, warning that failing to extend them could cost Republicans in next year’s midterms.

A poll conducted last month by Republican pollster John McLaughlin found that a majority of independent voters would be less likely to vote for politicians who voted to let the enhanced tax credits expire.

Given that “approximately 4 million” people would lose coverage and premiums would “skyrocket by an average of 75%,” the poll also concluded that: “A candidate for congress who let the healthcare tax cuts expire would also be vulnerable to more pointed messages.”

Red States Benefited From the Subsidies

Some red states have seen Obamacare enrollment balloon since the federal government began offering extra help paying premiums in the form of more generous subsidies.

Texas and Florida have added 2.8 million enrollees each since 2020, far outpacing growth in most other states. Together, the two states now account for more than a third of marketplace enrollment nationally.

A small chorus of Republican lawmakers — up for reelection next year, mostly in competitive races — have proposed an extension of the subsidies, urging Democrats to vote to reopen the government while simultaneously pleading with House Speaker Mike Johnson to work out a bipartisan deal that doesn’t allow them to simply lapse.

At Cleveland’s barbershops in Austin, about a third of his 18 employees rely on Obamacare coverage. He’s talked to them about their health insurance options for next year but said many hadn’t started thinking about open enrollment, which began Nov. 1.

He’s worried they’ll be baffled once they see the new prices, which currently reflect what customers will pay next year without an extension of the extra subsidies.

“There’s a couple of my barbers that are going to go without, because they’re healthy and young, but I thought I was too when everything happened to me,” said Cleveland, now 47.

Republicans, meanwhile, remain wary of voting to extend the additional Obamacare subsidies, said Rodney Whitlock, a vice president at the McDermott+ consultancy who was a longtime congressional staffer and advises on health care policy.

No Republican voted for the extra subsidies when they were introduced in 2021 or continued in 2022. Approving them now, he said, is viewed by many as a band-aid that would temporarily help a program GOP leaders have long lambasted as problematic and too costly.

But, Whitlock noted, many in the party are coming to terms with how the subsidies might affect their changing constituencies. Nearly 6 in 10 Obamacare enrollees live in a Republican-held congressional district.

“Republicans are slowly starting to grasp that the lower third of income earners are their voters,” he said. “For the first time, I think they’re getting there. That battleship turns slowly.”

Rep. Marjorie Taylor Greene, a Georgia Republican who has firmly backed Trump, broke with her party last month, calling on the GOP to extend the subsidies. Greene said in an interview that rising health care costs are the “No. 1 issue” she hears about from people living in her district.

“I know a lot of small-business owners, like a family of four, and they’re paying $2,000 a month,” Greene said during the television interview, adding that rising deductibles make the insurance hardly functional for anything other than catastrophes.

She warned in another TV interview that “ignoring” the issue could be “very bad for midterms” next year.

Miller, the farmer who lives in a conservative district in Northern California, expects monthly health insurance premiums for himself, his wife, and two of his children to jump from $264 to $600. His deductibles and copayments are going up, too. He expects all these new expenses will still be on his mind when he goes to vote in the midterm elections next year, he said. Describing himself as an independent, Miller said he is frustrated that few American politicians talk about the type of universal health care coverage that’s available in other countries.

“I’m definitely voting for those that will protect the working American, regardless of party,” he said.

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

USE OUR CONTENT

This story can be republished for free (details).

Advocates say the push burdens states with duplicative verification checks and could lead people to lose coverage just for missing paperwork deadlines. But the administrator of the Centers for Medicare & Medicaid Services, Mehmet Oz, said in a post on the social platform X on Oct. 31 that more than $1 billion “of federal taxpayer dollars were being spent on funding Medicaid for illegal immigrants” in five states and Washington, D.C.

Medicaid’s overall spending topped $900 billion in fiscal year 2024.

It wasn’t clear from Oz’s statement or an accompanying video over what period the spending happened, and CMS spokespeople did not immediately respond to questions, either for an earlier version of this article or after Oz’s statement was posted.

Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, which covers low-income and disabled people, and the closely related Children’s Health Insurance Program. Those without legal status are ineligible for federally funded health coverage, including Medicaid, Medicare, and plans through the Affordable Care Act marketplaces.

Several states disputed Oz’s comments.

“Our payments for coverage of undocumented individuals are in accordance with state and federal laws,” said Marc Williams, a spokesperson for Colorado’s Department of Health Care Policy & Financing, which administers the state’s Medicaid program. “The $1.5 million number referenced by federal leaders today is based on an incorrect preliminary finding, and has been refuted with supporting data by our Department experts.”

He added: “It is disappointing that the administration is announcing this number as final when it is clearly overstated and the conversations are very much in the education and discussion phase.”

Illinois Medicaid officials blasted Oz’s comments.

“Once again, the Trump administration is spreading misinformation about standard uses of Medicaid dollars,” said Illinois Medicaid spokesperson Melissa Kula. “This is not a reality show, and there is no conspiracy to circumvent federal law and provide ineligible individuals with Medicaid coverage. Dr. Oz should stop pushing conspiracy theories and focus on improving health care for the American people.”

The Washington State Health Care Authority, which runs the state’s Medicaid program, was also blunt.

“The numbers Dr. Oz posted on social media today are inaccurate,” said spokesperson Rachelle Alongi. “We were very surprised to see Dr. Oz’s post, especially considering we continue to work with CMS in good faith to answer their questions and clear up any confusion.”

In August, CMS began sending states the names of people enrolled in Medicaid that the agency suspected might not be eligible, demanding state Medicaid agencies check their immigration status.

KFF Health News in October reached out to Medicaid agencies in 10 states. Five provided the approximate number of names they had received from the Trump administration, with expectations of more to come: Colorado had been given about 45,000 names, Ohio 61,000, Pennsylvania 34,000, Texas 28,000, and Utah 8,000. More than 70 million people are enrolled in Medicaid.

Most of those states declined to comment further. Medicaid agencies in California, Florida, Georgia, New York, and South Carolina refused to say how many names they were ordered to review or did not respond.

Oz said in his X post that California had misspent $1.3 billion on care for people not eligible for Medicaid, while Illinois spent $30 million, Oregon $5.4 million, Washington state $2.4 million, Washington, D.C., $2.1 million, and Colorado $1.5 million.

“We notified the states, and many have begun refunding the money,” he said. “But what if we had never asked?”

Washington, D.C.’s Medicaid director, Melisa Byrd, said CMS had identified administrative expenses for the district program that covers people regardless of immigration status that should not have been billed to the federal government and her agency has already fixed some of those areas. “We run a big program that is very complex and when mistakes or errors happen, we fix them,” she said.

The program plans to pay $654,014 back to CMS by mid-November.

All five states, plus Washington, D.C., are led by Democrats, and President Donald Trump didn’t win any of them in the 2024 election.

In recent days, Deputy Health and Human Services Secretary Jim O’Neill began posting pictures on X of people he said are convicted criminals living in the U.S. without authorization who had received Medicaid benefits.

O’Neill could not be reached for comment.

“We are very concerned because this seems, frankly, to be a waste of state resources and furthers the administration’s anti-immigrant agenda,” said Ben D’Avanzo, senior health advocacy strategist with the National Immigration Law Center, an advocacy group. “This duplicates what states already do,” he said.

As part of the administration’s crackdown on people in the U.S. without authorization, President Donald Trump in February directed federal agencies to take action to ensure they are not obtaining benefits in violation of federal law.

In June, advisers to Health and Human Services Secretary Robert F. Kennedy Jr. ordered CMS to share information about Medicaid enrollees with the Department of Homeland Security, drawing a lawsuit by some states alarmed that the administration would use the information for its deportation campaign against unauthorized residents.

In August, a federal judge ordered HHS to stop sharing the information with immigration authorities.

State Medicaid agencies use databases maintained by the Social Security Administration and Department of Homeland Security to verify enrollees’ immigration status.

If states need to go back to individuals to reverify their citizenship or immigration status, it could lead some to fall off the rolls unnecessarily — for example, if they don’t see a letter requesting paperwork or fail to meet a deadline to respond.

“I am not sure that evidence suggests there really is a need for this” extra verification, said Marian Jarlenski, a health policy professor at the University of Pittsburgh School of Public Health.

Oz made clear that the Trump administration disagrees.

“Whether willful or not, the states’ conduct highlights a terrifying reality: American taxpayers have been footing the bill for illegal immigrants’ Medicaid coverage, despite many Democrats and the media insisting otherwise,” Oz said in his X post.

In an August press release, CMS said it would ask states to verify eligibility for enrollees whose immigration status could not be confirmed via federal databases. “We expect states to take quick action and will monitor progress on a monthly basis,” the agency said.

Leonardo Cuello, a research professor at Georgetown University’s Center for Children and Families, called the CMS order to states “unprecedented” in the Medicaid program’s 60-year history.

He said the federal government may have been unable to verify certain individuals’ immigration status because names were misspelled or outdated, such as when a beneficiary is identified by their maiden instead of married name. The names may also include people helped by Emergency Medicaid, a program that covers the cost of hospital emergency services, including labor and delivery, for people regardless of immigration status.

“CMS is conducting pointless immigration status reviews for people whose hospital bills were paid by Emergency Medicaid,” Cuello said.

Oz noted in his post that federal law “does permit states to use Medicaid dollars for emergency treatment, regardless of patients’ citizenship or immigration status,” and that states can “legally build Medicaid programs for illegal immigrants using their own state tax dollars, so long as no federal tax dollars are used.”

The states Oz mentioned all run their own such programs.

The verification checks create an added burden for state Medicaid agencies that are already busy preparing to implement the tax and policy law Trump signed in July. The measure, which Republicans call the One Big Beautiful Bill Act, makes many changes to Medicaid, including adding a work requirement in most states starting by 2027. The law also requires most states to more frequently check the eligibility of many adult Medicaid enrollees — at least twice a year.

“I fear states may do unnecessary checks that create a burden for some enrollees who will lose health coverage who should not,” Cuello said. “It’s going to be a whole lot of work for CMS and states for very little pay dirt.”

Cuello said the effort may have “greater political value than actual value.”

Brandon Cwalina, a spokesperson for the Pennsylvania Department of Human Services, which runs Medicaid in the state, said the state already requires every Medicaid applicant to verify their citizenship or, where applicable, their eligible immigration status.

However, he said, the directive issued by CMS “constitutes a new process, and DHS is carefully reviewing the list in order to take appropriate actions.”

Oz did not name Pennsylvania, which Trump won in 2024, in his post.

If a lawful resident does not have a Social Security number, the state confirms their legal status by checking a database from Homeland Security, as well as verifying specific immigration documents, he said.

Other state Medicaid agencies said they also needed to regroup before reaching out to enrollees.

“Our teams just received this notice and are working through a process by which we will perform these reviews,” Jennifer Strohecker, then Utah’s Medicaid director, told a state advisory board in August.

Renuka Rayasam and Rae Ellen Bichell contributed reporting.

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

USE OUR CONTENT

This story can be republished for free (details).

U.S. Immigration and Customs Enforcement agents have also shown up at community clinics. Health providers say that officers have tried to enter a parking lot hosting a mobile clinic, waved a machine gun in the faces of clinicians serving the homeless, and hauled a passerby into an unmarked car outside a community health center.

In response to such immigration enforcement activity in and around clinics and hospitals, Democratic Gov. Gavin Newsom last month signed SB 81, which prohibits medical establishments from allowing federal agents without a valid search warrant or court order into private areas, including places where patients receive treatment or discuss health matters.

But while the bill received broad support from medical groups, health care workers, and immigrant rights advocates, legal experts say California can’t stop federal authorities from carrying out duties in public places, which include hospital lobbies and general waiting areas, health facility parking lots, and surrounding neighborhoods — places where recent ICE activities have sparked outrage and fear. Previous federal restrictions on immigration enforcement in or near sensitive areas, including health care establishments, were rescinded by the Trump administration in January.

“The issue that states encounter is the supremacy clause,” said Sophia Genovese, a supervising attorney and clinical teaching fellow at Georgetown Law. She said the federal government does have the right to conduct enforcement activities, and there are limits to what the state can do to stop them.

California’s law designates a patient’s immigration status and birthplace as protected information, which like medical records cannot be disclosed to law enforcement without a warrant or court order. And it requires health care facilities to have clear procedures for handling requests from immigration authorities, including training staff to immediately notify a designated administrator or legal counsel if agents ask to enter a private area or review patient records.

Several other Democratic-led states have also taken up legislation to protect patients at hospitals and health centers. In May, Colorado Gov. Jared Polis signed the Protect Civil Rights Immigration Status bill, which penalizes hospitals for unauthorized sharing of information about people in the country illegally and bars ICE agents from entering private areas of health care facilities without a judicial warrant. In Maryland, a law requiring the attorney general to create guidance on keeping ICE out of health care facilities went into effect in June. New Mexico has instituted new patient data protections, and Rhode Island has prohibited health care facilities from asking patients about their immigration status.

Republican-led states have aligned with federal efforts to prevent health care spending on immigrants without legal authorization. Such immigrants are not eligible for comprehensive Medicaid coverage, but states do bill the federal government for emergency care in certain cases. Under a law that took effect in 2023, Florida requires hospitals that accept Medicaid to ask about a patient’s legal status. In Texas, hospitals now have to report how much they spend on care for immigrants without legal authorization.

“Texans should not have to shoulder the burden of financially supporting medical care for illegal immigrants,” Gov. Greg Abbott said in issuing his executive order last year.

California’s efforts to rein in federal enforcement come as the state, where more than a quarter of residents are foreign-born, has become a target of President Donald Trump’s immigration crackdown. Newsom signed SB 81 as part of a bill package prohibiting immigration agents from entering schools without a warrant, requiring law enforcement officers to identify themselves, and banning officers from wearing masks. SB 81 was passed on a party-line vote with no formal opposition.

“We’re not North Korea,” Newsom said during a September bill-signing ceremony. “We’re pushing back against these authoritarian tendencies and actions of this administration.”

Some supporters of the bill and legal experts said California’s law can prevent ICE from violating existing patient privacy rights. Those include the Fourth Amendment, which prohibits searches without a warrant in places where people have a reasonable expectation of privacy. Valid warrants must be issued by a court and signed by a judge. But ICE agents frequently use administrative warrants to try to gain access to private areas they don’t have the authority to enter, Genovese said.

“People don’t always understand the difference between an administrative warrant, which is a meaningless piece of paper, versus a judicial warrant that is enforceable,” Genovese said. Judicial warrants are rarely issued in immigration cases, she added.

The Department of Homeland Security has said it won’t abide by California’s mask ban or identification requirements for law enforcement officers, slamming them as unconstitutional. The department did not respond to a request for comment on the state’s new rules for health care facilities, which went into immediate effect.

Tanya Broder, a senior counsel with the National Immigration Law Center, said immigration arrests at health care facilities appear to be relatively rare. But the federal decision to rescind protections around sensitive areas, she said, “has generated fear and uncertainty across the country.” Many of the most high-profile news reports of immigration agents at health care facilities have been in California, largely involving detained patients brought in for care.

The California Nurses Association, the state’s largest nurses union, was a co-sponsor of the bill and raised concerns about the treatment of Milagro Solis-Portillo, a 36-year-old Salvadoran woman who was under round-the-clock ICE surveillance at Glendale Memorial Hospital over the summer.

Union leaders also condemned the presence of agents at California Hospital Medical Center south of downtown Los Angeles. According to Anne Caputo-Pearl, a labor and delivery nurse and the chief union representative at the hospital, agents brought in a patient on Oct. 21 and remained in the patient’s room for almost a week. The Los Angeles Times reported that a TikTok streamer, Carlitos Ricardo Parias, was taken to the hospital that day after he was wounded during an immigration enforcement operation in South Los Angeles.

The presence of ICE was intimidating for nurses and patients, Caputo-Pearl said, and prompted visitor restrictions at the hospital. “We want better clarification,” she said. “Why is it that these agents are allowed to be in the room?”

Hospital and clinic representatives, however, said they are already following the law’s requirements, which largely reinforce extensive guidance put out by state Attorney General Rob Bonta in December.

Community clinics throughout Los Angeles County, which serve over 2 million patients a year, including a large portion of immigrants, have been implementing the attorney general’s guidelines for months, said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County. But she said the law should help ensure uniform standards across health facilities that clinics refer out to and reassure patients that procedures are in place to protect them.

Still, it can’t prevent immigration raids from happening in the broader community, which have made some patients and even health workers afraid to venture outside, McCarthy said. Some incidents have occurred near clinics, including an arrest of a passerby outside a clinic in East Los Angeles, which a security guard caught on video, she said.

“We’ve had clinic staff say, ‘Is it safe for me to go out?’” she said.

At St. John’s Community Health, a network of 24 community health centers and five mobile clinics in South Los Angeles and the Inland Empire, CEO Jim Mangia agreed that the new law can’t prevent all immigration enforcement activity, but he said it does give clinics a tool to push back if agents show up, something his staff has already had to do.

Mangia said St. John’s staff had two encounters with immigration agents over the summer. In one, he said, staff stopped armed officers from entering a gated parking lot at a drug and alcohol recovery center where doctors and nurses were seeing patients at a mobile health clinic.

Another occurred in July, when immigration agents descended upon MacArthur Park on horses and in armored vehicles, in a show of force by the Trump administration. Mangia said masked officers in full tactical gear surrounded a street medicine tent where St. John’s providers were tending to homeless patients, screamed at staff to get out, and pointed a gun at them. The providers were so shaken by the episode, Mangia said, that he had to bring in mental health professionals to help them feel safe going back out on the street.

A DHS spokesperson told CalMatters that in the rare instance where agents enter certain sensitive locations, officers would need “secondary supervisor approval.”

Since then, St. John’s has doubled down on providing support and training to staff and has offered patients afraid to go out the option of home medical visits and grocery deliveries. Patient fears and ICE activity have decreased since the summer, Mangia said, but with DHS planning to hire an additional 10,000 ICE agents, he doubts that will last.

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

USE OUR CONTENT

This story can be republished for free (details).

More than a dozen states, including Washington, Oregon, California, Colorado, Minnesota, Maryland, New York, and most of New England, have enacted laws in recent years to keep medical debt from affecting consumers’ credit.

And more states — including several in conservative regions of the Midwest and Mountain West — have been considering similar protections, spurred by bipartisan concerns that medical debt on a credit report can make it harder for people to get a home, a car, or a job.

Nationwide, about 100 million people have some form of health care debt, with millions burdened by $10,000 or more in unpaid bills.

But in the new guidance, the Consumer Financial Protection Bureau asserts that federal law bars states from restricting medical debts from credit reports, arguing that only the federal government has this authority.

“Congress meant to occupy the field of consumer reporting and displace state laws,” the bureau concluded in an “interpretive rule” signed by Russell Vought, the White House budget director and acting head of the CFPB.

The guidance, which offers a new interpretation of the Fair Credit Reporting Act, reverses policies advanced under former President Joe Biden that sought to empower states to expand protections for people with medical debt.

The Trump administration’s latest move will not immediately roll back existing state protections.

But advocates for patients and consumers warn that the new guidance may stall progress elsewhere, just as millions of Americans are poised to lose federal aid that helps them buy health insurance through the Affordable Care Act. The aid is tied up in the current budget showdown between congressional Republicans and Democrats.

“You’d be hard-pressed to find a crueler regulatory interpretation,” said Elisabeth Benjamin, a vice president for the Community Service Society of New York. The nonprofit has pushed for medical debt protections in that state.

Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society, warned that the Trump administration’s guidance could reverberate across the country. “This rule will have a chilling effect on states’ willingness to pass these critical patient protections,” she said.

The CFPB did not respond to a request for comment.

The new CFPB guidance might spur more litigation challenging state restrictions on medical debt credit reporting.

Trade groups representing credit reporting agencies and debt collectors went to court early this year challenging regulations issued by the Biden administration that would have removed medical debt from credit reports nationwide. They argued that the administration exceeded its authority in issuing the credit reporting restrictions.

The federal restrictions would have helped an estimated 15 million people. But the Trump administration chose not to defend the new regulations, and a federal judge in Texas appointed by Trump ruled that the regulations should be scrapped. They never went into effect.

The Consumer Data Industry Association, which represents credit agencies and has argued that regulating medical debt should be left to the federal government, welcomed the new guidance from the Trump administration.

“There should be one national standard to govern how information is provided to consumer reporting agencies and what information can appear on a consumer’s credit report,” association president Dan Smith said in a statement.

Broader health insurance protections could prevent more Americans from sinking into debt and depressing their credit scores.

But millions of Americans are expected to lose health coverage in the coming years as a result of the tax and spending bill signed by the president in July.

“Millions of Americans are avoiding medical care, putting off needed surgeries, skipping essential treatments,” said Allison Sesso, president and chief executive of Undue Medical Debt, a nonprofit that buys up and retires patients’ debts and advocates for broader patient protections.

“This isn’t just a health care issue,” Sesso added. “It’s an economic crisis that’s keeping families from building wealth and fully participating in the economy. When credit scores are dinged by medical bills, everyone loses.”

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

USE OUR CONTENT

This story can be republished for free (details).

And, they warn, the economic burden will steer many medical students to lucrative specialties in more affluent, urban areas rather than lower-paying primary care jobs in underserved and rural communities, where doctors are in shortest supply.

“The growing financial barriers may deter some individuals from pursuing a career in medicine, particularly those from low-income backgrounds,” said Deena McRae, a psychiatrist and associate vice president for academic health sciences at University of California Health.

The new federal loan limits, which are enshrined in the GOP legislation signed by Trump on July 4, cap the amount professional degree students can borrow at $50,000 a year, up to a maximum of $200,000 — well below the average cost of a four-year medical school education.

For students who graduated this year with an MD degree from a four-year medical school in the United States, the median cost of attendance was $318,825, according to Kristen Earle, director of student financial services at the Association of American Medical Colleges. And for those who entered a U.S. medical school in the 2024-25 academic year, the median first-year cost was $83,700.

Health care experts and politicians on both sides of the aisle agree that medical schools must find ways to lower their costs, but critics of the loan caps say limiting federal lending isn’t the answer. Congressional Republicans, who voted for the caps, say they are intended to stem a sharp rise in federal student lending over the past two decades that has driven the cost of attendance higher.

“Uncapped loan limits gave no incentives for schools to reduce any of their costs, recognizing that taxpayers, students, or students’ families would eventually foot the bill,” said Sara Robertson, a spokesperson for the GOP-controlled House Committee on Education and Workforce. “Our reforms and loan limits will put downward pressure on costs to provide better outcomes and lower debt for all students.”

The budget law brings back caps for graduate and professional education that Congress eliminated in 2006. Since then, students have been able to get federal loans that cover the total cost of their degree programs. Reimposing the caps, along with other changes to federal student loans, is expected to save the federal government $349 billion over 10 years, according to the Congressional Budget Office.

Whether the new federal loan policy will push down tuition costs remains to be seen.

Robertson pointed to a 2023 study by the National Bureau of Economic Research showing that the more generous federal lending policy since 2006 has led to “significantly higher program prices” in graduate education. The study also found that the additional federal support failed to increase enrollment in graduate programs, including for underrepresented students.

However, data provided by the Association of American Medical Colleges shows that cost-of-living increases, not tuition, drove up the expense of studying medicine in recent years.

Students already in medical school who have taken out federal loans before the new rules take effect on July 1 will be exempted from the cap. But students whose loans are capped under the new law will need to make up the difference, in many cases by taking out private sector loans, which typically have less flexible repayment terms and require a strong credit rating — a heavy lift for students from low-income communities.

Robertson cited a 2017 analysis showing that nearly 60% of graduate students could have obtained a private loan at a lower interest rate than any available federal loan. Federal loans, however, come with advantages that private loans don’t. For instance, federal loans can include monthly repayments calibrated to income, and they offer two debt forgiveness paths, including the Public Service Loan Forgiveness program, which erases the balance for those who work in a government or nonprofit organization and make their monthly payments for 10 years.

Critics and proponents agree on at least one thing: Now is the time for medical schools to think creatively about lowering costs for students. This might include reduced tuition, more chances for debt forgiveness, and accelerated programs that allow students to graduate in three years rather than four, reducing costs by 25% and getting them more quickly into paid jobs.

“I hope that coming out of this, medical schools and others find a way to seize the moment and help us figure out how to reduce the total cost of medical school,” said Martha Santana-Chin, CEO of L.A. Care. “Maybe this is an opportunity for us to rethink how the system is working.”

Roughly a fifth of medical schools offering an MD degree have accelerated programs, including the University of California-Davis, according to the Consortium of Accelerated Medical Pathway Programs.

A data analysis of eight medical schools led by the NYU Grossman School of Medicine, whose core MD curriculum is three years, shows that students in three-year programs derive a lifetime financial gain totaling over $240,000 due to the cost savings of less time in medical school, interest not paid on the corresponding amount not borrowed, and faster progression to a salaried position.

In addition to lowering costs, accelerated medical programs seek to address health care workforce shortages by training physicians more quickly. And with the new loan caps about to make it more difficult for many students to finance their medical education, these programs suddenly have a new timeliness.

Students who spend three years in medical school instead of four have lower debt and get to a higher salary sooner, said Caroline Roberts, a family physician and director of rural education at the University of North Carolina’s School of Medicine. UNC offers a three-year track for students who want to be primary care doctors and work in rural areas of the state, where doctor shortages are a major problem.

Zoe Priddy, who is in her second year of UNC’s three-year program, said that if the federal loan limits had been in place at the time she was making plans to attend medical school, she would have needed a job that paid better than the research lab where she worked after completing her undergraduate degree.

“I would have had to change my trajectory if I still wanted to pursue medicine, and I don’t know if it would have been possible for me,” Priddy said. However, the lower debt associated with the three-year track “eased my decision” to go into pediatrics, a lower-paying specialty, she said.

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

USE OUR CONTENT

This story can be republished for free (details).

As shopping season opens for Affordable Care Act plans in some states, customers are confronting staggering costs for their health insurance next year. The extra federal subsidies put in place in 2021 that made coverage more affordable for millions of people will expire at the end of this year unless a gridlocked and idle Congress acts.

With Democratic and Republican lawmakers at an impasse, the federal government shut down on Oct. 1, spurred by the need for an estimated $353 billion over a decade to continue providing enhanced ACA subsidies for roughly 24 million people. Both sides have dug in, with Republicans saying Senate Democrats must vote to reopen the government before they’re willing to negotiate on the ACA’s costs.

If Congress does manage to strike a deal in the coming days or weeks to extend some subsidies, the prices and types of plans available on the online marketplaces could change dramatically, bringing unprecedented uncertainty and upheaval to this year’s open enrollment, which begins in most states on Nov. 1.

Michele Eberle, executive director of the Maryland Health Benefit Exchange, the state-run marketplace, is gaming out strategies should that happen, including the possibility of pausing enrollment so her 200-person team can update the plans to reflect any changes, should Congress pass a new bill on ACA subsidies.

“We will do whatever it takes to make sure we can provide Marylanders with the most affordable health coverage,” Eberle said. “The mechanics of how that gets done, we don’t really know until we figure out what Congress might do.”

“I think everyone realizes that, depending on what happens, we just can’t flip a switch overnight,” she added.

Exchange customers in Maryland can expect to pay, on average, about 35% more next year, even with help from the state, which agreed to offer backup subsidies should the federal government’s discounts expire at the end of this year. Eberle said notices of premium hikes — which assumed the federal subsidies would expire — already were sent to mailboxes and inboxes. One middle-income family of four in the state, for example, will see their monthly premiums go from $916 to $1,427.

People living in most states still use healthcare.gov, the federal marketplace, to enroll in coverage. The Centers for Medicare & Medicaid Services, which oversees the federal exchange, declined to answer questions about how quickly the agency could pivot on any changes Congress may make after sign-ups start.

“CMS does not speculate on potential Congressional action,” Health and Human Services spokesperson Emily Hilliard said in an email.

Like other states that run their own ACA exchanges, California has sent letters to policyholders with information about their 2026 coverage, with costs calculated under the assumption that the subsidies would expire.

But the California exchange team, too, devised backup plans to contact policyholders and revamp its online marketplace if Congress acts before year’s end.

“At no point is it too late,” said Jessica Altman, executive director of Covered California, the state’s exchange. “We are ready to move any mountain we can possibly move to make any changes as quickly as we possibly can.”

It could take about a week to reprogram the site to reflect prices that factor in more generous subsidies, if Congress were to approve them exactly as they currently are, Altman said.

States may also have to update premiums themselves to reflect new rates. Most insurers submitted two sets of premium rates to states this year in case Congress agreed to extend the subsidies.

Right now, many shoppers are seeing the set of higher rates that insurers plan to charge if the subsidies expire.

Insurers say it is necessary to raise premiums without the subsidies because they anticipate healthier, younger people will drop coverage rather than pay more. That would leave insurers with a sicker, older pool of people to cover.

If a subsidy deal is reached, insurers could lower the premiums.

The complications don’t end there.

If Congress passes a subsidy deal after customers have started picking plans, people might see the new prices and want to reconsider the type of coverage for which they already signed up. Enrollees may change plans as long as enrollment is open, through Jan. 15 in most states.

Dozens of insurers offer ACA plans across the country. Those plans range widely in the doctors or medications they cover, as well as how much customers contribute in copays, the fees owed for medical services, and deductibles, the out-of-pocket amount paid before insurers pitch in.

Some people might be willing to pay a higher monthly premium in exchange for a lower deductible. Others, especially those who don’t expect to incur major medical bills, might risk a higher deductible to keep monthly premium payments lower.

In Virginia, some customers are being presented with strikingly high deductibles for next year, said Deepak Madala, the director of Enroll Virginia, which assists people with enrolling in coverage.

He said he’s helping one family in Virginia Beach facing a jump in premium costs from $70 to about $280 a month.

To buy a plan at a similar price, the family, with a household income of about $60,000, would need to look at coverage that carries a deductible of $20,000 or more, he said. Right now, their deductible is $800.

With premiums and deductibles that high, some customers might rethink coverage entirely, he said.

They’re deciding whether “to go without or switch to a plan with a very high deductible,” Madala said of ACA customers’ options.

Pennsylvania’s state-based exchange, which last week started sending out notices detailing 2026 rates, estimates a 102% increase in premiums for its roughly 500,000 customers. About a third of customers are expected to drop coverage, said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority.

The timing of any subsidy deal reached by Congress is most precarious, though, for the roughly 135,000 Idahoans enrolled in ACA coverage.

That’s because their state opened enrollment on Oct. 15, weeks before the rest of the country — and it will end earlier, on Dec. 15.

With ACA enrollees facing average increases of 75% for coverage costs, about 20% are expected to drop out of the marketplace, said Pat Kelly, executive director of Your Health Idaho, the state exchange.

Idaho is prepared to revamp its website if anything changes on the subsidies — a process that could take days — and has “notices ready to go” to inform policyholders of additional savings, Kelly said.

“We would work to do it as quickly as possible, and make sure it is done right,” he said, adding that factors such as the day of the week or proximity to the Thanksgiving holiday could add time.

If Congress waited to act until the federal subsidies expire on Dec. 31 — the date Republican House Speaker Mike Johnson has repeatedly raised as the deadline for a deal — it would be too late for people in Idaho.

“We would run out of open enrollment, and there would not be enough time to make changes,” Kelly said of any congressional deals reached after mid-December.

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

USE OUR CONTENT

This story can be republished for free (details).

But there was one glaring omission that LGBTQ+ advocates and political strategists say is part of an increasingly complex dance the Democrat faces as he curates a more centrist profile for a potential presidential bid.

Newsom vetoed a bill that would have required insurers to cover, and pharmacists to dispense, 12 months of hormone therapy at one time to transgender patients and others. The proposal was a top priority for trans rights leaders, who said it was crucial to preserve care as clinics close or limit gender-affirming services under White House pressure.

Political experts say Newsom’s veto highlights how charged trans care has become for Democrats nationally and, in particular, for Newsom, who as San Francisco mayor engaged in civil disobedience by allowing gay couples to marry at City Hall. The veto, along with his lukewarm response to anti-trans rhetoric, they argue, is part of an alarming pattern that could damage his credibility with key voters in his base.

“Even if there were no political motivations whatsoever under Newsom’s decision, there are certainly political ramifications of which he is very aware,” said Dan Schnur, a former GOP political strategist who is now a politics lecturer at the University of California-Berkeley. “He is smart enough to know that this is an issue that’s going to anger his base, but in return, may make him more acceptable to large numbers of swing voters.”

Earlier this year on Newsom’s podcast, the governor told the late conservative activist Charlie Kirk that trans athletes competing in women’s sports was “deeply unfair,” triggering a backlash among his party’s base and LGBTQ+ leaders. And he has described trans issues as a “major problem for the Democratic Party,” saying Donald Trump’s trans-focused campaign ads were “devastating” for his party in 2024.

Still, in a conversation with YouTube streamer ConnorEatsPants this month, Newsom defended himself “as a guy who’s literally put my political life on the line for the community for decades, has been a champion and a leader.”

“He doesn’t want to face the criticism as someone who, I’m sure, is trying to line himself up for the presidency, when the current anti-trans rhetoric is so loud,” said Ariela Cuellar, a spokesperson for the California LGBTQ Health and Human Services Network.

Caroline Menjivar, the state senator who introduced the measure, described her bill as “the most tangible and effective” measure this year to help trans people at a time when they are being singled out for what she described as “targeted discrimination.” In a legislature in which Democrats hold supermajorities in both houses, lawmakers sent the bill to Newsom on a party-line vote. Earlier this year, Washington became the first to enact a state law extending hormone therapy coverage to a 12-month supply.

In a veto message on the California bill, Newsom cited its potential to drive up health care costs, impacts that an independent analysis found would be negligible.

“At a time when individuals are facing double-digit rate increases in their health care premiums across the nation, we must take great care to not enact policies that further drive up the cost of health care, no matter how well-intended,” Newsom wrote.

Under the Trump administration, federal agencies have been directed to limit access to gender-affirming care for children, which Trump has referred to as “chemical and surgical mutilation,” and demanded documents from or threatened investigations of institutions that provide it.

In recent months, Stanford Medicine, Children’s Hospital Los Angeles, and Kaiser Permanente have reduced or eliminated gender-affirming care for patients under 19, a sign of the chilling effect Trump’s executive orders have had on health care, even in one of the nation’s most progressive states.

California already mandates wide coverage of gender-affirming health care, including hormone therapy, but pharmacists can currently dispense only a 90-day supply. Menjivar’s bill would have allowed 12-month supplies, modeled after a 2016 law that allowed women to receive an annual supply of birth control.

Luke Healy, who told legislators at an April hearing that he was “a 24-year-old detransitioner” and no longer believed he was a woman, criticized the attempt to increase coverage of services he thought were “irreversibly harmful” to him.

“I believe that bills like this are forcing doctors to turn healthy bodies into perpetual medical problems in the name of an ideology,” Healy testified.

The California Association of Health Plans opposed the bill over provisions that would limit the use of certain practices such as prior authorization and step therapy, which require insurer approval before care is provided and force patients and doctors to try other therapies first.

“These safeguards are essential for applying evidence-based prescribing standards and responsibly managing costs — ensuring patients receive appropriate care while keeping premiums in check,” said spokesperson Mary Ellen Grant.

An analysis by the California Health Benefits Review Program, which independently reviews bills relating to health insurance, concluded that annual premium increases resulting from the bill’s implementation would be negligible and that “no long-term impacts on utilization or cost” were expected.

Shannon Minter, legal director for the National Center for LGBTQ Rights, said Newsom’s economic argument was “not plausible.” Although he said he considers Newsom a strong ally of the transgender community, Minter noted he was “deeply disappointed” to see the governor’s veto. “I understand he’s trying to respond to this political moment, and I wish he would respond to it by modeling language and policies that can genuinely bring people along.”

Newsom’s press office declined to comment further.

Following the podcast interview with Kirk, Cuellar said, advocacy groups backing SB 418 grew concerned about a potential veto and made a point to highlight voices of other patients who would benefit, including menopausal women and cancer patients. It was a starkly different strategy than what they might have done before Trump took office.

“Had we run this bill in 2022-2023, the messaging would have been totally different,” said another proponent who requested anonymity because they were not authorized to speak publicly on the issue. “We could have been very loud and proud. In 2023, we might have gotten a signing ceremony.”

Advocates for trans rights were so wary of the current political climate that some also felt the need to steer clear of promoting a separate bill that would have expanded coverage of hormone therapy and other treatments for menopause and perimenopause. That bill, authored by Assembly member Rebecca Bauer-Kahan, who has spoken movingly about her struggles with health care for perimenopause, was also vetoed.

In the meantime, said Jovan Wolf, a trans man and military veteran, patients like him will be left to suffer.

Wolf, who had taken testosterone for more than 15 years, tried to restart hormone therapy in March, following a two-year hiatus in which he contemplated having children.

Doctors at the Department of Veterans Affairs told him it was too late. Days earlier, the Trump administration had announced it would phase out hormone therapy and other treatments for gender dysphoria.

“Having estrogen pumping through my body, it’s just not a good feeling for me, physically, mentally. And when I’m on testosterone, I feel balanced,” said Wolf, who eventually received care elsewhere. “It should be my decision and my decision only.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

USE OUR CONTENT

This story can be republished for free (details).

Health care analysts say the nation’s uninsured population will rise significantly if federal lawmakers do not agree to renew covid-era tax credits, which Congress authorized in 2021 to supplement ACA subsidies.

They’re popular too. According to a KFF poll, more than three-quarters of adults, including 59% of Republicans, say they want Congress to extend the enhanced tax credits for people with low and moderate incomes. KFF is a health information nonprofit that includes KFF Health News, the publisher of California Healthline.

The additional credits have lowered premiums, helped millions of Americans afford the cost of ACA insurance, and lowered the nation’s uninsured rate.

Last week, President Donald Trump suggested a health care deal might be in the works. And Republican U.S. Rep. Marjorie Taylor Greene of Georgia, long aligned with the “Make America Great Again” movement, appeared to endorse an extension of the tax credits, saying in a social media post that she was “absolutely disgusted that health insurance premiums will DOUBLE if the tax credits expire this year.”

However, Republican leaders want to reopen the government first, while Democrats want a deal in a bill that ends the shutdown.

If the supplemental subsidies are not extended beyond this year, the amount subsidized consumers pay for their ACA health plans is expected to more than double on average. That would be a painful cost-of-living increase for most of the country’s more than 24 million marketplace enrollees, including almost 90% of the nearly 2 million people in Covered California, the largest state-run health insurance marketplace. Analysts say the loss of enhanced credits would lead millions to drop their coverage nationally, including hundreds of thousands in California.

The federal government shutdown stems primarily from a disagreement between Democratic lawmakers, who want to extend the tax credits, and Republicans opposed to the cost and, in many cases, to the landmark health care law itself. One estimate puts the price tag at $350 billion over 10 years. The Democrats hope their stance can help them win back the House in next year’s midterm elections, as they did in 2018 following a failed GOP effort to repeal the ACA.

Open enrollment season for 2026 ACA health plans starts Nov. 1 in most states, including California, and enrollees still have no clue whether their premiums will rise exorbitantly next year.

“People need to be able to shop for health plans,” says Jessica Altman, executive director of Covered California. “We are at a pivotal moment.”

In July, Covered California sent notices to enrollees breaking out the enhanced portion of their federal subsidy that is set to expire. The idea was to give them a warning of how much their costs might rise if they chose to keep the same health plan next year.

In one case, a common scenario for middle-income enrollees, the entire subsidy of $200 a month would go away. Another enrollee stood to lose one-third of a total $600 per month in aid, according to sample notices provided by Covered California.

The additional tax credits have provided financial assistance to many middle-income health plan shoppers who didn’t qualify for the original subsidies and increased the amount of aid for many others.

Senate Majority Leader John Thune in late September left the door open to extending the otherwise-expiring tax credits but said “it would have to come with some reforms.”

Those might include changes that would reduce the number of enrollees eligible for the extra financial aid, based on income, and reduce or eliminate zero-premium plans, which have become widely available with the advent of the additional tax credits.

If the enhanced subsidies end, Covered California projects its enrollees receiving enhanced subsidies will see their premium costs rise an average of 97%. But the increases will not be borne equally. Depending on age, income, and location, some people will see smaller jumps while others could see their out-of-pocket costs triple, Altman says.

Rural residents, especially in the northern and eastern counties, and along the Monterey Coast, will see disproportionately large cost increases, according to projections from Covered California. Enrollees with incomes over $62,600 will lose financial aid altogether, leaving some who are ages 55-64 with premium bills as high as 30% of their income.

Without the enhanced subsidies, “we’re going to see more people experiencing medical debt, more people being either uninsured or underinsured,” says Cary Sanders, senior policy director at the nonprofit California Pan-Ethnic Health Network. “And that is the quickest way for families to lose their economic security.”

Covered California estimates about 400,000 people would leave the exchange and likely go without insurance. And that, health care professionals and advocates warn, will only heap stress — in the form of more crowded emergency rooms and community clinics — on an already stressed health care system.

But the proportional impact in California will be smaller than in some Republican-led states such as Florida, Texas, and Georgia. Since those states did not embrace the ACA’s Medicaid expansion, millions of residents thronged to Obamacare marketplace plans, particularly after the enhanced tax credits made coverage eminently more affordable.

From 2020 to 2025, ACA marketplace enrollment grew nearly 2.5 times in Florida to 4.7 million — more than double California’s marketplace enrollment. In Texas, it more than tripled to just under 4 million. Georgia’s tripled, too, to 1.5 million.

California has about $190 million for 2026 in state funds to help offset the loss of the enhanced premium subsidies. But that money is currently used to help offset enrollee deductibles, coinsurance payments, and other out-of-pocket expenses. And it’s a drop in the bucket compared with the $2.5 billion annually in financial aid Covered California enrollees currently receive from the expiring tax credits.

“A lot of people are going to be shocked at what they’re facing,” says Rachel Linn Gish, a spokesperson for the nonprofit advocacy group Health Access California. “They’re going to have to make super hard choices of, ‘Do I cut back on my groceries, or my rent, or do I go uninsured?’”

Very soon, Covered California and other ACA marketplaces will have to send out formal open enrollment letters, notifying enrollees precisely what to expect for 2026 coverage.

Covered California typically sends those letters out Oct. 1 but has delayed them to around Oct. 15 in the hope that Washington will provide clarity. For now, Covered California has two versions of the letter on ice, one with tax credit extensions and one without.

Altman says she is hoping for congressional action before sending the one with whopping premium increases. But she may have no choice.

“That’s the default here, as in the thing that will happen if nothing changes,” Altman says. “It is also the worst-case scenario, unfortunately.”

She fears that if Covered California informs enrollees that their rates will likely rise sharply, it will scare many away, even if Congress later agrees to extend the credits.

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

USE OUR CONTENT

This story can be republished for free (details).

• Click here to watch Rovner on “Quest Means Business.”
• Click here to hear Rovner on “Morning Edition.”

KFF Health News South Carolina correspondent Lauren Sausser discussed a Trump administration pilot program to have AI approve and deny care for Medicare patients on Apple News’ “Apple News Today” on Oct. 7.

• Click here to hear Sausser on “Apple News Today.”
• Read Sausser and Darius Tahir’s “AI Will Soon Have a Say in Approving or Denying Medicare Treatments.”

KFF Health News Midwest correspondent Bram Sable-Smith appeared on NPR’s “Weekend Edition Sunday” on Oct. 5 to discuss states’ cutting of Medicaid provider payments to close budget gaps.

• Click here to hear Sable-Smith on “Weekend Edition Sunday.”
• Read Sable-Smith and Sarah Jane Tribble’s “States Are Cutting Medicaid Provider Payments Long Before Trump Cuts Hit.”

KFF Health News senior correspondent Bernard J. Wolfson appeared on The Daily Yonder’s “The Yonder Report” newscast on Oct. 8 to discuss local solutions to rural doctor shortages in California.

• Click here to hear Wolfson on “The Yonder Report.”
• Read Wolfson’s “Health Care Cuts Threaten Homegrown Solutions to Rural Doctor Shortages.”

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

USE OUR CONTENT

This story can be republished for free (details).