Kopplin, a physician assistant who works with seniors, low-income people, and mental health patients in the rural Black Hills, shared her thoughts at a meeting hosted by state officials.

South Dakota’s leaders did a “good job of diving in” and asking questions to get “deeper at the root of the problem,” she said.

Kopplin later told KFF Health News how one of her rural patients recently missed two appointments because of a broken-down car and no access to public transportation.

Nationwide, health care workers like Kopplin and thousands of others — from patient advocates to technology executives — flocked to town halls or online portals during the seven weeks state leaders had to craft and submit their applications for the Rural Health Transformation Program to the federal Centers for Medicare & Medicaid Services. That deadline was Nov. 5.

“We will give $50 billion away by the end of the year,” CMS Administrator Mehmet Oz said Nov. 6 at a Milken Institute event in Washington. He said all 50 states had submitted applications.

The program will “allow us to right-size the health care system,” Oz said, adding that innovations from the rural work “will spill over to suburban and urban America as well.”

Among applications and summaries publicly shared by states, themes include workforce development, telehealth, and access to healthy food. In Kansas, leaders want to build a “Food is Medicine” program. Wyoming officials propose a new program called “BearCare,” a state-sponsored health insurance plan that patients could use only after medical emergencies.

But many health policy experts and Democrats are raising alarms that the Republican-backed program will become a “slush fund.” Critics worry it will fail to reach the small-town patients they say need it most, especially as states face nearly a trillion dollars in Medicaid spending reductions over the next decade. Medicaid, a joint federal-state program, serves nearly 1 in 4 rural Americans.

“The status quo is tremendous distress in rural communities,” said Heather Howard, a professor of the practice at Princeton University and director of the university’s State Health and Value Strategies program, which is tracking the rural health fund. The new funding won’t be enough to offset the Medicaid losses, she said.

Congressional Republicans added the five-year, $50 billion Rural Health Transformation Program as a last-minute sweetener to President Donald Trump’s massive tax-and-spending legislation. The move helped win support for the One Big Beautiful Bill Act from conservative holdouts who worried that the Medicaid cuts in the bill would harm rural hospitals in their states.

In Montana, which hosted an online public forum before submitting its application, a nonprofit director pitched youth peer support as a way of battling high suicide rates. A registered nurse asked state leaders to “think maybe even bigger” and consider statewide universal health care.

And in Georgia, a technology-focused chain of primary care clinics that serves seniors proposed expanding its operations into that state in its online public comment. A rural grant writer asked for “safe and stable housing.”

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be doled out according to a points-based system. Of the second half, $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that score well on initiatives and policies that, in part, mirror the Trump administration’s “Make America Healthy Again” objectives.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who called on a federal watchdog agency to investigate the fairness and implementation of the fund. Taylor Harvey, a Wyden aide, said the Government Accountability Office has confirmed it will investigate.

According to the federal statute, no less than a quarter of states with an approved application may share the second half of the funding each fiscal year, CMS spokesperson Catherine Howden said. The agency plans to publish summaries of approved state projects, according to CMS guidance.

A handful of conservative-leaning states — including Texas, Arkansas, Louisiana, and Oklahoma — have already instituted regulatory and legislative initiatives, such as prohibiting “non-nutritious” foods in benefit programs, that garner additional points in the program application process.

Michael Chameides, a county supervisor in rural New York, said he fears the money could “be used in ways that would hurt certain states or reward certain states.” Chameides is also the communications and policy director with the Rural Democracy Initiative, a national advocacy organization that released a rural action report last month.

Edwin Park, a research professor at Georgetown University’s Center for Children and Families, said federal lawmakers gave Oz and his agency “really excessive discretion” when awarding the money.

Federal administrators have added rules that aren’t within the statute that created the program, Park said. For example, its application guidelines say states cannot use more than 15% of their funding to pay providers for patient care — payments that are expected to take a hit due to the Medicaid cuts.

Georgetown’s health policy experts and Democrats aren’t the only ones with concerns. Some Republicans and small hospitals in Ohio worry the money will go to large health systems instead of smaller, independent hospitals that serve people within their rural communities.

CMS’ Oz repeated the idea of getting “big hospitals to adopt smaller institutions” at the Washington gathering after applications were filed. He used similar language at a rural health summit hosted by South Dakota-based Sanford Health. “How do we get big hospitals to adopt smaller hospitals? Not to take them over, but to keep them viable by giving them good telehealth services, specialty support, radiology support,” he said at the October event.

Sanford owns or manages dozens of hospitals and hundreds of clinics and long-term care centers, as well as a health insurance company. The system reported about $81 million in operating income during the first six months of fiscal year 2025, according to a recent bond rating report.

Last year, Sanford opened a “command center” for its systemwide telehealth initiative. It launched a telehealth expansion in 2021 and offers virtual care for 78 medical specialties, Sanford President and CEO Bill Gassen said.

“We’ve tried to imagine, what if that number doubles?” Gassen said. The startup costs for telehealth are high, he said, and the rural fund could be a unique opportunity “for us to make virtual care available to more patients, to more communities, to more hospitals and health systems across the country.”

Gassen, who is set to chair the American Hospital Association in 2027, said Sanford leaders have met with state and federal officials, including Oz, whom he’s known for years, and Chris Klomp, a top deputy at CMS and a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

The word “telehealth” appears 36 times in the rural health program’s 124-page application guidelines. But Don Robbins Jr., chief executive of a small hospital on the Illinois-Kentucky border, chuckled at the idea of using the funding for that purpose.

Robbins, whose 25-bed Massac Memorial Hospital averages five to seven patients in its beds each day, said his hospital does not regularly offer telehealth. Even if it did, he said, patients living more than a mile outside of town couldn’t use it because they don’t have a good internet connection.

The small hospital reported a $31,314 loss in September, Robbins said. “I think if we get anything out of it,” Robbins said of the rural health program, “we’ll be lucky.”

Kopplin, the physician assistant who attended the South Dakota meeting, is cautiously optimistic about the rural health fund. She views it as a wonderful chance for states to test out ideas and learn from what works and what doesn’t.

But “in a lot of ways this bill is going to be a band-aid approach” for rural health, she said. “It’s not really going to fix the problem.”

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.

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Bre Dolan, a 35-year-old resident of Hardy County, West Virginia, understands why. Throughout her childhood, when her dad had addiction and mental health crises, police officers were often the first ones to respond. Dolan calls them “good men and women” who “care about seeing their community recover.”

But she’s skeptical that they can mitigate the root causes of an addiction epidemic that has racked her home state for decades.

“Most of the busts that go down are addicts,” she said — people who need treatment, not prison.

Dolan’s father was one of them. And so was she.

Now 14 years into recovery, she’s been surprised to see many local officials spending opioid settlement money — an influx of cash from companies accused of fueling the overdose crisis — on police Tasers, cruisers, night vision gear, and more.

“How is that really tackling an issue?” Dolan said. “How will it help families battling addiction?”

Nationwide, more than $61 million in opioid settlement funds were spent on law enforcement-related efforts in 2024, according to a yearlong investigation by KFF Health News and researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction. That included initiatives that public health experts largely support, such as hiring social workers to accompany officers on overdose calls, as well as actions they’re more skeptical of, such as beefing up police arsenals.

Over nearly two decades, state and local governments are set to receive more than $50 billion in opioid settlement money, which is intended to be used to fight addiction. The settlement agreements even outlined suggested uses and established other guardrails to limit unrelated uses of the funds — as happened with the Tobacco Master Settlement Agreement of the 1990s.

But there’s still significant flexibility with these dollars, and what constitutes a good use to one person can be deemed waste by another.

To Stephen Loyd, an addiction medicine doctor who was once addicted to opioids and has served as an expert in several opioid lawsuits, some law enforcement expenses fall into that second category.

Drones and police officer salaries are not “in the spirit of what we wanted to use the money for when we were fighting for it,” Loyd said.

“People died for this money. Families were torn apart for this money. And to not spend it to try to make our system better, so that people don’t have to experience those losses going forward, to me, is unconscionable,” he said.

As part of this investigation, KFF Health News and its partners compiled the most comprehensive national database of opioid settlement spending to date, featuring more than 10,500 examples of how the money was used (or not) last year. The team filed public records requests, scoured government websites, and extracted expenditures, which were then sorted into categories, such as treatment or prevention. The findings include:

• Nearly $2.7 billion — that’s the amount states and localities spent or committed in 2024, according to public records. The lion’s share went to investments addiction experts consider crucial, including about $615 million to treatment, $279 million to overdose reversal medications and related training, and $227 million to housing-related programs for people with substance use disorders.
• Smaller, though notable, amounts funded law enforcement initiatives — such as creating a shooting range and tinting patrol car windows — and prevention programs that experts called questionable, such as putting on a fishing tournament.
• Some jurisdictions paid for basic government services, such as firefighter salaries.
• The money is controlled by different entities in each state, and about 20% of it is untrackable through public records.

This year’s database, including the expenditures and untrackable percentages, should not be compared with the one KFF Health News and its partners compiled last year, due to methodology changes and state budget quirks. The database cannot present a full picture because some jurisdictions don’t publish reports or delineate spending by year. What’s shown is a snapshot of 2024 and does not account for decisions in 2025.

Still, the database helps counteract the secrecy among some of those in charge of settlement money and confusion among those tracking it.

‘How My Population Would Like Me To Vote’

Dolan has seen intergenerational addiction up close. When her father was high, he sometimes kicked teenage Dolan out of the house with her toddler siblings. She started drinking early and progressed to other drugs, eventually landing in prison.

Although she managed to find recovery on her own, even landing a job as an EMT, she wants to make the path easier for others.

If settlement money were used to hire social workers or build family recovery programs, it could change the course of a kid’s life, she said.

“Maybe people could have helped my dad get into recovery and gave him therapy,” she said. “Anything could have happened.”

But many local officials say law enforcement is one of the few tools they have, especially in rural areas. And their constituents believe it’s effective.

“If the goal was treatment and prevention, it would have been better to throw [the money] into a big grant system and give it to treatment centers,” said Cris Meadows, city manager of Oak Hill, West Virginia, which paid more than $67,000 for a drone and surveillance cameras for its police department. “Unfortunately, local governments are really not set up to do that.”

Clarkdale, Arizona, Town Manager Susan Guthrie said her town bought nearly $15,000 worth of drones because they help with enforcement — such as recording crime scenes and conducting search-and-rescue operations — as well as education, when officers interact with kids at community events.

Similar perspectives nationwide have led to spending that includes:

• About $12,000 for rifle suppressors (also known as silencers) in Alexandria, Indiana.
• About $21,000 for Tasers in Mooresville, Indiana.
• About $49,000 to replace outdated body cameras and Tasers in Hardy County, West Virginia.
• Nearly $70,000 in Lewisburg, West Virginia, to add a police officer to the county’s drug task force, replace that officer locally, buy guns and vehicles, and tint car windows.

Several elected officials said their choices reflect local politics.

That’s “how my population would like me to vote,” Hardy County Commissioner Steven Schetrom said of his commission’s goal to spend about a quarter of its settlement money on law enforcement.

Mooresville Town Council President Tom Warthen told KFF Health News, “People have petitioned our government for less taxes but have never petitioned for less services” from the local police force. With federal and state budget cuts looming, the town must be resourceful, he said, adding that the Tasers were bought with a portion of settlement funds that have no restrictions.

After these purchases, an Indiana commission issued a list of law enforcement equipment that it cautioned against buying with restricted settlement dollars. California, Kansas, and Virginia have released similar lists.

Research backs those restrictions. Studies have shown that drug busts and arrests can exacerbate the overdose crisis. Officers responding to overdoses often arrest people, making people who use drugs fearful of calling 911 or seeking treatment through police.

In contrast, equipping police officers with overdose reversal medications has been shown to save lives. That’s a key component of an $18 million effort in Texas, the state with the highest percentage of reported law enforcement spending.

Police and Firefighter Salaries

Some places used settlement funds to maintain basic first responder services.

For example, Mantua Township, New Jersey, used about $79,000 to “offset police salary and wages” and, according to its public spending report, plans to do so annually. Township officials did not respond to requests for comment.

Los Angeles County allocated $1 million to cover a portion of firefighter salaries and benefits last year and estimates it will use another $1 million this year.

County fire department spokesperson Heidi Oliva said opioid funds were used to fill a budget gap until revenue kicked in from a new tax voters approved last November.

The use of funds was “appropriate,” she said in an email, because “the opioid crisis presents a significant burden to EMS response, from dispatch through arrival at hospitals, clinician mental health/burnout, and a variety of other factors.”

Using opioid money to replace other revenue is legal in most places. But it’s considered bad practice.

“I don’t want to see this money used to make up for stuff that would be paid for anyway,” said Daniel Busch, chair of the FED UP! Coalition, a national advocacy organization representing many parents who’ve lost children to addiction.

Settlement dollars are “the only financial representation from the governments and from the drug companies” of families’ losses, Busch said. To see that money used to maintain the status quo is “painful” and “distressing.”

Busch fears this practice will become more common as states grapple with federal budget cuts.

Already in New Jersey, lawmakers allocated $45 million in settlement funds to health systems to cushion against anticipated Medicaid losses — a move opposed by the state’s attorney general, opioid settlement advisory council, and advocates.

However, some states are taking proactive steps.

Colorado released guidance this year against such actions.

“These dollars can’t be part of budget games where we simply backfill existing programs,” state Attorney General Phil Weiser told KFF Health News. “We have to build on whatever we’re doing because it hasn’t been enough.”

Other states, such as Maine, Maryland, and Kentucky, are newly requiring local governments to report how they spend the money, which may make it easier to spot disputed practices. Officials in Delaware, Hawaii, Massachusetts, and Missouri said they expect to revamp their public reporting systems to increase transparency by early 2026.

In Mississippi, which produced no substantive public reports last year, the attorney general’s office has set up a website that will host spending information after Dec. 1.

Jennifer Twyman is anxious to see some positive changes.

“We have people literally dying on our sidewalks,” said the Louisville, Kentucky, advocate.

Twyman struggled with opioid misuse for 20 years and now works with Vocal-KY to end homelessness and the war on drugs. To her, any spending that doesn’t directly help people with addiction betrays the settlement’s purpose.

“It is the blood from many of my friends, people that I care deeply about,” she said. “That money could have been me, could have been my life.”

Read the methodology behind this project.

KFF Health News’ Henry Larweh; Shatterproof’s Kristen Pendergrass and Lillian Williams; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Samantha Harris, Isha Desai, Katibeth Blalock, Erin Wang, Olivia Allran, Connor Gunn, Justin Xu, Ruhao Pang, Jirka Taylor, and Valerie Ganetsky contributed to the database featured in this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team that worked on this report are not involved in those efforts.

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.

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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.

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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.

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“People don’t realize how much these clinics hold together the local health system until they’re gone,” said George Hill, the group’s president and CEO. “For thousands of patients, that was their doctor, their lab, and their lifeline.”

Maine Family Planning’s closures are among the first visible signs of what health leaders call the biggest setback to reproductive care in half a century. The U.S. Department of Health and Human Services’ Office of Population Affairs, which administers the Title X family planning program, has been effectively shut down. At the same time, Medicaid cuts, the potential lapse of Affordable Care Act subsidies, as well as cuts across programs in the Health Resources and Services Administration and Centers for Disease Control and Prevention are eroding the broader safety net.

“When you cut OPA, HRSA, and Medicaid together, you’re removing every backup we have,” said Clare Coleman, president of the National Family Planning and Reproductive Health Association. “It’s like taking EMTs off the road while closing the emergency rooms.”

Asked about the cutbacks, HHS press secretary Emily G. Hilliard said, “HHS will continue to carry out all of OPA’s statutory functions.”

How the Safety Net Frays

For more than 50 years, Title X has underwritten a national network of clinics, now numbering over 4,000, that provide contraception, pregnancy testing, testing and treatment for sexually transmitted infections, cancer screening, and other primary and preventive care to nearly 3 million low-income or uninsured patients annually. OPA managed nearly $400 million in grants, issued clinical guidance, and ensured compliance.

In mid-October, OPA’s operations went dark amid federal layoffs that also affected hundreds of CDC staffers. “Under the Biden administration, HHS became a bloated bureaucracy — expanding its budget by 38% and its workforce by 17%,” a spokesperson for the department said at the time, adding, “HHS continues to eliminate wasteful and duplicative entities, including those inconsistent with the Trump administration’s Make America Healthy Again agenda.”

According to Jessica Marcella, who led OPA under the Biden administration, the office was previously staffed by 40 to 50 people. Now, she says, only one U.S. Public Health Service Commissioned Corps officer remains.

“The structure to run the nation’s family planning program disappeared overnight,” said Liz Romer, OPA’s former chief clinical adviser.

“This isn’t just about government jobs,” Coleman said. “It’s a patient care crisis. Every safety net program that touches reproductive health is being weakened.”

A Policy Linking Health, Autonomy, and Opportunity

Created in 1970 under President Richard Nixon and rooted in President Lyndon Johnson’s War on Poverty, Title X was designed as a cornerstone of preventive public health, not a partisan cause. Nixon called family planning assistance key to a “national commitment to provide a healthful and stimulating environment for all children,” and Congress agreed overwhelmingly across party lines.

Sara Rosenbaum, a professor of health law at George Washington University, said the program reflected a pivotal shift in how policymakers understood health itself.

“By the late 1960s, there was a deep appreciation that the ability to time and space pregnancies was absolutely essential to women’s and children’s health,” she said. “Title X represented the idea that reproductive care wasn’t a privilege or a moral issue. It was basic health care.”

UCLA economist Martha Bailey later found that children born after the first federally funded family planning programs were 7% less likely to live in poverty, and had household incomes 3% higher, than those born before. Research by Bailey just published by the National Bureau of Economic Research showed that when low-income women can access free birth control, unintended pregnancies drop by 16% and abortions drop by 12% within two years.

Those findings underscore what Rosenbaum calls “one of the great public health achievements of the 20th century — a program that linked economic opportunity to health and autonomy.”

That bipartisan foundation and evidence-based mission, Rosenbaum said, make today’s unraveling especially striking.

“What was once common sense, that access to family planning is essential to a functioning health system, has become politically fragile,” she noted. “Title X was built for continuity, but it’s being undone by neglect.”

The Hidden Health Risks Behind Unplanned Pregnancies

Family planning is central to maternal and infant health because it gives women the time to optimize medical conditions like high blood pressure, diabetes, and heart disease before pregnancy, and allows them to safely space out their births.

“Pregnancy is the ultimate stress test,” said Andra James, a maternal-fetal medicine specialist who advised the CDC on its contraceptive guidelines. “It increases the heart’s workload by up to 50%. For people with heart disease, diabetes, or hypertension, that stress can be dangerous.”

Brianna Henderson, a Texas mother, learned this firsthand. Weeks after delivery, she developed peripartum cardiomyopathy, a form of heart failure that can occur during or after pregnancy. She survived. Her sister, who had the same undiagnosed condition, died three months after giving birth to her second child. Those kids are now 12 and 16, and they’re growing up without a mom. Their dad and his mother look after the kids now.

“Contraception has been a lifesaving option for me,” Henderson said.

James and other specialists warn that without CDC-informed guidance on contraceptive safety for complex conditions, clinicians and patients are left without clear, current standards.

What History and the Data Predict Happens Next

Title X clinics provide millions of STI tests each year and are often the only cancer screening sites for uninsured women. Cuts to Medicaid and ACA subsidies will make it even harder for people to afford preventive visits.

“If these clinics close, we’ll see more infections, more unplanned pregnancies, and more maternal deaths, especially among Black, Indigenous, and rural communities,” said Whitney Rice, an expert on reproductive health at Emory University.

And the geographic gaps are large already. Power to Decide, a nonprofit reproductive rights group, counts more than 19 million women living in “contraceptive deserts,” where there’s no reasonable access to publicly supported birth control. 

“These are places where the nearest clinic might be 60 or 100 miles away,” said Power to Decide interim co-CEO Rachel Fey. “For many families, that distance might as well be impossible.”

The High Price of Short-Term Savings

Each pregnancy averted through Title X saves about $15,000 in public spending on medical and social services, according to an analysis by Power to Decide. And an analysis by the Guttmacher Institute shows that every $1 invested in publicly funded family planning programs saves roughly $7 in Medicaid costs.

Cutting federal funding for reproductive health services “isn’t saving money. It’s wasting it,” said Brittni Frederiksen, an associate director with KFF’s Women’s Health Policy program and a former OPA health scientist. “We’ll spend far more fixing the problems these cuts create.” KFF is a health information nonprofit that includes KFF Health News.

Supporters of cuts argue federal spending must be reduced and states should set their own priorities.

Strain on the Ground

Affirm, Arizona’s Title X grantee, oversees a statewide network of clinics that provide family planning services to more than 33,000 patients each year.

Affirm CEO Bré Thomas said the state could lose $6.1 million in Title X funding if federal appropriations expire after March 31. It’s a cut that would reduce access to care across the network. “That’s $6.1 million for Arizona,” she said. “That means over 33,000 patients in our state could lose access to services.”

Thomas noted that two consecutive funding reductions, combined with 11 years of flat federal support and rising health care costs, have already strained operations. Without new funding, she warned, clinics may be forced to limit contraceptive options to cheaper methods, reduce preventive care, and lay off staff, especially in rural communities. “We’re talking about impacts to people’s jobs and their ability to access the care they need,” she said.

Megan Kavanaugh, a scientist at the Guttmacher Institute, underscored those limits.

“Federally Qualified Health Centers do not have the capacity to absorb the number of patients who will lose care,” she said, referring to federally funded community-based clinics for underserved populations. “Some people may find another clinic, but a large share simply won’t, and we’ll see that reflected in higher rates of unintended pregnancy, untreated infections, and later-stage disease.”

Hospitals are beginning to absorb the spillover.

“The safety net is shrinking, and hospitals can’t absorb everyone,” said Sonya Borrero, a reproductive health expert at the University of Pittsburgh School of Medicine and a former chief medical and scientific adviser at OPA. “Wait times will get longer, and preventable problems will rise.”

Funding Frozen, Oversight Halted

With OPA offline, Title X dollars already awarded can be spent, but no new funds are moving.

“Most programs can hang on for a few months,” Romer said. “By spring, many won’t have enough money to stay open.”

The halt also suspends compliance reviews and technical assistance tied to CDC-aligned guidelines.

Marcella, the former OPA leader, warned of a “backdoor dismantling.”

“If there aren’t people to administer the grants, then the administration can later argue the program isn’t working and redirect the funds elsewhere,” she said. “This is a functional elimination, done quietly.”

Kavanaugh called the moment “one more step toward dismantling the public health infrastructure that has supported people’s reproductive health for decades.”

Without staff to move money and guidance, she said, “that’s how a system collapses.”

What Can Still Be Done

According to the National Association of Community Health Centers, Federally Qualified Health Centers can still use HRSA money that was already approved, even during the government shutdown. But no new funding is being released, similar to the freeze on Title X funds. At the same time, HRSA has stopped first-quarter payments for its Title V Maternal and Child Health program, which limits how states can provide preventive care and services for children and young people with special health needs.

Some states — California, New Mexico, Washington — are plugging holes with state dollars, and health systems are expanding telehealth, but most jurisdictions cannot replace federal support at scale.

“Private donors can’t replace the federal government,” said Hill, of Maine Family Planning. “You can’t crowdfund your way to a working health system.”

Congress could restore Title X and rebuild OPA’s staffing, but without administrators in place, money can’t reach clinics quickly. States have a short window to bridge care by stabilizing Medicaid coverage, shoring up community health centers, and protecting contraceptive access.

“This isn’t a political debate,” Romer said. “It’s women showing up for care and finding the doors locked.”

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A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, ‘Yes.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital — which was not in-network with the insurance plan she got through her job — for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It’s crazy.”

Insurers have broad power to determine whether care is medically necessary — that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to KFF Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the No Surprises Act, which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that’s when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for any care needed in a nursing home if the patient was not first formally admitted to a hospital for at least three days.

“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

The Resolution

As a physician and a director of a health policy center at the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital — and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also reached out to KFF Health News, which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to KFF Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 — about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is stable enough to travel to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient to sign a consent form, agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”

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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.”

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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.

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• Click here to watch Rovner on MSNBC.

Rovner also discussed the shutdown and health care costs on WYPR’s “Midday” on Oct. 20.

• Click here to hear Rovner on WYPR.

KFF Health News senior correspondent Renuka Rayasam discussed the shutdown on WUGA’s “The Georgia Health Report” on Oct. 17.

• Click here to hear Rayasam on WUGA.

KFF Health News Southern correspondent Sam Whitehead discussed Georgia’s work requirement extension on WUGA’s “The Georgia Health Report” on Oct. 10.

• Click here to hear Whitehead on WUGA.

KFF Health News Colorado correspondent Rae Ellen Bichell discussed wage garnishment in Garfield County, Colorado, on Aspen Public Radio on Oct. 7.

• Click here to hear Bichell on Aspen Public Radio.
• Read Bichell’s “Workers’ Wages Siphoned To Pay Medical Bills, Despite Consumer Protections.”

KFF Health News correspondent Darius Tahir discussed the use of artificial intelligence for prior authorizations in Medicare on KUOW’s “Soundside” on Oct. 20.

• Click here to hear Tahir on KUOW.
• Read Tahir’s “AI Will Soon Have a Say in Approving or Denying Medicare Treatments.”

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.

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The texts were part of a pilot run to test technology the Trump administration says will make it easier for some Medicaid enrollees to prove they meet new requirements — working, studying, job training, or volunteering at least 80 hours a month — set to take effect in just over a year.

But only 894 people completed the quarterly wage check, or just under 7% of enrollees who got the text, according to Drew Maranto, undersecretary for the Louisiana Department of Health.

“We’re hoping to get more to opt in,” Maranto said. “We plan to raise awareness.”

The clock is ticking for officials in 42 states — excluding those that did not expand Medicaid at all — and Washington, D.C., to figure out how to verify that an estimated 18.5 million Medicaid enrollees meet rules included in President Donald Trump’s tax and spending law. They have until the end of next year, and federal officials are giving those jurisdictions a total of $200 million to do so.

The policy change is one of several to free up money for Trump’s priorities, such as increased border security and tax breaks that mainly benefit the wealthy.

The nonpartisan Congressional Budget Office has said the work rules will be the main reason millions of people won’t be able to access health insurance over the next decade. It estimates changes to the Medicaid program will result in 10 million fewer Americans covered by 2034 — more than half of them because of the eligibility rules.

For now, state officials, health policy researchers, and consumer advocates are watching the pilot program in Louisiana and another in Arizona. Mehmet Oz, director of the Centers for Medicare & Medicaid Services, has touted those test-drives and said they will allow people to verify their incomes “within seven minutes.”

“There have been efforts to do this in the past, but they haven’t been able to achieve what we can achieve because we have technologies now,” said Oz, during a television appearance in August.

Brian Blase, the president of the conservative Paragon Health Institute and a key architect of Medicaid changes in the new law, has chimed in, saying during a recent radio appearance that with today’s artificial intelligence “people should be able to seamlessly enter how they are spending their time.”

KFF Health News found scant evidence to support such claims. Federal and state officials have offered little insight into what new technology the two pilots have tested. They do say, however, that it connects directly with the websites of Medicaid enrollees’ payroll providers, rather than using artificial intelligence to draw conclusions about their activities.

Oz said the Trump administration’s efforts started “as soon as the bill was signed” in July. But work on the pilot programs began under the Biden administration.

And Medicaid is a state-federal program: The federal government contributes most of the funds, but it is up to the states to administer them, not the federal government.

“Oz can say, ‘Oh no, we’re going to fix this. We’re going to do this.’ Well, they don’t actually run the program,” said Joan Alker, a health policy researcher at Georgetown’s Center for Children and Families.

Officials have also offered few details about the pilots’ effectiveness in assisting enrollees in Medicaid or other public benefit programs.

The shortage of information has some state officials and health policy researchers worried that the Trump administration lacks viable solutions to help states implement the work rules. As a result, they say, people with a legal right to Medicaid benefits could lose access to them.

“What actually keeps me up at night is the fear that members that are eligible for Medicaid and are trying to get health care services would fall through the cracks and lose coverage,” said Emma Sandoe, Oregon’s Medicaid director.

Officials involved in the Louisiana and Arizona projects declined to answer many specific questions about their efforts, instead directing KFF Health News to federal officials.

Spokespeople for Arizona’s Medicaid and Economic Security departments — Johnny Córdoba and Brett Bezio, respectively — did not share data on how many people participated in the state’s pilot test nor describe the outcome. They said the pilot had been used to verify eligibility only for the federal Supplemental Nutrition Assistance Program, a smaller program than Medicaid.

The Community Food Bank of Southern Arizona, a nonprofit that helps people sign up for such SNAP benefits, hadn’t heard of the pilot program.

State officials and health policy researchers said neither pilot program could confirm whether a person meets other qualifying activities — such as community service — or any of the numerous exemptions. The tools being tested can verify only income.

Andrew Nixon, director of communications for the U.S. Department of Health and Human Services, which oversees Oz’s agency, wrote in a statement that the digital tools officials aim to share with states “are largely under development.”

One person doing that development is Michael Burstein, who until recently worked at the U.S. Digital Service, which later became known as the Department of Government Efficiency.

As the U.S. Digital Service was turned into DOGE, Burstein and other staffers left and started a nonprofit called Digital Public Works to finish supporting the technology to make it easier for people to verify their incomes for Medicaid enrollment.

But without permission from state officials, Burstein would not describe the tool in development, aside from saying that it’s mobile-first, can quickly verify income for a new or returning client, “and we’re pretty happy with it.”

The state agencies that manage benefit programs, such as Medicaid and SNAP, are understaffed, and they use different eligibility systems, many of which need updating, which makes improving them “a challenging task,” he said.

The $200 million in start-up costs the federal government has earmarked for systems to track work requirements equals roughly four times what it cost to administer Georgia’s Medicaid work requirement program alone.

That state, which has the nation’s only active work requirement program, called Georgia Pathways to Coverage, in September was granted a temporary extension, despite a recent report from a federal watchdog saying it hadn’t received enough federal oversight. A complicated sign-up process has kept enrollment in the program far below Georgia’s own projections.

Trump’s tax and spending law allows states to ask for extra time — until the end of 2028 — to start enforcing the rules, but only with the approval of HHS Secretary Robert F. Kennedy Jr. It also allows counties with high unemployment rates to be exempted, but states must apply for that exemption.

Even with an app that states can use to prove people are eligible for Medicaid, enrollees would still need to know that app existed and how to use it — neither of which is a given, Alker said. There is also no guarantee they’d have reliable cell service or internet access. As KFF Health News has reported, millions of Americans live in rural areas without reliable internet.

Private vendors also have been working on such apps, said Jennifer Wagner, who researches Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities. Wagner said she has seen several vendors demonstrate products they plan to pitch to states for the work rules. Many are limited in scope, she said, like those in the pilot tests.

“Nobody has a magical solution that’ll make sure eligible people don’t lose coverage,” 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.

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