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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Se había atendido en la sala de emergencias del hospital sin fines de lucro Montrose Regional Health en 2020, pero no recordaba que le hubieran llegado facturas por atención médica.

Por eso se sorprendió cuando, tres años después, su empleador recibió una orden judicial para que le retuviera parte de su salario y comenzara a derivarlo a una agencia de cobro por una factura médica impaga de $881 que, con intereses y costos judiciales, ya sumaba $1.155,26.

El momento no podía ser peor. Luego de salir de un matrimonio problemático y vivir en un refugio, Knoll había conseguido la custodia total de sus tres hijos, una vivienda estable en Montrose, Colorado, y un trabajo en una gasolinera.

“Y justo en ese momento recibí la orden de embargo del tribunal”, contó. “Fue aterrador. Nunca había estado sola ni había criado a mis hijos sola”.

KFF Health News revisó 1.200 casos —registrados en Colorado entre el 1 de febrero de 2022 y el 1 de febrero de 2024— en los que la justicia había   autorizado embargar sueldos por deudas impagas. Al menos el 30% de esos casos estaban relacionados con servicios médicos, incluso cuando las facturas deberían haber sido cubiertas por Medicaid, el programa  de salud federal gerenciado por los estados para personas con bajos ingresos o discapacidades.

Ese 30% probablemente sea una subestimación, ya que muchas veces la deuda médica se oculta bajo otras formas de deuda, como tarjetas de crédito o adelantos de sueldos. Pero incluso esa cifra mínima equivaldría a unos 14.000 casos al año, en los que los tribunales aprueban embargos de sueldo por deudas médicas en Colorado.

Otros hallazgos

• Se persiguió a los pacientes por facturas médicas que iban desde menos de $30 hasta más de $30.000, y la mayoría era menor de $2.400. A medida que los casos avanzaban en el sistema judicial, acumulando intereses y costos legales, las deudas solían crecer en un 25%. En un caso, se multiplicó por más del 400%.
• Las personas podían ser embargadas hasta 14 años después de haber recibido atención médica, incluso si cambiaban de trabajo.
• Detrás del cobro de esas deudas hay todo tipo de proveedores médicos: grandes cadenas de salud, hospitales rurales pequeños, grupos de médicos, servicios públicos de ambulancia, entre otros. En varios casos, los hospitales obtuvieron autorización para embargar el salario de sus propios empleados por facturas pendientes de pago por haberse atendido en esas mismas instituciones.

Sin embargo, Colorado no es una excepción: es uno de los 45 estados que permiten el embargo de sueldos por deudas médicas. Solo Delaware, Nueva York, North Carolina, Pennsylvania y Texas lo prohíben.

Como ha informado KFF Health News, la deuda médica es devastadora para millones de personas en todo el país. Y es probable que el problema se agrave aún más a nivel nacional. Se prevé que millones pierdan su seguro médico en los próximos años debido a los cambios en Medicaid introducidos en la ley fiscal y de presupuesto del presidente Donald Trump y si el Congreso permite que expiren algunos subsidios de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Eso significa que, para quienes pierdan el seguro, la crisis de salud también podría convertirse en una espiral de deudas médicas

Y el daño perdurará: las grandes facturas médicas impagas seguirán apareciendo en los informes crediticios en la mayoría de los estados después de que, en julio, un juez federal anuló una nueva norma destinada a proteger a los consumidores.

“Si no puedes mantener tu salud, ¿cómo vas a trabajar para pagar una deuda?”, dijo Adam Fox, subdirector de Colorado Consumer Health Initiative, una organización sin fines de lucro cuyo objetivo es reducir los costos de atención médica. “Y si, básicamente, no puedes pagar la factura, el embargo de tu salario no te va a ayudar a hacerlo. Te va a poner en una situación financiera aún más difícil”.

A ciegas ante la deuda médica

Cuando una persona no paga una deuda, el acreedor —ya sea que deba la reparación de una puerta de garaje, un préstamo para comprar un auto o atención médica— puede llevarla a juicio. También puede vender la deuda a una agencia de cobro o a un comprador de deuda, que a su vez puede hacer lo mismo.

“En cualquier momento, alrededor del 1% de los adultos con empleo están siendo embargados por alguna razón”, dijo Anthony DeFusco, economista de la University of  Wisconsin-Madison, quien estudió datos de sueldos de ADP, una empresa que procesa las nóminas de alrededor del 20% de los trabajadores del sector privado en Estados Unidos. “Eso es una porción grande de la población”.

Sin embargo, hay pocos estudios específicos sobre la práctica de embargar salarios por deudas médicas. Estudios realizados en North Carolina, Virginia y Nueva York han demostrado que los hospitales sin fines de lucro frecuentemente embargan salarios y en muchos casos las personas afectadas tienen empleos de bajos ingresos.

Marty Makary, quien dirigió una investigación sobre este tema en Virginia desde la Johns Hopkins University, antes de unirse al gabinete de Trump como comisionado de la Administración de Alimentos y Medicamentos (FDA), calificó esta práctica como “agresiva”.

En un estudio que escribió con otros profesionales, Makary encontró que en 2017 el 36% de los hospitales en Virginia —la mayoría sin fines de lucro y en zonas urbanas— embargaban sueldos para cobrar deudas, afectando a miles de pacientes.

Sin embargo, los hallazgos de KFF Health News en Colorado muestran que los hospitales no son los únicos proveedores médicos que persiguen los cheques de pago de los pacientes.

Investigadores y defensores advierten que, además de la falta de datos en los tribunales, hay otro factor que oculta la magnitud del problema. “La gente siente vergüenza de tener deudas”, afirmó Lester Bird, gerente sénior de Pew Charitable Trusts, especialista en temas judiciales. “Todo esto ocurre en las sombras”.

Sin datos sobre la frecuencia de esta práctica, los legisladores están tomando decisiones a ciegas, aunque una encuesta de Associated Press-NORC en 2024 reveló que 4 de cada 5 adultos creen que el gobierno federal debería ayudar a aliviar la deuda médica.

Embargos imposibles

Colorado fue uno de los primeros 15 estados que eliminaron la deuda médica de los informes de crédito. Además, los compradores de deuda no pueden embargar la vivienda de un paciente. Si quienes reúnen los requisitos aceptan pagar en cuotas mensuales, los pagos no deberían superar el 6% de los ingresos familiares y la deuda restante se cancela después de unos tres años de pagos.

Pero si no aceptan un plan de pago, a los habitantes de Colorado se les puede embargar hasta el 20 % de sus ingresos disponibles. El National Consumer Law Center otorgó al estado una calificación “D” por la protección estatal de las finanzas familiares.

Grupos defensores dicen que no tienen certeza de que estas protecciones realmente se estén cumpliendo. Varias personas enviaron cartas a los tribunales advirtiendo que el embargo de salarios empeoraría su ya precaria situación financiera.

“Ya me estoy atrasando con el pago de la electricidad, el gas, el agua, las tarjetas de crédito”, escribió un hombre del oeste de Colorado en una carta a un juez, que KFF Health News obtuvo en los expedientes judiciales. Los registros muestran que trabajaba en construcción y en una tienda de alquiler con opción a compra y debía unos $8.000 por atención médica. Le dijo al juez que estaba pagando cerca de $1.000 al mes.

 “Si esto sigue así, voy a perderlo todo”, explicó.

Las personas demandadas que figuraban en la muestra se desempeñaban en muy diversos rubros: distritos escolares, ganadería, minería, construcción, gobiernos locales e incluso el propio sector de salud. Varias trabajaban en Walmart, Family Dollar, gasolineras, restaurantes o supermercados.

“Están golpeando a la gente cuando ya está en el suelo”, dijo Lois Lupica, exabogada de la organización Community Economic Defense Project, con sede en Denver, y del proyecto Debt Collection Lab de la Princeton University. “Básicamente están demandando a gente que no tiene ni un centavo para dar”.

En 2022, los tribunales autorizaron al sistema de salud Valley View, con sede en Glenwood Springs, a embargar el sueldo de una paciente por una factura médica de $400. La paciente trabajaba en una organización local que el sistema sanitario apoyaba como parte de los beneficios comunitarios que ofrece para mantener su estatus libre de impuestos.

Los hospitales sin fines de lucro como Valley View están obligados a proporcionar beneficios comunitarios, que pueden incluir atención gratuita que ayuda a cubrir las facturas médicas de los pacientes.

Stacey Gavrell, directora de relaciones comunitarias de Valley View, dijo que ofrecen opciones como planes de pago sin intereses y atención gratuita o con descuento para familias con ingresos de hasta el 500% del nivel federal de pobreza.

“Como el proveedor de salud más grande de nuestra región rural, es fundamental para la salud y el bienestar de nuestra comunidad que Valley View siga siendo financieramente viable”, señaló. “La mayoría de nuestros pacientes trabajan con nosotros para desarrollar un plan de pago o solicitan asistencia financiera”.

La agencia de cobro que llevó a juicio a esa trabajadora, A-1 Collection Agency, se presenta en su sitio web como empática: “Entendemos que los tiempos son difíciles y el dinero escasea”.

Pilar Mank, encargada de operaciones de Healthcare Management —la empresa matriz de A-1— dijo que aceptan pagos desde $50 dólares mensuales y que la mayoría de los hospitales con los que trabajan permiten ofrecer un descuento si el paciente abona todo de una vez.

“Demandar a un paciente es absolutamente el último recurso”, afirmó. “Hacemos todo lo posible para trabajar con ellos”.

En algunas ocasiones, los hospitales embargan el salario de sus propios empleados por atención médica recibida en la misma institución. En un caso, una trabajadora del hospital pasó de ser empleada de limpieza a registradora y luego analista de calidad. Incluso participó en eventos públicos representando a su empleador y apareció en el sitio web del hospital como empleada destacada. Aun así, los tribunales emitieron órdenes de embargo hasta que pagó su deuda médica de $10.000.

“El cuidado hospitalario cuesta dinero”, argumentó Julie Lonborg, vocera de la Colorado Hospital Association, sobre esta práctica. “En cierto modo, me parece gracioso que nos hagan esta pregunta. Entendería si alguien preguntara: ‘¿Por qué no están embargando su salario?’”.

Según April Kuehnhoff, abogada sénior del National Consumer Law Center (Centro Nacional de Derecho del Consumidor), los embargos salariales representan solo el 0,2% de los ingresos hospitalarios.

“Y sabemos que hay estados que directamente no lo permiten”, añadió. “Los hospitales siguen brindando atención médica a los pacientes”.

Bueno para unos, malo para otros

Los prestadores de salud aparecieron como demandantes directos en solo el 2% de los casos de deuda médica. Casi todas las demandas fueron presentadas por agencias de cobro o compradores de deuda, siendo BC Services y Professional Finance Company responsables de más de la mitad, seguidos por A-1 Collection Agency y Wakefield & Associates.

Estas empresas ganan dinero comprando deudas que los proveedores ya dieron por perdidas y luego intentando cobrar lo que puedan, con intereses. Cobran un porcentaje de lo que logran recuperar. Algunas compañías hacen ambas cosas.

BC Services no hizo comentarios y Wakefield & Associates no respondió a las preguntas.

Charlie Shoop, presidente de Professional Finance Company, dijo que su empresa inicia embargos en menos del 1% de todas las cuentas que recibe para cobro.

Los proveedores de atención médica de Colorado ya no pueden esconderse detrás de los nombres de los cobradores de deudas cuando demandan a las personas. Lo prohibió una ley estatal de 2024 impulsada por una investigación de 9News-Colorado Sun en colaboración con un proyecto informativo de Colorado News Collaborative-KFF Health News.

En muchos estados, el proceso de demanda y embargo es relativamente sencillo, sobre todo si la persona demandada no se presenta ante el tribunal.

“Es increíblemente fácil”, dijo Dan Vedra, un abogado de Colorado que representa a consumidores en casos de deuda. “Si tienes un procesador de textos y una hoja de cálculo, puedes generar miles de demandas en horas o minutos”.

En la muestra revisada por KFF Health News, casi todos los casos de deuda médica terminaron con sentencias en rebeldía, lo que significa que el paciente no se defendió en el tribunal ni por escrito. Las ausencias pueden deberse a varios motivos: no recibir la notificación por correo, suponer que es una estafa, ignorarla deliberadamente o no poder ausentarse del trabajo.

Vedra y otros expertos dijeron que un alto número de sentencias en rebeldía indica un sistema que favorece a los acreedores por sobre los deudores y que aumenta la probabilidad de que alguien termine perjudicado por una factura incorrecta.

En New Hampshire, por ejemplo, los acreedores deben acudir al tribunal por cada cheque que desean embargar, ya que solo se les permite retener  salarios ya devengados, explicó Maanasa Kona, profesora investigadora asociada al Center on Health Insurance Reforms de la Georgetown University.

“No parece gran cosa en los papeles”, dijo. “Pero si tienen que regresar al tribunal una y otra vez, no les conviene”.

Demandados por error

El sistema de facturación médica en Estados Unidos tiende a generar errores debido a su complejidad, afirmó Barak Richman, profesor de Derecho en la George Washington University y académico sénior de Stanford Medicine. Richman ha estudiado prácticas de cobro de deudas médicas en varios estados. “Las facturas no solo son incomprensibles, sino que a menudo están equivocadas”, sostuvo.

De hecho, el Health Care Policy & Financing Department de Colorado, que administra Medicaid en el estado, indicó que durante el último año fiscal envió cerca de 11.000 cartas a proveedores y agencias de cobro que, erróneamente, intentaron exigir pagos a pacientes que estaban cubiertos por Medicaid. Las facturas de estos pacientes deben enviarse a Medicaid, no a ellos directamente, ya que normalmente solo pagan una cantidad simbólica, si acaso.

Shoop, de Professional Finance Company, dijo que su industria le ha pedido sin éxito al estado de Colorado acceso a una base de datos que le permita verificar si los pacientes están cubiertos por Medicaid.

El programa de Medicaid de Colorado no hizo comentarios.

Patricia DeHerrera, residente de Rifle, Colorado, tuvo que demostrar que ella y sus hijos estaban inscritos en Medicaid cuando recibieron atención en Grand River Health. Pero eso fue después de que A-1 contactara a quien era entonces su empleador, la cadena de gasolineras Kum & Go, llevando una orden judicial para retener parte de sus salarios.

DeHerrera contactó al estado, que envió cartas al hospital y a la agencia de cobro notificándoles que estaban llevando a cabo una “acción de cobro ilegal” y ordenándoles detenerse. Las empresas acataron.

Theresa Wagenman, jefa de contabilidad de Grand River Health, explicó que si un paciente presenta un documento de Medicaid que demuestre su elegibilidad, la deuda se retira del proceso de cobro.

Wagenman también dijo que los pacientes reciben al menos ocho cartas por correo y varias llamadas telefónicas antes de que el hospital autorice al cobrador a llevar el caso a los tribunales.

El consejo principal de DeHerrera para otras personas en esta situación es este: “Conozcan sus derechos. Si no, se van a aprovechar de ustedes”.

Pero defenderse no es fácil.

Nicole Silva, que vive en Sanford, un pueblo de 900 habitantes en el sur de Colorado, contó que toda su familia tenía cobertura de Medicaid cuando su hija sufrió un accidente automovilístico. Aun así, los registros judiciales muestran que le embargaron el salario por un traslado en ambulancia que costó $2.181,60  y que, con intereses y tarifas judiciales, superó los $3.000.

Silva intentó demostrar que la factura era incorrecta y se puso en contacto con la oficina de servicios sociales de su condado, pero dijo que no recibió ayuda y que no pudo comunicarse con la persona adecuada en la oficina estatal. El programa de Medicaid del estado confirmó a KFF Health News que su hija tenía cobertura en el momento del accidente.

Luchar contra la factura era demasiado para Silva y su marido, que tenían que criar a un número cada vez mayor de hijos, uno de ellos con una discapacidad grave. Y, además, trabajan: ella como profesora de preescolar y él en un rancho.

Dejar de recibir aproximadamente $500 al mes, que, según dijo, se le descontaban del sueldo, afectó su capacidad para pagar otras cuentas. “Teníamos que decidir entre comprar comida o pagar la electricidad”, explicó.

Cuando les cortaron el servicio eléctrico, tuvieron que pedir dinero prestado a colegas y amigos para restablecerlo, con un cargo adicional incluido.

Silva dijo que todo este proceso la hace dudar si en el futuro llamaría a una ambulancia.

Fox, de Colorado Consumer Health Initiative, señaló que muchos consumidores piensan que no pueden hacer nada para evitar que les retengan el salario. Sin embargo, pueden impugnar el embargo en el tribunal. Por ejemplo, señalando que deberían haber tenido derecho a una atención médica con descuento o gratuita si el hospital que brindó el servicio es una institución sin fines de lucro.

El economista DeFusco cree que declararse en  bancarrota bajo el Capítulo 7 es una opción subutilizada por los deudores. La bancarrota detiene el embargo de inmediato, aunque no siempre de forma permanente, y tiene otras consecuencias. Pero entiende que es una situación sin salida: es un proceso complejo y usualmente requiere contratar a un abogado.

“Para deshacerse de la deuda, se necesita dinero”, afirma. “Y la razón por la que se encuentra en esta situación es precisamente porque no tiene dinero”.

El pasante de KFF Health News Henry Larweh, la editora de datos Holly K. Hacker, el editor de Mountain States Matt Volz y la editora web Lydia Zuraw contribuyeron con este informe.

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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So she was shocked when, three years after the trip to the hospital, her employer received court orders requiring it to start funneling a chunk of her paychecks to a debt collector for an unpaid $881 medical bill — which had grown to $1,155.26 from interest and court fees.

The timing was terrible. After leaving a bad marriage and staying in a shelter, she had just gotten full custody of her three children, steady housing in Montrose, Colorado, and a job at a gas station.

“And that’s when I got that garnishment from the court,” she said. “It was really scary. I’d never been on my own or raised kids on my own.”

KFF Health News reviewed 1,200 Colorado cases in which judges, over a two-year period from Feb. 1, 2022, through Feb. 1, 2024, gave permission to garnish wages over unpaid bills. At least 30% of the cases stemmed from medical care — even when patients’ bills should have been covered by Medicaid, the public insurance program for those with low incomes or disabilities. That 30% is likely an underestimate since medical debt is often hidden behind other types of debt, such as from credit cards or payday loans. But even that minimum would translate to roughly 14,000 cases a year in Colorado in which courts approved taking people’s wages because of unpaid medical bills.

Among the other findings:

• Patients were pursued for medical bills ranging from under $30 to over $30,000, with most of the bills amounting to less than $2,400. As the cases rolled through the legal system, accumulating interest and court fees, the amount that patients owed often grew by 25%. In one case, it snowballed by more than 400%.
• Cases trailed people for up to 14 years after they received medical care, with debt collectors reviving their cases even as they moved from job to job.
• Medical providers of all stripes are behind these bills — big health care chains, small rural hospitals, physician groups, public ambulance services, and more. In several cases, hospitals won permission to take the pay of their own employees who had unpaid bills from treatment at the facilities.

Colorado has company. It is one of 45 states that allow wage garnishment for unpaid medical bills. Only Delaware, New York, North Carolina, Pennsylvania, and Texas have banned wage garnishment for medical debt.

As KFF Health News has reported, medical debt is devastating for millions of people across the country. And now the problem is likely to grow more pressing nationwide. Millions of Americans are expected to lose health insurance in the coming years due to Medicaid changes in President Donald Trump’s tax and spending law and if Congress allows some Affordable Care Act subsidies to expire. That means health crises for the newly uninsured could lead them, too, into a spiral of medical debt.

And the hurt will linger: Large unpaid medical bills are staying on credit reports in most states after a July decision from a federal judge reversed a new rule aimed at protecting consumers.

“If you can't maintain your health, how are you going to work to pay back a debt?” said Adam Fox, deputy director of the Colorado Consumer Health Initiative, a nonprofit aimed at lowering health costs. “And if you fundamentally can't pay the bill, wage garnishment isn't going to help you do that. It's going to put you in more financial distress.”

Flying Blind on Medical Debt

When someone fails to pay a bill, the creditor that provided the service — whether for a garage door repair, a car loan, or medical care — can take the debtor to court. Creditors can also pass the debt to a debt collector or debt buyer, who can do the same.

“At any given point, about 1% of working adults are being garnished for some reason,” said Anthony DeFusco, an economist at the University of Wisconsin-Madison, who studied paycheck data from ADP, a payroll processor that distributes paychecks to about a fifth of private sector U.S. workers. “That's a big chunk of the population.”

But specific research into the practice of garnishing wages over medical debt is scant. Studies in North Carolina, Virginia, and New York have found that nonprofit hospitals commonly garnish wages from indebted patients, with some studies finding those patients tend to work in low-wage occupations.

Marty Makary, who led research on medical debt wage garnishment in Virginia at Johns Hopkins University before joining Trump’s cabinet as Food and Drug Administration commissioner, has called the practice “aggressive.” He co-authored a study that found 36% of Virginia hospitals, mostly nonprofit and mostly in urban areas, were using garnishment to collect unpaid debts in 2017, affecting thousands of patients.

The Colorado findings from KFF Health News show that hospitals are far from the only medical providers going after patients’ paychecks, though.

Researchers and advocates say that, in addition to a dearth of court case data, another phenomenon tends to obscure how often this happens. “People find debt shameful,” said Lester Bird, a senior manager at the Pew Charitable Trusts who specializes in courts. “A lot of this exists in the shadows.”

Without data on how often this tactic is employed, lawmakers are flying blind — even as a 2024 Associated Press-NORC poll showed about 4 in 5 U.S. adults believe it’s important for the federal government to provide medical debt relief.

‘Blood From a Turnip’

Colorado was among the first of 15 states to scratch medical debt from credit reports. Debt buyers in the state aren’t allowed to foreclose on a patient’s home. If qualified patients opt to pay in monthly installments, those payments shouldn’t exceed 6% of their household income — and the remaining debt gets wiped after about three years of paying.

But if they don’t agree to a payment plan, Coloradans can have up to 20% of their disposable earnings garnished. The National Consumer Law Center gave the state a “D” grade for state protections of family finances.

Consumer advocates said they aren’t sure how well even those Colorado requirements are being followed. And people wrote letters to the courts saying wage garnishment would exacerbate their already dire financial situations.

“I have begun to fall behind on my electricity, my gas, my water my credit cards,” wrote a man in western Colorado in a letter to a judge that KFF Health News obtained in the court filings. Court records show he was working in construction and at a rent-to-own store, with about $8,000 in medical debt. He wrote to the judge that he was paying close to $1,000 a month. “The way things are going now I will lose everything.”

The people being sued in KFF Health News’ Colorado review worked in a wide array of jobs. They worked in school districts, ranching, mining, construction, local government, even health care. Several worked at stores such as Walmart and Family Dollar, or at gas stations, restaurants, or grocery stores.

“You're really kicking people when they're down,” said Lois Lupica, a former attorney working with the Denver-based Community Economic Defense Project and the Debt Collection Lab at Princeton. “They're basically suing the you-can't-get-blood-from-a-turnip population.”

In 2022, court records show, Valley View health system based in Glenwood Springs was allowed to garnish the wages of one of its patients over a $400 medical bill. The patient was working at a local organization that the health system supported as part of the community benefits it provides to keep its tax-exempt status. Nonprofit hospitals like Valley View are required to provide community benefits, which can also include charity care that covers patients’ bills.

Stacey Gavrell, the health system’s chief community relations officer, said it offers options such as interest-free payment plans and care at reduced or no cost to families with incomes up to 500% of the federal poverty level.

“As our rural region’s largest healthcare provider, it is imperative to the health and well-being of our community that Valley View remains a financially viable organization,” she said. “Most of our patients work with us to develop a payment plan or pursue financial assistance.”

The collection agency that took the employee to court, A-1 Collection Agency, advertises itself on its website as empathetic: “We understand times are tough and money is tight.”

Pilar Mank, who oversees operations at A-1’s parent company, Healthcare Management, said it accepts payment plans as small as $50 a month and that most of the hospitals it works with allow it to offer a discount if patients pay all at once.

“Suing a patient is the absolute last resort,” she said. “We try everything we can to work with the patient.”

If you can't maintain your health, how are you going to work to pay back a debt?

Adam Fox, deputy director of the Colorado Consumer Health Initiative

Hospitals sometimes also garnish wages from their own employees for care they provided them. In one case, a hospital employee worked her way up from housekeeper to registrar to quality analyst. She even participated in public events representing her employer and appeared on the hospital’s website as a featured employee — while the court issued writs of garnishment until her $10,000 in medical bills from the hospital was paid off.

“Hospital care costs money to deliver,” said Colorado Hospital Association spokesperson Julie Lonborg about hospitals’ garnishing their own employees’ wages. “In some ways, I think it's funny to be asked the question. I would understand if someone said, ‘Why aren't you garnishing their wages?’”

Studies show that hospital debt collection efforts through wage garnishment bring in only about 0.2% of hospital revenues, said April Kuehnhoff, a senior attorney with the National Consumer Law Center, which advocates for people with low incomes.

"We also know that there are states that don't allow this at all,” she said. “Hospitals are continuing to provide medical care to consumers.”

Smooth Sailing for Collectors — But Not for Patients

Health care providers appeared as the plaintiffs in only 2% of the medical debt cases. Instead, cases were filed almost entirely by third-party debt collectors and buyers, with BC Services and Professional Finance Company behind more than half of the cases, followed by A-1 Collection Agency and Wakefield & Associates.

Debt buyers make money by buying debt from providers who’ve given up on getting paid then collecting what they can of the money owed, plus interest. Debt collectors get paid a percentage of what they recover. Some companies do a bit of both.

BC Services declined to comment, and Wakefield & Associates did not respond to questions.

Charlie Shoop, president of Professional Finance Company, said his company initiates wage garnishment on less than 1% of all accounts placed with it for collection.

Health care providers in Colorado can no longer hide behind debt collectors’ names when they sue people, according to a 2024 state law prompted by a 9News-Colorado Sun investigation in partnership with a Colorado News Collaborative-KFF Health News reporting project.

In many states, the path for filing a case against a debtor and garnishing their wages is relatively smooth — especially if the debtor doesn’t appear in court.

“It's unbelievably easy,” said Dan Vedra, a lawyer in Colorado who often represents consumers in debt cases. “If you have a word processor and a spreadsheet, you can mass-produce thousands of lawsuits in a matter of hours or minutes.”

Within KFF Health News’ sample, nearly all the medical debt cases were default judgments, meaning the patient did not defend themselves in court or in writing. Missing a court date can happen for a variety of reasons, such as not receiving the notice in the mail, assuming it was a scam, knowingly ignoring it, or not having the time to take off from work.

Vedra and other debt law experts said a high rate of default judgments indicates a system that favors the pursuers over the pursued — and increases the chances someone will be harmed by an erroneous bill.

But in New Hampshire, creditors now have to keep going to court for each paycheck they want to garnish, because the state allows creditors to garnish only wages that have already been earned, said Maanasa Kona, an associate research professor at the Center on Health Insurance Reforms at Georgetown University.

“It might not look like much on paper,” she said. “It's just not worth it if they have to keep going back to court.”

If you have a word processor and a spreadsheet, you can mass-produce thousands of lawsuits in a matter of hours or minutes.

Dan Vedra

Wrongly Pursued for Bills

The nation’s medical billing setup is already prone to errors due to its complexity, according to Barak Richman, a law professor at George Washington University and a senior scholar at Stanford Medicine who has studied medical debt collection practices in several states. “Bills are not only noncomprehensible, but often wrong,” Richman said.

Indeed, Colorado’s Health Care Policy & Financing Department, which runs Medicaid in the state, said it sent out nearly 11,000 letters in the past fiscal year to health providers and collectors that erroneously went after patients on Medicaid. Bills for Medicaid recipients are supposed to be sent to Medicaid, not the patients, who typically pay a nominal amount, if anything, for their care.

Shoop said his industry has pushed Colorado, without success, for access to a database that would allow them to confirm if patients had Medicaid coverage.

Colorado’s Medicaid program declined to comment.

Patricia DeHerrera in Rifle, Colorado, had to prove that she and her children had Medicaid when they received care at Grand River Health — but only after A-1 contacted her employer at the time, the gas station chain Kum & Go, with court-approved paperwork to take a portion of her paychecks.

She contacted the state, which sent letters to the hospital and the collector notifying them they were engaging in “illegal billing action” and telling the collector to stop. The companies did.

Theresa Wagenman, controller for Grand River Health, said if a patient can present a letter from a Medicaid caseworker saying they’re eligible, then their bills get removed from the collections pipeline. Wagenman also said patients get at least eight letters in the mail and several phone calls before Grand River gives the go-ahead for the collector to send them to court.

DeHerrera’s main advice to others in this situation: “Know your rights. Otherwise, they’re going to take advantage of you.”

Yet fighting back isn’t easy.

Nicole Silva, who lives in the 900-person town of Sanford in south-central Colorado, said she and her family were all on Medicaid when her daughter was in a car crash. Still, court records show, her wages were garnished for a $2,181.60 ambulance ride, which grew to more than $3,000 from court fees and interest.

She tried to prove the bill was wrong, contacting her county’s social services office, but Silva said it wasn’t helpful and she wasn’t able to reach the right person at a state office. The state Medicaid program confirmed to KFF Health News that her daughter was covered at the time of the wreck.

Fighting the bill felt like too much for Silva and her husband to handle while parenting a growing number of kids, one of them severely disabled, and working — she as a preschool teacher and he as a rancher.

Not receiving the roughly $500 a month that she said came out of her pay was enough to affect their ability to pay other bills. “It was deciding to buy groceries or pay the electric bill,” Silva said.

When their electricity got shut off, she said, they had to scramble to borrow money from colleagues and friends to get it turned back on — with an extra fee.

She said the saga makes her hesitant to call an ambulance in the future.

Fox, of the Colorado Consumer Health Initiative, said consumers often think they cannot do anything to stop their wages from being garnished, but they can contest it in court, for example by pointing out they should have qualified for discounted — or charity — care if the hospital that provided the treatment is a nonprofit.

DeFusco, the economist, believes filing for Chapter 7 bankruptcy is an underused option for debtors. It halts garnishment in its tracks, though not always permanently, and it comes with other consequences. But he understands it’s a Catch-22: It’s a complex process and typically necessitates hiring a lawyer.

“To get rid of your debt, you need money,” he said. “And the whole reason you're in this situation is because you don't have money.”

Methodology

We wanted to know how often Coloradans get their wages garnished due to medical debt. Courts don’t compile this information, and researchers and advocates haven’t tracked it systematically.

So we created our own database. We requested a list of all civil cases across the state in which judges gave permission for a person’s earnings to be garnished — known as writs of garnishment in court lingo — from Feb. 1, 2022, through Feb. 1, 2024. The Colorado Supreme Court Library provided a list from all courts except for Denver County Court, which provided its own records. The combined list comprised nearly 90,000 unique court cases. We split up the cases by county population — small (fewer than 10,000 people), medium (10,000 to 100,000 people), and large (more than 100,000 people) — then generated a random sample of 400 cases from each group to ensure we evaluated medical debt across counties of all sizes.

To identify medical debt cases, we looked at the original creditors named in court records, primarily the complaints or affidavits of indebtedness. Often, this information was available through a state website. When it wasn’t available online, we asked county courthouses to send us supporting documents. We counted dentists as medical providers. We excluded 14 cases in which the debt wasn’t exclusively medical.

We looked only at cases in which courts approved money to be garnished from someone’s paycheck, as opposed to from other sources such as their bank accounts. We did not review garnishment cases involving child support, taxes, or federal student loans.

KFF Health News intern Henry Larweh, data editor Holly K. Hacker, Mountain States editor Matt Volz, and web editor Lydia Zuraw contributed to this report.

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 Department of Health and Human Services in late March canceled nearly 700 Centers for Disease Control and Prevention grants nationwide — together worth about $11 billion. Awarded during the covid-19 pandemic, they supported efforts to vaccinate people, reduce health disparities among demographic groups, upgrade antiquated systems for detecting infectious disease outbreaks, and hire community health workers.

Initially, grant cancellations hit blue and red states roughly evenly. Four of the five jurisdictions with the largest number of terminated grants were led by Democrats: California, the District of Columbia, Illinois, and Massachusetts.

But after attorneys general and governors from about two dozen blue states sued in federal court and won an injunction, the balance flipped. Of the five states with the most canceled grants, four are led by Republicans: Texas, Georgia, Oklahoma, and Ohio.

In blue states, nearly 80% of the CDC grant cuts have been restored, compared with fewer than 5% in red states, according to the KFF Health News analysis. Grant amounts reported in an HHS database known as the Tracking Accountability in Government Grants System, or TAGGS, often don’t match what states confirmed. Instead, this analysis focused on the number of grants.

The divide is an example of the polarization that permeates health care issues, in which access to safety-net health programs, abortion rights, and the ability of public health officials to respond to disease threats diverge significantly depending on the political party in power.

In an emailed statement, HHS spokesperson Andrew Nixon said the agency “is committed to protecting the health of every American, regardless of politics or geography. These funds were provided in response to the COVID pandemic, which is long over. We will continue working with states to strengthen public health infrastructure and ensure communities have the tools they need to respond to outbreaks and keep people safe.”

The money in question wasn’t spent solely on covid-related activities, public health experts say; it was also used to bolster public health infrastructure and help contain many types of viruses and diseases, including the flu, measles, and RSV, or respiratory syncytial virus.

“It really supported infrastructure across the board, particularly in how states respond to public health threats,” said Susan Kansagra, chief medical officer of the Association of State and Territorial Health Officials.

The Trump cutbacks came as the U.S. recorded its largest measles outbreak in over three decades and 266 pediatric deaths during the most recent flu season — the highest reported outside of a pandemic since 2004. Public health departments canceled vaccine clinics, laid off staff, and put contracts on hold, health officials said in interviews.

After its funding cuts were blocked in court, California retained every grant the Trump administration attempted to claw back, while Texas remains the state with the most grants terminated, with at least 30. As the CDC slashed grants in Texas, its measles outbreak spread across the U.S. and Mexico, sickening at least 4,500 people and killing at least 16.

Colorado, which joined the lawsuit, had 11 grant terminations at first, but then 10 were retained. Meanwhile, its neighboring states that didn't sue — Wyoming, Utah, Kansas, Nebraska, and Oklahoma — collectively lost 55 grants, with none retained.

In Jackson, Ohio, a half-dozen community health workers came to work one day in March to find the Trump administration had canceled their grant five months early, leaving the Jackson County Health Department half a million dollars short — and them without jobs.

“I had to lay off three employees in a single day, and I haven’t had to do that before. We don’t have those people doing outreach in Jackson County anymore,” Health Commissioner Kevin Aston said.

At one point, he said, the funding helped 11 Appalachian Ohio counties. Now it supports one.

Marsha Radabaugh, one employee who was reassigned, has scaled back her community health efforts: She’d been helping serve hot meals to homeless people and realized that many clients couldn’t read or write, so she brought forms for services such as Medicaid and the Supplemental Nutrition Assistance Program to their encampment in a local park and helped fill them out.

“We would find them rehab places. We’d get out hygiene kits, blankets, tents, zero-degree sleeping bags, things like that,” she said. As a counselor, she’d also remind people “that they're cared for, that they're worthy of being a human — because, a lot of the time, they're not treated that way.”

Sasha Johnson, who led the community health worker program, said people like Radabaugh “were basically a walking human 411,” offering aid to those in need.

Radabaugh also partnered with a food bank to deliver meals to homebound residents.

Aston said the abrupt way they lost the funds — which meant the county unexpectedly had to pay unemployment for more people — could have ruined the health district financially. Canceling funding midcycle, he said, “was really scary.”

HHS Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist and promoter of vaccine misinformation, has called the CDC a “cesspool of corruption.” At HHS, he has taken steps to undermine vaccination in the U.S. and abroad.

Federal CDC funding accounts for more than half of state and local health department budgets, according to KFF, a health information nonprofit that includes KFF Health News. States that President Donald Trump won in the 2024 election received a higher share of the $15 billion the CDC allocated in fiscal 2023 than those that Democrat Kamala Harris won, according to KFF.

The Trump administration’s nationwide CDC grant terminations reflect this. More than half were in states that Trump won in 2024, totaling at least 370 terminations before the court action, according to KFF Health News’ analysis.

The Columbus, Ohio, health department had received $6.2 million in CDC grants, but roughly half of it — $3 million — disappeared with the Trump cuts. The city laid off 11 people who worked on investigating infectious disease outbreaks in such places as schools and nursing homes, Columbus Health Commissioner Mysheika Roberts said.

She also said the city had planned to buy a new electronic health record system for easier access to patients’ hospital records — which could improve disease detection and provide better treatment for those infected — but that was put on ice.

“We’ve never had a grant midcycle just get pulled from us for no reason,” Roberts said. “This sense of uncertainty is stressful.”

Columbus did not receive its money directly from the CDC. Rather, the state gave the city some funds it received from the federal government. Ohio, led by Republican Gov. Mike DeWine and a Republican attorney general, did not sue to block the funding cuts.

Columbus sued the federal government in April to keep its money, along with other Democratic-led municipalities in Republican-governed states: Harris County, Texas, home to Houston; the Metropolitan Government of Nashville and Davidson County in Tennessee; and Kansas City, Missouri. A federal judge in June blocked those cuts.

As of mid-August, Columbus was awaiting the funds. Roberts said the city won’t rehire staff because the federal funding was expected to end in December.

Joe Grogan, a senior scholar at the University of Southern California’s Schaeffer Institute and former director of the White House Domestic Policy Council in Trump’s first term, said state and local agencies “are not entitled” to the federal money, which was awarded “to deal with an emergency” that has ended.

“We were throwing money out the door the last five years,” Grogan said of the federal government. “I don’t understand why there would ever be a controversy in unspent covid money coming back.”

Ken Gordon, Ohio Department of Health spokesperson, wrote in an email that the $250 million in grants lost had helped with, among other things, upgrading the disease reporting system and boosting public health laboratory testing.

Some of the canceled HHS funding wasn’t slated to end for years, including four grants to strengthen public health in Indian Country, a grant to a Minnesota nonprofit focused on reducing substance use disorders, and a few to universities about occupational safety, HIV, tuberculosis, and more.

Brent Ewig, chief policy and government relations officer for the Association of Immunization Managers, said the cuts were “the predictable result of ‘boom, bust, panic, neglect’ funding” for public health.

The association represents 64 state, local, and territorial immunization programs, which Ewig said will be less prepared to respond to disease outbreaks, including measles.

“The system is blinking red,” Ewig said.

Methodology

KFF Health News’ analysis of Centers for Disease Control and Prevention grants sought to answer four questions: 1) How many grants have been terminated in the U.S. under the Trump administration since March? 2) Which states saw the most grants cut? 3) What were the grants for? and 4) Did the grant terminations affect blue, red, and purple states differently? This follows a similar analysis by KFF Health News for an article on nationwide NIH grant terminations.

Our primary data source was a Department of Health and Human Services website showing grant terminations. We compared an initial list of grant terminations from April 3 with one from July 11 to determine how many grants had been restored. The USAspending.gov database helped us track grants by state.

To classify states politically, we followed the same steps from our April coverage of National Institutes of Health grant terminations. States were “blue” if Democrats had complete control of the state government or if the majority of voters favored Democratic presidential candidates in the last three elections (2016, 2020, 2024). “Red” states were classified similarly with respect to the Republican Party. “Purple” states had politically split state governments and/or were generally considered to be presidential election battleground states. The result was 25 red states, 17 blue states, and eight purple states. The District of Columbia was classified as blue using similar methods.

This analysis does not account for potential grant reinstatements in local jurisdictions where the funds were awarded indirectly rather than directly from the CDC; it accounts only for the recipients’ location, and excludes grants terminated from Compacts of Free Association states and other foreign entities that received grants directly from the CDC. At least 40 CDC grants were terminated that were meant for global health efforts or assisting public health activities in other nations following the Trump administration’s order for the CDC to withdraw support for the World Health Organization.

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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Silva’s daughter was on Medicaid, which was supposed to cover the cost of the ambulances. But one of the three ambulance companies, Northglenn Ambulance, a public company since acquired by a private one, sent Silva’s bill to a debt collector. It was for $2,181.60, which grew to more than $3,000 with court fees and interest, court records show. The preschool teacher couldn’t pay, and the collector garnished Silva’s wages.

“It put us so behind on bills — our house payment, electric, phone bills, food for the kids,” said Silva, whose daughter recovered fully from the 2015 crash. “It took away from everything.”

Some state legislators are looking to curb bills like the one she received — surprise bills for ground ambulance rides.

When an ambulance company charges more than an insurer is willing to pay, patients can be left with a big bill they probably had no choice in.

States are trying to fill a gap left by the federal No Surprises Act, which covers air ambulances but not ground services, including ambulances that travel by road and water. This year, Utah and North Dakota joined 18 other states that have passed protections against surprise billing for such rides.

Those protections often include setting a minimum for insurers to pay out if someone they cover needs a ride. But the sticking point is where to set that bar. Legislation in Colorado and Montana stalled this year because policymakers worried that forcing insurers to pay more would lead to higher health coverage costs for everyone.

Surprise ambulance bills are one piece of a health care system that systematically saddles Americans with medical debt, straining their finances, preventing them from accessing care, and increasing racial disparities, as KFF Health News has reported.

“If people are hesitating to call the ambulance because they’re worried about putting a huge financial burden on their family, it means we’re going to get stroke victims who don’t get to the hospital on time,” said Patricia Kelmar, who directs health care campaigns at PIRG, a national consumer advocacy group. “It means that person who’s worried it might be a heart attack won’t call.”

The No Surprises Act, signed into law by President Donald Trump in 2020, says that for most emergency services, patients can be billed for out-of-network care only for the same amount they would have been billed if it were in-network. Like doctors or hospitals, ambulance companies can contract with insurers, making them in-network. Those that don’t remain out-of-network.

But unlike when making an appointment with a doctor or planning a surgery, a patient generally can’t choose the ambulance company that will respond to their 911 call. This means they can get hit with large out-of-network bills.

Federal lawmakers punted on including ground ambulances, in part because of the variety of business models — from private companies to volunteer fire departments — and a lack of data on how much rides cost.

Instead, Congress created an advisory committee that issued recommendations last year. Its overarching conclusion — that patients shouldn’t be stuck in the crossfire between providers and payers — was not controversial or partisan. In Colorado, a measure aimed at expanding protections from surprise ambulance bills got a unanimous thumbs-up in both legislative chambers.

Colorado had previously passed a law protecting people from surprise bills from private ambulance companies. This new measure was aimed at providing similar protections against bills from public ambulance services and for transfers between hospitals.

“We knew it had bipartisan support, but there are some people that vote no on everything,” said a pleasantly surprised Karen McCormick, a Democratic state representative.

A less pleasant surprise came later, when Gov. Jared Polis, who is also a Democrat, vetoed it, citing the fear of rising premiums.

States can do only so much on this issue, because state laws apply only to state-regulated health plans. That leaves out a lot of workers. According to a 2024 national survey by KFF, a health information nonprofit that includes KFF Health News, 63% of people who work for private employers and get health insurance through their jobs have self-funded plans, which aren’t state-regulated.

“It’s why we need a federal ambulance protection law, even if we passed 50 state laws,” Kelmar said.

According to data from the Colorado secretary of state’s office, the only lobbying groups registered as “opposing” the bill were Anthem and UnitedHealth Group, plus UnitedHealth subsidiaries Optum and UnitedHealthcare.

As soon as the legislative session ended in May, Kevin McFatridge, executive director of the Colorado Association of Health Plans, a trade group representing health insurance companies in the state, sent a letter to the governor requesting a veto, with an estimate that the legislation would result in premiums rising 0.4%.

The Colorado bill said local governments — such as cities, counties, or special districts — would set rates.

“We are in a much better place by not having local entities set their own rates,” McFatridge told KFF Health News. “That’s almost like the fox managing the henhouse.”

Jack Hoadley, an emeritus research professor with Georgetown University’s McCourt School of Public Policy, said it isn’t clear whether state laws approved elsewhere are raising premiums, or if so by how much. Hoadley said Washington state is expected to come out with an impact analysis of its law in a couple of years.

The national trade association for insurance companies declined to provide a comment for this article. Instead, AHIP forwarded letters that its leaders submitted to lawmakers in Ohio, West Virginia, and North Dakota this year opposing measures in each state to set base ambulance rates. AHIP leadership described the proposals as inflated, government-mandated pricing that would reduce insurers’ chance to negotiate fair prices. Ultimately, the association warned, the proposed minimums would increase health care costs.

In Montana, legislators were considering a minimum reimbursement for ground ambulances of 400% of what Medicare pays, or at a set local rate if one exists. The proposal was sponsored by two Republicans and backed by ambulance companies. Health insurers successfully lobbied against it, arguing that the price was too steep.

Sarah Clerget, a lobbyist representing AHIP, told Montana lawmakers in a legislative hearing that it’s already hard to get ambulance companies to go in-network with insurers, “because folks are going to need ambulance care regardless of whether their insurance company will cover it.” She said the state’s proposal would leave those paying for health coverage with the burden of the new price.

“None of us like our insurance rates to move,” Republican state Sen. Mark Noland said during a legislative meeting as a committee tabled the bill. He equated the proposed minimum to a mandate that could lead to people having to pay more for health coverage for an important but nonetheless niche service.

Colorado’s governor was similarly focused on premiums. Polis said in his veto letter that the legislation would have raised premiums between 73 cents and $2.15 per member per month.

“I agree that filling this gap in enforcement is crucial to saving people money on health care,” he wrote. “However, those cost savings are outweighed in my view by the premium increases.”

Isabel Cruz, policy director at the Colorado Consumer Health Initiative, which supported the bill, said that even if premiums did rise, Coloradans might be OK with the change. After all, she said, they’d be trading the threat of a big ambulance bill for the price of half a cup of coffee per month.

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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La hija de Silva tenía Medicaid, que supuestamente cubría el costo de las ambulancias. Pero una de las tres compañías que operaron ese día, Northglenn Ambulance, una empresa pública que había sido adquirida por una privada, envió la factura de Silva a un cobrador de deudas. Era de $2.181,60, pero con los costos judiciales y los intereses aumentó a más de $3.000, según consta en los registros judiciales.

La maestra de preescolar no pudo pagar, y el cobrador embargó el salario de Silva.

“Nos atrasó muchísimo con las facturas: la casa, la luz, el teléfono, la comida de los niños”, contó Silva, cuya hija se recuperó completamente del accidente de 2015. “Nos quitó todo”.

Algunos legisladores estatales buscan reducir facturas como la que recibió Silva: cuentas sorpresa por traslados terrestres en ambulancia.

Cuando una compañía de ambulancias cobra más de lo que una aseguradora está dispuesta a pagar, los pacientes pueden terminar con una factura enorme de la que no tienen escapatoria.

Los estados intentan cubrir el vacío dejado por la ley federal No Surprises Act, que cubre las ambulancias aéreas, pero no los servicios terrestres, incluyendo las ambulancias que viajan por carretera y agua.

Este año, Utah y Dakota del Norte se unieron a otros 18 estados que han aprobado protecciones contra las facturas sorpresa por este tipo de traslados.

Esas protecciones suelen incluir el establecimiento de un mínimo que las aseguradoras deben pagar si alguno de sus afiliados necesita transporte. Pero el punto de fricción es dónde establecer ese límite. La legislación en Colorado y Montana se estancó este año debido a la preocupación de los legisladores de que obligar a las aseguradoras a pagar más resultaría en mayores costos de cobertura médica para todos.

Las facturas sorpresa de ambulancias son un componente más de un sistema de salud que sistemáticamente endeuda a los estadounidenses, agobiando sus finanzas, impidiéndoles acceder a la atención médica y aumentando las disparidades raciales, como informó KFF Health News.

“Si las personas dudan en llamar a la ambulancia por temor a sufrir una gran carga financiera para su familia, significa que tendremos víctimas de accidentes cerebrovasculares que no llegarán al hospital a tiempo”, expresó Patricia Kelmar, directora de campañas de atención médica en PIRG, un grupo nacional de defensa del consumidor. “Significa que esa persona que teme un ataque cardíaco no llamará”.

El No Surprises Act, promulgado por el presidente Donald Trump en 2020, establece que, para la mayoría de los servicios de emergencia, a los pacientes se les puede facturar por la atención fuera de la red solo el mismo monto que se les habría facturado si estuvieran dentro de ella. Al igual que los médicos u hospitales, las compañías de ambulancias pueden tener contratos con aseguradoras, lo que las convierte en parte de la red. Las que no lo hacen, permanecen fuera de la red.

Pero a diferencia de cuando se programa una cita con un médico o se planifica una cirugía, un paciente generalmente no puede elegir la compañía de ambulancias que responderá a su llamada al 911. Esto significa que puede recibir grandes facturas fuera de la red.

Los legisladores federales postergaron la inclusión de las ambulancias terrestres, en parte debido a la variedad de modelos de negocio —desde empresas privadas hasta departamentos de bomberos voluntarios— y a la falta de datos sobre el costo de los traslados.

En cambio, el Congreso creó un comité asesor que emitió recomendaciones el año pasado. Su conclusión general —que los pacientes no deberían verse atrapados en el fuego cruzado entre proveedores y aseguradoras— no fue controvertida ni partidista. En Colorado, una medida destinada a ampliar las protecciones contra facturas sorpresa de ambulancias recibió el visto bueno unánime de ambas cámaras legislativas.

Colorado ya había aprobado una ley que protegía a las personas de facturas sorpresa de compañías privadas de ambulancias. Esta nueva medida buscaba brindar protecciones similares contra las facturas de los servicios públicos de ambulancia y para los traslados entre hospitales.

“Sabíamos que contaba con apoyo bipartidista, pero hay quienes votan en contra de todo”, dijo gratamente sorprendida Karen McCormick, representante estatal demócrata.

Una sorpresa menos agradable llegó después, cuando el gobernador Jared Polis, también demócrata, la vetó, alegando temor a que aumentaran las primas.

Los estados tienen un margen de maniobra limitado en este tema, ya que las leyes estatales solo se aplican a los planes de salud regulados por el estado.

Esto deja fuera a muchos trabajadores. Según una encuesta nacional de 2024 realizada por KFF, el 63% de las personas que trabajan para empleadores privados y obtienen seguro médico a través de sus empleos tienen planes autofinanciados, que no están regulados por el estado.

“Por eso necesitamos una ley federal de protección de ambulancias, incluso si aprobáramos 50 leyes estatales”, dijo Kelmar.

Según datos de la oficina del secretario de estado de Colorado, los únicos grupos de presión registrados como “opositores” al proyecto de ley fueron Anthem y UnitedHealth Group, además de las subsidiarias de UnitedHealth, Optum y UnitedHealthcare.

En mayo, tan pronto como finalizó la sesión legislativa, Kevin McFatridge, director ejecutivo de la Colorado Association of Health Plans, un grupo comercial que representa a las compañías de seguros médicos del estado, envió una carta al gobernador solicitando su veto, con una estimación de que la legislación provocaría un aumento del 0,4% en las primas.

El proyecto de ley de Colorado establecía que los gobiernos locales, como ciudades, condados o distritos especiales, fijarían las tarifas.

“Estamos en una situación mucho mejor al no tener entidades locales que fijen sus propias tarifas”, declaró McFatridge a KFF Health News.

Jack Hoadley, profesor emérito de investigación de la Escuela de Políticas Públicas McCourt de la Universidad de Georgetown, afirmó que no está claro si las leyes estatales aprobadas en otros estados están aumentando las primas, o en qué medida. Hoadley agregó que se espera que el estado de Washington presente un análisis del impacto de su ley en un par de años.

La asociación nacional de compañías de seguros se negó a comentar para este artículo. En su lugar, la Association of Health Insurance Plans (AHIP) remitió cartas que sus líderes presentaron a legisladores de Ohio, West Virginia y Dakota del Norte este año, oponiéndose a las medidas de cada estado para establecer tarifas base para ambulancias.

Los líderes de la AHIP describieron las propuestas como precios inflados, impuestos por el gobierno, que reducirían la posibilidad de que las aseguradoras negocien precios justos. En última instancia, advirtió la asociación, los mínimos propuestos aumentarían los costos de la atención médica.

En Montana, los legisladores estaban considerando un reembolso mínimo para ambulancias terrestres del 400% de lo que paga Medicare, o una tarifa local fija, si hay alguna. La propuesta fue patrocinada por dos republicanos y respaldada por las compañías de ambulancias. Las aseguradoras de salud presionaron con éxito en contra, argumentando que el precio era demasiado alto.

Sarah Clerget, lobista que representa a la AHIP, declaró a los legisladores de Montana en una audiencia legislativa que ya es difícil lograr que las compañías de ambulancias se integren a la red de las aseguradoras, “porque la gente va a necesitar atención de ambulancia independientemente de si su compañía de seguros la cubre”.

Agregó que la propuesta estatal dejaría a quienes pagan la cobertura médica con la carga del nuevo precio.

“A nadie le gusta que nuestras tarifas de seguro se modifiquen”, declaró el senador estatal republicano Mark Noland durante una reunión legislativa mientras un comité archivaba el proyecto de ley. Comparó el mínimo propuesto con un mandato que podría llevar a que las personas tengan que pagar más por la cobertura médica de un servicio importante, pero a la vez especializado.

El gobernador de Colorado se centró de forma similar en las primas. Polis afirmó en su carta de veto que la legislación habría aumentado las primas entre 73 centavos y $2,15 por miembro al mes.

“Estoy de acuerdo en que subsanar esta deficiencia en la aplicación de la ley es crucial para que la gente ahorre dinero en atención médica”, escribió. “Sin embargo, en mi opinión, esos ahorros van a compensarse con el aumento de las primas”.

Isabel Cruz, directora de políticas de la Colorado Consumer Health Initiative, que apoyó el proyecto de ley, afirmó que incluso si las primas aumentaran, los habitantes de Colorado podrían aceptar el cambio. Después de todo, remarcó, estarían cambiando la amenaza de una gran factura de ambulancia por el precio de media taza de café al mes.

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An analysis by KFF Health News found that the Trump administration’s cuts to the National Institutes of Health have been felt in both red and blue states, across political and geographic lines. Scientists warn these cuts will stall progress on urgent health issues and could set back care for vulnerable communities. 

More reductions in health research spending could be ahead. The Trump administration’s budget proposal for next year calls on Congress to slash the NIH budget more than 40%. 

KFF Health News correspondent Rae Ellen Bichell appeared on WAMU’s “Health Hub” on June 11 to explain how these cuts could set back research for years to come. 

KFF Health News audio producer Taylor Cook contributed reporting to this segment. 

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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A KFF Health News analysis underscores that the terminations are sparing no part of the country, politically or geographically. About 40% of organizations whose grants the NIH cut in its first month of slashing, which started Feb. 28, are in states Trump won in November.

The Trump administration has singled out Ivy League universities including Columbia and Harvard for broad federal funding cuts. But the spending reductions at the NIH, the nation’s foremost source of funding for biomedical research, go much further: Of about 220 organizations that had grants terminated, at least 94 were public universities, including flagship state schools in places such as Florida, Georgia, Ohio, Nebraska, and Texas.

The Trump administration has canceled hundreds of grants supporting research on topics such as vaccination; diversity, equity, and inclusion; and the health of LGBTQ+ populations. Some of the terminations are a result of Trump’s executive orders to abandon federal work on diversity and equity issues. Others followed the Senate confirmation of anti-vaccine activist Robert F. Kennedy Jr. to lead the Department of Health and Human Services, which oversees the NIH. Many mirror the ambitions laid out in Project 2025’s “Mandate for Leadership,” the conservative playbook for Trump’s second term.

Affected researchers say Trump administration officials are taking a cudgel to efforts to improve the lives of people who often experience worse health outcomes — ignoring a scientific reality that diseases and other conditions do not affect all Americans equally.

KFF Health News found that the NIH terminated about 780 grants or parts of grants between Feb. 28 and March 28, based on documents published by the Department of Health and Human Services and a list maintained by academic researchers. Some grants were canceled in full, while in other cases, only supplements — extra funding related to the main grant, usually for a shorter-term, related project — were terminated.

Among U.S. recipients, 96 of the institutions that lost grants in the first month are in politically conservative states including Florida, Ohio, and Indiana, where Republicans control the state government or voters reliably support the GOP in presidential campaigns, or in purple states such as North Carolina, Michigan, and Pennsylvania that were presidential battleground states. An additional 124 institutions are in blue states.

Sybil Hosek, a research professor at the University of Illinois-Chicago, helps run a network that focuses on improving care for people 13 to 24 years old who are living with or at risk for HIV. The NIH awarded Florida State University $73 million to lead the HIV project.

“We never thought they would destroy an entire network dedicated to young Americans,” said Hosek, one of the principal investigators of the Adolescent Medicine Trials Network for HIV/AIDS Interventions. The termination “doesn’t make sense to us.”

NIH official Michelle Bulls is director of the Office of Policy for Extramural Research Administration, which oversees grants policy and compliance across NIH institutes. In terminating the grant March 21, Bulls wrote that research “based primarily on artificial and nonscientific categories, including amorphous equity objectives, are antithetical to the scientific inquiry, do nothing to expand our knowledge of living systems, provide low returns on investment, and ultimately do not enhance health, lengthen life, or reduce illness.”

Adolescents and young adults ages 13 to 24 accounted for 1 in 5 new HIV infections in the U.S. in 2022, according to the Centers for Disease Control and Prevention.

“It’s science in its highest form,” said Lisa Hightow-Weidman, a professor at Florida State University who co-leads the network. “I don’t think we can make America healthy again if we leave youth behind.”

HHS spokesperson Emily Hilliard said in an emailed statement that “NIH is taking action to terminate research funding that is not aligned with NIH and HHS priorities.” The NIH and the White House didn’t respond to requests for comment.

“As we begin to Make America Healthy Again, it's important to prioritize research that directly affects the health of Americans. We will leave no stone unturned in identifying the root causes of the chronic disease epidemic as part of our mission to Make America Healthy Again,” Hilliard said.

Harm to HIV, Vaccine Studies

The NIH, with its nearly $48 billion annual budget, is the largest public funder of biomedical research in the world, awarding nearly 59,000 grants in the 2023 fiscal year. The Trump administration has upended funding for projects that were already underway, stymied money for new applications, and sought to reduce how much recipients can spend on overhead expenses.

Those changes — plus the firing of 1,200 agency employees as part of mass layoffs across the government — are alarming scientists and NIH workers, who warn that they will undermine progress in combating diseases and other threats to the nation’s public health. On April 2, the American Public Health Association, Ibis Reproductive Health, and affected researchers, among others, filed a lawsuit in federal court against the NIH and HHS to halt the grant cancellations.

Two National Cancer Institute employees, who were granted anonymity because they were not authorized to speak to the press and feared retaliation, said its staff receives batches of grants to terminate almost daily. On Feb. 27, the cancer institute had more than 10,800 active projects, the highest share of the NIH’s roughly two dozen institutes and centers, according to the NIH’s website. At least 47 grants that NCI awarded were terminated in the first month.

Kennedy has said the NIH should take a years-long pause from funding infectious disease research. In November 2023, he told an anti-vaccine group, “I’m gonna say to NIH scientists, ‘God bless you all. Thank you for public service. We’re going to give infectious disease a break for about eight years,’” according to NBC News.

For years, Kennedy has peddled falsehoods about vaccines — including that “no vaccine” is “safe and effective,” and that “there are other studies out there” showing a connection between vaccines and autism, a link that has repeatedly been debunked — and claimed falsely that HIV is not the only cause of AIDS.

KFF Health News found that grants in blue states were disproportionately affected, making up roughly two-thirds of terminated grants, many of them at Columbia University. The university had more grants terminated than all organizations in politically red states combined. On April 4, Democratic attorneys general in 16 states sued HHS and the NIH to block the agency from canceling funds.

Researchers whose funding was stripped said they stopped clinical trials and other work on improving care for people with HIV, reducing vaping and smoking rates among LGBTQ+ teens and young adults, and increasing vaccination rates for young children. NIH grants routinely span several years.

For example, Hosek said that when the youth HIV/AIDS network’s funding was terminated, she and her colleagues were preparing to launch a clinical trial examining whether a particular antibiotic that is effective for men to prevent sexually transmitted infections would also work for women.

“This is a critically important health initiative focused on young women in the United States,” she said. “Without that study, women don’t have access to something that men have.”

Other scientists said they were testing how to improve health outcomes among newborns in rural areas with genetic abnormalities, or researching how to improve flu vaccination rates among Black children, who are more likely to be hospitalized and die from the virus than non-Hispanic white children.

“It's important for people to know that — if, you know, they are wondering if this is just a waste of time and money. No, no. It was a beautiful and rare thing that we did,” said Joshua Williams, a pediatric primary care doctor at Denver Health in Colorado who was researching whether sharing stories about harm experienced due to vaccine-preventable diseases — from missed birthdays to hospitalizations and job loss — might inspire caregivers to get their children vaccinated against the flu.

He and his colleagues had recruited 200 families, assembled a community advisory board to understand which vaccinations were top priorities, created short videos with people who had experienced vaccine-preventable illness, and texted those videos to half of the caregivers participating in the study.

They were just about to crack open the medical records and see if it had worked: Were the group who received the videos more likely to follow through on vaccinations for their children? That’s when he got the notice from the NIH.

“It is the policy of NIH not to prioritize research activities that focuses gaining scientific knowledge on why individuals are hesitant to be vaccinated and/or explore ways to improve vaccine interest and commitment,” the notice read.

Williams said the work was already having an impact as other institutions were using the idea to start projects related to cancer and dialysis.

A Hit to Rural Health

Congress previously tried to ensure that NIH grants also went to states that historically have had less success obtaining biomedical research funding from the government. Now those places aren’t immune to the NIH’s terminations.

Sophia Newcomer, an associate professor of public health at the University of Montana, said she had 18 months of work left on a study examining undervaccination among infants, which means they were late in receiving recommended childhood vaccines or didn’t receive the vaccines at all. Newcomer had been analyzing 10 years of CDC data about children’s vaccinations and had already found that most U.S. infants from 0 to 19 months old were not adequately vaccinated.

Her grant was terminated March 10, with the NIH letter stating the project “no longer effectuates agency priorities,” a phrase replicated in other termination letters KFF Health News has reviewed.

“States like Montana don’t get a lot of funding for health research, and health researchers in rural areas of the country are working on solutions to improve rural health care,” Newcomer said. “And so cuts like this really have an impact on the work we’re able to do.”

Montana is one of 23 states, along with Puerto Rico, that are eligible for the NIH’s Institutional Development Award program, meant to bolster NIH funding in states that historically have received less investment. Congress established the program in 1993.

The NIH’s grant terminations hit institutions in 15 of those states, more than half that qualify, plus Puerto Rico.

Researchers Can’t ‘Just Do It Again Later’

The NIH’s research funds are deeply entrenched in the U.S. health care system and academia. Rarely does an awarded grant stay within the four walls of a university that received it. One grant’s money is divvied up among other universities, hospitals, community nonprofits, and other government agencies, researchers said.

Erin Kahle, an infectious disease epidemiologist at the University of Michigan, said she was working with Emory University in Georgia and the CDC as part of her study. She was researching the impact of intimate partner violence on HIV treatment among men living with the virus. “They are relying on our funds, too,” she said.

Kahle said her top priority was to ethically and safely wind down her nationwide study, which included 418 people, half of whom were still participating when her grant was terminated in late March. Kahle said that includes providing resources to participants for whom sharing experiences of intimate partner violence may cause trauma or mental health distress.

Rachel Hess, the co-director of the Clinical & Translational Science Institute at the University of Utah, said the University of Nevada-Reno and Intermountain Health, one of the largest hospital systems in the West, had received funds from a $38 million grant that was awarded to the University of Utah and was terminated March 12.

The institute, which aims to make scientific research more efficient to speed up the availability of treatments for patients, supported over 5,000 projects last year, including 550 clinical trials with 7,000 participants. Hess said that, for example, the institute was helping design a multisite study involving people who have had heart attacks to figure out the ideal mix of medications “to keep them alive” before they get to the hospital, a challenge that’s more acute in rural communities.

After pushback from the university — the institute’s projects included work to reduce health care disparities between rural and urban areas — the NIH restored its grant March 29.

Among the people the Utah center thanked in its announcement about the reversal were the state’s congressional delegation, which consists entirely of Republican lawmakers. “We are grateful to University of Utah leadership, the University of Utah Board of Trustees, our legislative delegation, and the Utah community for their support,” it said.

Hilliard, of HHS, said that “some grants have been reinstated following the appeals process, and the agency will continue to carry out the remaining appeals as planned to determine their alignment.” She declined to say how many had been reinstated, or why the University of Utah grant was among them.

Other researchers haven’t had the same luck. Kahle, in Michigan, said projects like hers can take a dozen years from start to finish — applying for and receiving NIH funds, conducting the research, and completing follow-up work.

“Even if there are changes in the next administration, we’re looking at at least a decade of setting back the research,” Kahle said. “It’s not as easy as like, ‘OK, we’ll just do it again later.’ It doesn’t really work that way.”

Methodology

KFF Health News analyzed National Institutes of Health grant data to determine the states and organizations most affected by the Trump administration’s cuts.

We tallied the number of terminated NIH grants using two sources: a Department of Health and Human Services list of terminated grants published April 4; and a crowdsourced list maintained by Noam Ross of rOpenSci and Scott Delaney of the Harvard T.H. Chan School of Public Health, as of April 8. We focused on the first month of terminations: from Feb. 28 to March 28. We found that 780 awards were terminated in total, with 770 of them going to recipients based in U.S. states and two to recipients in Puerto Rico.

The analysis does not account for potential grant reinstatements, which we know happened in at least one instance.

Additional information on the recipients, such as location and business type, came from the USAspending.gov Award Data Archive.

There were 222 U.S. recipients in total. At least 94 of them were public higher education institutions. Forty-one percent of organizations that had NIH grants cut in the first month were in states that President Donald Trump won in the 2024 election.

Some recipients, including the University of Texas MD Anderson Cancer Center and Vanderbilt University Medical Center, are medical facilities associated with higher education institutions. We classified these as hospitals/medical centers.

We also wanted to see whether the grant cuts affected states across the political spectrum. We generally classified states as blue if Democrats control the state government or Democratic candidates won them in the last three presidential elections, and red if they followed this pattern but for Republicans. Purple states are generally presidential battleground states or those where voters regularly split their support between the two parties: Arizona, Michigan, Nevada, New Hampshire, North Carolina, Pennsylvania, Virginia, and Wisconsin. The result was 25 red states, 17 blue states, and eight purple states. The District of Columbia was also blue.

We found that, of affected U.S. institutions, 96 were in red or purple states and 124 were in blue states.

KFF Health News intern Henry Larweh contributed to this report.

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GRAND JUNCTION, Colo. — On a Friday after school, 6-year-old Esa Rodrigues had unraveled a ball of yarn, spooked the pet cat, polled family members about their favorite colors, and tattled on a sibling for calling her a “butt-face mole rat.”

Next, she was laser-focused on prying open cherry-crisp-flavored lip gloss with her teeth.

“Yes!” she cried, twisting open the cap. Esa applied the gloopy, shimmery stuff in her bedroom, where a large transgender pride flag hung on the wall.

Esa said the flag makes her feel “important” and “happy.” She’d like to take it down from the wall and wear it as a cape.

Her parents questioned her identity at first, but not anymore. Before, their anxious child dreaded going to school, bawled at the barbershop when she got a boy’s haircut, and curled into a fetal position on the bathroom floor when she learned she would never get a period.

Now, that child is happily bounding up a hill, humming to herself, wondering aloud if fairies live in the little ceramic house she found perched on a stone.

Her mom, Brittni Packard Rodrigues, wants this joy and acceptance to stay. Depending on a combination of Esa’s desire, her doctors’ recommendations, and when puberty sets in, that might require puberty blockers, followed by estrogen, so that Esa can grow into the body that matches her being.

“In the long run, blockers help prevent all of those surgeries and procedures that could potentially become her reality if we don’t get that care,” Packard Rodrigues said.

The medications known as puberty blockers are widely used for conditions that include prostate cancer, endometriosis, infertility, and puberty that sets in too early. Now, the Trump administration is seeking to limit their use specifically for transgender youth.

Esa’s home state of Colorado has long been known as a haven for gender-affirming care, which the state considers legally protected and an essential health insurance benefit. Medical exiles have moved to Colorado for such treatment in the past few years. As early as the 1970s, the town of Trinidad became known as “the sex-change capital of the world” when a cowboy-hat-wearing former Army surgeon, Stanley Biber, made his mark performing gender-affirming surgeries for adults.

On his first day in office, President Donald Trump signed an executive order refuting the existence of transgender people by saying it is a “false claim that males can identify as and thus become women and vice versa.” The following week, he issued another order calling puberty blockers and hormones for anyone under age 19 a form of chemical “mutilation” and “a stain on our Nation’s history.” It directed agencies to take steps to ensure that recipients of federal research or education grants stop providing it.

Subsequently, health care organizations in Colorado; California; Washington, D.C.; and elsewhere announced they would preemptively comply. In Colorado, that included three major health care organizations: Children’s Hospital Colorado, Denver Health, and UCHealth. At the end of January and in early February, the three systems announced changes to the gender-affirming care they provide to patients under 19, effective immediately: no new hormone or puberty blocker prescriptions for patients who hadn’t had them before, limited or no prescription renewals for those who had, and no surgeries, though Children’s Hospital had never offered it, and such surgery is rare among teens: For every 100,000 trans minors, fewer than three undergo surgery.

Children’s Hospital and Denver Health resumed offering puberty blockers and hormones on Feb. 24 and Feb. 19, respectively, after Colorado joined a U.S. District Court lawsuit in Washington state. The court concluded that Trump’s orders relating to gender “discriminate on the basis of transgender status and sex.” It granted a preliminary injunction blocking them from taking effect in the four states involved in the lawsuit.

Surgeries, however, have not resumed. Denver Health said it will “continue its pause on gender-affirming surgeries for patients under 19 due to patient safety and given the uncertainty of the legal and regulatory landscape.”

UCHealth has resumed neither medication nor surgery for those under 19. “Our providers are awaiting a more permanent decision from federal courts that may resolve the uncertainty around providing this care,” spokesperson Kelli Christensen wrote.

Trans youth and their families said the court ruling and the two Colorado health systems’ decisions to resume treatments haven’t resolved matters. It has bought them time to stockpile prescriptions, to try to find private practice physicians with the right training to monitor blood work and adjust prescriptions accordingly, and, for some, to work out the logistics of moving to another state or country.

The Trump administration has continued to press health providers beyond the initial executive orders by threatening to withhold or cancel federal money awarded to them. In early March, the Health Resources and Services Administration said it would review funding for graduate medical education at children’s hospitals.

KFF Health News requested comment from White House deputy press secretary Kush Desai but did not receive a response. HHS deputy press secretary Emily Hilliard responded with links to two prior press releases.

Medical interventions are just one type of gender-affirming care, and the process to get treatment is long and thorough. Researchers have found that, even among those with private insurance, transgender youth aren’t likely to receive puberty blockers and hormones. Interestingly, most gender-affirming breast reduction surgeries performed on men and boys are done on cisgender — not transgender — patients.

Kai, 14, wishes he could have gone on puberty blockers. He lives in Centennial, a Denver suburb. KFF Health News is not using his full name because his family is worried about him being harassed or targeted.

Kai got his period when he was 8 years old. By the time he realized he was transgender, in middle school, it was too late to start puberty blockers.

His doctors prescribed birth control to suppress his periods, so he wouldn’t be reminded each month of his gender dysphoria. Then, once he turned 14, he started taking testosterone.

Kai said if he didn’t have hormone therapy now, he would be a danger to himself.

“Being able to say that I’m happy in my body, and I get to be happy out in public without thinking everyone’s staring at me, looking at me weird, is such a huge difference,” he said.

His mom, Sherry, said she is happy to see Kai relax into the person he is.

Sherry, who asked to use her middle name to prevent her family from being identified, said she started stockpiling testosterone the moment Trump got elected but hadn’t thought about what impact there would be on the availability of birth control. Yet after the executive orders, that prescription, too, became tenuous. Sherry said Kai’s doctor at UCHealth had to set up a special meeting to confirm the doctor could keep prescribing it.

So, for now, Kai has what he needs. But to Sherry, that is cold comfort.

“I don’t think that we are very safe,” she said. “These are just extensions.”

The family is coming up with a plan to leave the country. If Sherry and her husband can get jobs in New Zealand, they’ll move there. Sherry said such mobility is a privilege that many others don’t have.

For example, David, an 18-year-old student at Western Colorado University in the Rocky Mountain town of Gunnison. He asked to be identified only by his middle name because he worries he could be targeted in this conservative, rural town.

David doesn’t have a passport, but even if he did, he doesn’t want to leave Gunnison, he said. He is studying geology, is learning to play the bass, and has a good group of friends. He has plans to become a paleontologist.

His dorm room shelves are scattered with his essentials: fossils, Old Spice deodorant, microwave macaroni and cheese. But there are no mirrors. David said he got in the habit of avoiding them.

“For the longest time, I just had so much body dysphoria and dysmorphia that it can be kind of hard to look in the mirror,” David said. “But when I do, most of the time, I see something that I really like.”

He’s been taking testosterone for three years, and the hormone helped him grow a beard. In January, his doctor at Denver Health was told to stop prescribing it. His mom drove hours from her home to Gunnison to deliver the news in person.

That prescription is back on track now, but the mastectomy he’d planned for this summer isn’t. He’d hoped to have adequate recovery time before sophomore year. But he doesn’t know anyone in Colorado who would perform it until he is 19. He could easily get surgery to enhance his breasts, but he must seek surgical options in other states to reduce or remove them.

“Colorado as a state was supposed to be a safe haven,” said his mother, Louise, who asked to be identified by her middle name. “We have a law that makes it a right for trans people to have health care, and yet our health care systems are taking that away.”

It has taken eight years and about 10 medical providers and therapists to get David this close to the finish line. That’s a big deal after living through so many years of dysphoria and dysmorphia.

“I’m still going, and I’m going to keep going, and there’s almost nothing they can do to stop me — because this is who I am,” David said. “There have always been trans people, and there always will be trans people.”

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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Luego, se concentró en abrir con los dientes un brillo labial con sabor a cereza.

“¡Sí!”, exclamó, cuando logró abrir la tapa. Esa se puso el brillo en su habitación, donde colgaba en la pared una gran bandera del orgullo transgénero.

Esa dijo que la bandera la hace sentir “importante” y “feliz”. Le gustaría quitarla de la pared y usarla como capa.

Al principio, sus padres cuestionaron su identidad, pero ya no. Antes, su hija, ansiosa, temía ir a la escuela, lloraba en la barbería cuando le hacían un corte “varonil”, y se acurrucó en posición fetal en el suelo del baño cuando supo que nunca tendría la menstruación.

Ahora, esa niña vive la vida con entusiasmo, preguntándose en voz alta si las hadas viven en la casita de cerámica que encontró encaramada en una piedra.

Su madre, Brittni Packard Rodrigues, quiere que esta alegría y aceptación perduren. Dependiendo de la combinación del deseo de Esa, las recomendaciones de sus médicos y el inicio de la pubertad, esto podría requerir bloqueadores, seguidos de estrógeno, para que Esa pueda desarrollar el cuerpo que se adapte a su ser.

“A largo plazo, los bloqueadores ayudan a prevenir todas esas cirugías y procedimientos que podrían convertirse en su realidad si no recibimos esa atención”, dijo Packard Rodrigues.

Los medicamentos conocidos como bloqueadores de la pubertad se usan ampliamente para afecciones como el cáncer de próstata, la endometriosis, la infertilidad y la pubertad precoz. Ahora, la administración Trump busca limitar su uso específicamente para jóvenes transgénero.

Colorado, el estado natal de Esa, es reconocido desde hace tiempo como un refugio para la atención de afirmación de género: se considera legalmente protegida y un beneficio esencial del seguro médico.

En los últimos años, “exiliados médicos” se han mudado a Colorado para recibir este tratamiento. Ya en la década de 1970, el pueblo de Trinidad se hizo conocida como “la capital mundial del cambio de sexo” cuando Stanley Biber, un ex cirujano del ejército con sombrero de vaquero, dejó su huella realizando estas cirugías en adultos.

En su primer día en el cargo, el presidente Donald Trump firmó una orden ejecutiva que refuta la existencia de personas transgénero, argumentando que es una “afirmación falsa que los hombres puedan identificarse como mujeres y, por lo tanto, convertirse en mujeres, y viceversa”.

A la semana siguiente, emitió otra orden que calificaba los bloqueadores de la pubertad y las hormonas para menores de 19 años como una forma de “mutilación” química y “una mancha en la historia de nuestra nación”. La orden instruía a las agencias a tomar medidas para garantizar que los beneficiarios de subvenciones federales para investigación o educación dejaran de proporcionarlos.

Organizaciones de atención médica en Colorado, California, Washington, D.C. y otros lugares anunciaron que cumplirían con la orden preventivamente.

En Colorado, esto incluía a tres importantes organizaciones de atención médica: Children’s Hospital Colorado, Denver Health y UCHealth.

Entre finales de enero y principios de febrero, los tres sistemas anunciaron cambios en la atención de afirmación de género que ofrecían a pacientes menores de 19 años, con efecto inmediato.

Dijeron que ya no recetarían nuevas hormonas ni bloqueadores de la pubertad para pacientes que no los hubieran recibido previamente, se limitarían o no se renovarían las recetas para quienes sí los hubieran recibido, y no se realizarían cirugías. Esto último aunque el Children’s Hospital nunca las había ofrecido, y este tipo de cirugía es poco común en adolescentes: por cada 100.000 menores trans, menos de tres se someten a ella.

El hospital infantil y Denver Health reanudaron la oferta de bloqueadores de la pubertad y hormonas el 24 y el 19 de febrero, respectivamente, después que Colorado se uniera a una demanda presentada ante el tribunal de distrito de EE. UU. en el estado de Washington.

El tribunal concluyó que las órdenes de Trump relacionadas con el género “discriminan por motivos de condición transgénero y sexo”. Otorgó una orden judicial preliminar que impide su entrada en vigencia en los cuatro estados involucrados.

Sin embargo, las cirugías no se han reanudado. Denver Health afirmó que “mantendrá la pausa en las cirugías de afirmación de género para pacientes menores de 19 años debido a la seguridad del paciente y dada la incertidumbre del panorama legal y regulatorio”.

UCHealth no ha reanudado ni la medicación ni la cirugía para menores de 19 años. “Nuestros proveedores esperan una decisión más definitiva de los tribunales federales que pueda resolver la incertidumbre en torno a la prestación de esta atención”, escribió la vocera Kelli Christensen.

Los jóvenes trans y sus familias afirmaron que el fallo judicial y las decisiones de los dos sistemas de salud de Colorado de reanudar los tratamientos no han resuelto el problema. Les ha dado tiempo para acumular recetas, para intentar encontrar médicos privados con la formación adecuada para supervisar los análisis de sangre, y ajustar las recetas en consecuencia, y, en algunos casos, para resolver la logística de mudarse a otro estado o país.

La administración Trump ha seguido presionando a los proveedores de salud más allá de las órdenes ejecutivas iniciales, amenazando con retener o cancelar los fondos federales que se les habían otorgado. A principios de marzo, la Administración de Recursos y Servicios de Salud (RHSA) anunció que revisaría la financiación de la educación médica de posgrado en hospitales pediátricos.

KFF Health News solicitó comentarios a Kush Desai, subsecretario de prensa de la Casa Blanca, pero no recibió respuesta. La subsecretaria de prensa del Departamento de Salud y Servicios Sociales (HHS), Emily Hilliard, respondió con enlaces a dos comunicados de prensa anteriores.

Las intervenciones médicas son solo un tipo de atención de afirmación de género, y el proceso para obtener el tratamiento es largo y exhaustivo.

Investigadores han descubierto que, incluso entre quienes tienen seguro médico privado, es poco probable que los jóvenes transgénero reciban bloqueadores de la pubertad ni hormonas. Curiosamente, la mayoría de las cirugías de reducción de senos para afirmación de género realizadas en hombres y menores se practican en pacientes cisgénero, no transgénero.

Kai, de 14 años, quisiera haber podido tomar bloqueadores de la pubertad. Vive en Centennial, un suburbio de Denver. KFF Health News no divulga su nombre completo porque a su familia le preocupa que pueda sufrir acoso.

Kai tuvo su primera menstruación a los 8 años. Para el momento en el que se dio cuenta de que era transgénero, en la secundaria, ya era demasiado tarde para empezar a tomar bloqueadores de la pubertad.

Sus médicos le recetaron anticonceptivos para suprimir sus períodos, así no le recordaban cada mes su disforia de género. Luego, al cumplir los 14, empezó a tomar testosterona.

Kai dijo que si no estuviera en terapia hormonal ahora, sería un peligro para sí mismo.

“Poder decir que estoy feliz con mi cuerpo y poder ser feliz en público sin pensar que todos me miran raro, es una gran diferencia”, dijo.

Su madre, Sherry, dijo que se alegra de ver a Kai relajarse y convertirse en la persona que es.

Sherry, quien pidió usar su segundo nombre para evitar que se identificara a su familia, dijo que comenzó a guardar testosterona en cuanto Trump fue elegido, pero no había pensado en el impacto que esto tendría en la disponibilidad de anticonceptivos. Sin embargo, después de las órdenes ejecutivas, esa receta también se volvió difícil  de conseguir. Sherry dijo que el médico de Kai en UCHealth tuvo que programar una reunión especial para confirmar que podía seguir recetándosela.

Así que, por ahora, Kai tiene lo que necesita. Pero para Sherry, eso no es un gran consuelo.

“No creo que estemos muy seguros”, dijo. “Son solo prórrogas”.

La familia está ideando un plan para salir del país. Si Sherry y su esposo consiguen trabajo en Nueva Zelanda, se mudarán allí. Sherry dijo que esa posibilidad es un privilegio que muchos otros no tienen.

Por ejemplo, David, un estudiante de 18 años de la Universidad Western Colorado en Gunnison, un pueblo de las Montañas Rocallosas, pidió ser identificado solo por su segundo nombre porque le preocupa ser objeto de persecución en este pueblo rural y conservador.

David no tiene pasaporte, pero incluso si lo tuviera, no quiere irse de Gunnison, dijo. Está estudiando geología y aprendiendo a tocar el bajo.

Y tiene un buen grupo de amigos. Planea ser paleontólogo.

Los estantes de su dormitorio están llenos de sus artículos esenciales: fósiles, desodorante Old Spice, macarrones con queso para microondas. Pero no hay espejos. David dijo que se acostumbró a evitarlos.

“Durante mucho tiempo, tuve tanta disforia corporal y dismorfia que puede ser un poco difícil mirarme al espejo”, dijo David. “Pero cuando lo hago, la mayoría de las veces, veo algo que realmente me gusta”.

Lleva tres años tomando testosterona, y la hormona le ayudó a que creciera su barba. En enero, le dijeron a su médico de Denver Health que dejara de recetársela. Su madre condujo horas desde su casa hasta Gunnison para darle la noticia en persona.

La receta ya está activa de nuevo, pero la mastectomía que había planeado para este verano no. Esperaba tener un tiempo de recuperación adecuado antes de empezar el segundo año de la universidad. Pero no conoce a nadie en Colorado que lo haga antes de los 19 años. Podría operarse fácilmente para aumentar sus pechos, pero debe buscar opciones quirúrgicas en otros estados para reducirlos o extirparlos.

“Se suponía que Colorado, como estado, era un refugio”, dijo su madre, Louise, quien pidió ser identificada por su segundo nombre. “Tenemos una ley que otorga a las personas trans el derecho a la atención médica, y sin embargo, nuestros sistemas de salud se la están quitando”.

Han sido necesarios ocho años y unos diez profesionales médicos y terapeutas para que David esté tan cerca de la meta. Es un gran logro después de haber vivido tantos años de disforia y dismorfia.

“Sigo adelante, y seguiré adelante, y casi nada podrá detenerme, porque así soy”, dijo David. “Siempre ha habido personas trans y siempre las habrá”.

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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