Aunque la temporada de inscripciones ya está en marcha, el futuro de los subsidios ampliados —que hacen más accesible el seguro para el 92% de las personas inscritas— sigue siendo incierto, con la posibilidad de que las primas aumenten significativamente.

Aun así, hay medidas que puedes tomar para asegurarte de elegir correctamente tu plan para el próximo año.

1. Entender cómo llegamos hasta aquí

En 2021, como parte de un paquete de ayuda por covid, se ampliaron los subsidios de ACA para reducir los costos de las personas que ya calificaban y extender la elegibilidad a quienes tenían ingresos superiores al 400% del nivel federal de pobreza (unos $63.000 para una sola persona en 2025).

Estas ampliaciones, que fueron renovadas en 2022, vencerán al finalizar 2025, a menos que el Congreso actúe.

El debate sobre si renovar los subsidios ha sido el centro de una lucha política entre republicanos y demócratas en el Congreso, conflicto que contribuyó al cierre del gobierno federal que ya lleva más de un mes.

Las implicaciones económicas para muchas personas inscritas en los mercados son enormes.

Según KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News, se proyecta que los pagos de bolsillo de las primas (lo que pagas cada mes por tu cobertura) para los inscritos subirán más del doble si expiran los subsidios ampliados.

“Cuanto más tiempo dure esto, mayor será el daño”, dijo Cynthia Cox, vicepresidenta y directora del Programa sobre ACA en KFF. “Si alguien entra al sitio web el 1 de noviembre y ve que su prima se duplicó, es posible que se vaya”.

Eso sería un error, según las personas expertas en los mercados. Lo que sí está claro es que quienes buscan seguro deben estar informados y tener precaución.

2. Seguir las noticias

Puede resultar frustrante seguir el día a día las peleas en el Capitolio, pero puede ser la mejor manera de mantenerse al tanto.

El Congreso podría llegar a un acuerdo para renovar los subsidios en cualquier momento durante los próximos meses, o no. En cualquier caso, eso puede afectar tu decisión de inscripción. Así que, mantente atento.

No cuentes con que el mercado o tu aseguradora te informen sobre lo que podrías llegar a pagar. “Muchos mercados estatales han retrasado” el envío de notificaciones a los consumidores con las primas netas (que ya tienen en cuenta los subsidios), dijo Sabrina Corlette, codirectora del Centro sobre Reformas del Seguro de Salud de la Universidad Georgetown.

El gobierno federal no envía notificaciones a las personas inscritas sobre las primas para el próximo año en los 28 mercados administrados a nivel federal. Para 2026, también ha indicado que los planes de salud pueden optar por no hacerlo.

3. Actualizar la información de tu cuenta

Ingresa a tu cuenta del mercado de seguros y actualiza tus ingresos, el tamaño de tu hogar y cualquier otro dato que haya cambiado.

Este año, es particularmente importante proporcionar una estimación precisa de tus ingresos pronosticados para 2026.

Una disposición en la ley HR 1, a veces llamada One Big Beautiful Bill Act, eliminó los límites sobre lo que muchas personas debían devolver si subestimaban sus ingresos y recibían más ayuda de la que les correspondía.

El próximo año, tendrán que reembolsar la totalidad del monto recibido de más.

Dada la incertidumbre sobre las primas, este probablemente no sea un buen año para permitir que el mercado te reinscriba automáticamente en tu plan actual o en uno similar, según especialistas.

Esto es especialmente importante para quienes, si no hay un nuevo acuerdo, ya no calificarán para subsidios el próximo año, específicamente quienes tengan ingresos superiores al 400% del nivel federal de pobreza.

4. Elegir el plan según el precio publicado

Si el Congreso no llega a un acuerdo para extender los subsidios ampliados, muchas personas se sorprenderán al ver el costo proyectado de sus primas.

Según KFF, se espera que las primas de los seguros de salud en los mercados aumenten, en promedio, un 26% el próximo año. Es el mayor incremento desde 2018.

Hasta ahora, las personas han estado protegidas en gran medida de estos aumentos gracias a los subsidios ampliados, que casi todas reciben. Así funciona: la mayoría de las personas con planes de ACA pagan una parte de su prima según una escala progresiva basada en sus ingresos, y el gobierno cubre el resto.

Según un análisis de KFF, si no se renuevan los subsidios ampliados, una familia de cuatro con ingresos de $75.000 tendrá que pagar $5.865 anuales por un plan de referencia de nivel plata en 2026: más del doble de los $2.498 que pagaría si se renuevan.

Al evaluar un plan, concéntrate en el precio publicado. Si no es accesible sin los subsidios ampliados, no es una buena opción.

“Las personas deben tomar decisiones basadas en lo que tienen delante”, señaló Cox.

Si no puedes pagar ese precio sin los subsidios ampliados, considera inscribirte en un plan menos generoso con una prima más baja pero un deducible más alto, dijo Cox. Los planes de nivel bronce deben ofrecer cobertura integral, incluyendo atención preventiva gratuita, y pueden cubrir algunas visitas médicas antes de que se alcance el deducible (lo que tú debes pagar antes de que la aseguradora se haga cargo del gasto).

“En la mayoría de los casos, tiene más sentido tener un plan bronce que no tener seguro”, explicó.

La administración Trump ha estado promoviendo los planes catastróficos como una opción más accesible para quienes enfrentan dificultades económicas, incluyendo a las personas que no califican para subsidios porque sus ingresos están por debajo del 100% o por encima del 400% del nivel federal de pobreza.

Al igual que los planes bronce, los planes catastróficos cubren un conjunto de beneficios esenciales, ofrecen atención preventiva gratuita y deben cubrir al menos tres visitas al médico antes de alcanzar el deducible. Pero estos planes tienen los deducibles más altos de todos los planes del mercado: $10.600 para individuos y $21.200 para familias en 2026.

“Son caros en relación con lo que cubren”, señaló Jennifer Sullivan, directora de acceso a la cobertura médica en el Centro de Prioridades Presupuestarias y Políticas (CBPP), quien advirtió que las primas pueden costar varios cientos de dólares.

5. Revisar más de una vez

Si te desanimas al ver los precios de las primas en tu primera visita, “no apagues la computadora ni llegues a la conclusión de que no hay opciones para ti”, dijo Sullivan. “El Congreso aún podría actuar y las cosas podrían cambiar drásticamente”.

Los legisladores podrían restaurar los subsidios ampliados hasta fin de año que viene, o incluso después.

En la mayoría de los estados, incluyendo los 28 que usan el mercado federal centralizado, el período de inscripción abierta dura hasta el 15 de enero. También hay otras fechas clave que debes tener en cuenta.

En la mayoría de los estados, las personas deben inscribirse antes del 15 de diciembre para tener cobertura a partir del 1 de enero, y antes del 15 de enero para comenzar la cobertura el 1 de febrero, aunque algunos estados tienen plazos más extensos.

6. Esperar para pagar la prima

Generalmente, las primas deben pagarse antes de que entre en vigencia el plan, aunque los mercados y las aseguradoras tienen la flexibilidad de extender los plazos, explicó Corlette.

Podrían, por ejemplo, permitir más tiempo para hacer el primer pago. “Ya hemos visto eso en el pasado. Funcionarios estatales y aseguradoras han procurado por todos los medios mantener a las personas con cobertura”, dijo.

Pero si se llega a un acuerdo de último minuto y alguien ya pagó su prima para la cobertura de enero y recibió un subsidio menor al que correspondería con el nuevo acuerdo, aún debería poder recibir el subsidio más alto.

“Existen maneras de compensar a las personas”, aseguró Corlette, aunque no está claro cómo sucederá eso en este periodo de inscripción.

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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Even with sign-up season underway, the fate of the enhanced premium tax credits that make coverage more affordable for 92% of enrollees remains up in the air, with the prospect of significantly higher premiums looming.

But there are steps marketplace shoppers can take to ensure they make the right choices for the upcoming plan year.

1. Understand How We Got Here

In 2021, as part of a covid-era relief package, the ACA premium tax credits were enhanced to lower costs for previously eligible people and expand eligibility to people with incomes over 400% of the federal poverty level (which amounts to about $63,000 for one person in 2025). But those enhancements, which were extended in 2022, will expire at the end of 2025 unless Congress acts.

The debate over whether to extend them again has been at the center of a political battle of wills between Republicans and Democrats in Congress, a fight at the heart of the now month-old government shutdown.

The financial implications for many marketplace enrollees are huge. Average out-of-pocket premium payments for subsidized enrollees are projected to more than double if the enhanced tax credits expire, according to KFF, a health information nonprofit that includes KFF Health News.

“The longer this goes on, the more damage is done,” said Cynthia Cox, a vice president and the director of the Program on the ACA at KFF. “If someone logs on Nov. 1 and sees their premium doubling, they might just walk away.”

That would be a mistake, marketplace experts agree. What is clear, though, is that buyers need to beware and be informed.

2. Follow the News

It can be frustrating to track day-to-day Capitol Hill machinations. But that may be your best source for up-to-date information. Congress could make a deal to extend the enhanced subsidies anytime during the next few days, weeks, or months — or not. Either way, it could affect your enrollment decision. So, pay attention.

Don’t count on the marketplace or your insurer to notify you about what you should expect to pay. “Many state marketplaces have hit delay” on sending consumers notices of net premiums, which take premium tax credits into account, said Sabrina Corlette, a co-director of Georgetown University’s Center on Health Insurance Reforms.

The federal government doesn’t send enrollees notices about plan premiums for the coming year for the 28 federally facilitated marketplaces. For 2026, it has said that health plans can also opt not to.

3. Update Your Account Information

Log in to your marketplace account and update your income, household size, and any other details that have changed.

This year, it’s particularly important to provide an accurate estimate of your anticipated income for 2026.

A provision in HR 1, sometimes called the One Big Beautiful Bill Act, eliminated the caps on what many people were required to repay if they underestimated their projected income and received more premium assistance than they should have. Next year, people will have to repay the entire excess amount.

In the past few years, it’s been possible to put your ACA insurance “on autopilot,” with automatic reenrollment in your current or a similar plan. Given the uncertainty around premiums, this is not a good year to do that, enrollment specialists say.

This is especially true for people who, without a deal in Congress, will no longer qualify for subsidies next year, specifically those whose incomes are over 400% of the federal poverty level.

4. Shop Based on Sticker Prices

When people see their projected premiums, assuming Congress hasn’t reached a deal to extend the enhanced credits, many will be shocked.

Health insurance premiums on the marketplaces are expected to increase, on average, 26% next year, according to KFF. That’s the largest rate increase since 2018.

Until now, people have largely been shielded from those increases by the enhanced premium tax subsidies that nearly all enrollees receive. Here’s how it works: Most people with ACA marketplace plans are responsible for paying a portion of their premium based on a sliding income scale, and the government pays the rest.

According to an analysis by KFF, if the enhanced credits are not renewed, a family of four with $75,000 in income, for example, will be responsible for paying $5,865 in annual premiums for a benchmark silver plan in 2026 — more than double the $2,498 it’ll pay if they are renewed.

When evaluating a plan, focus on the listed price. If it’s not affordable without the enhanced tax credits, it’s not a good buy.

“People need to make a decision based on what is in front of them,” Cox said.

If you can’t afford the sticker price without the enhanced credits, consider enrolling in a less generous plan with a lower premium but a higher deductible, Cox said. Bronze plans must provide comprehensive coverage, including covering preventive care at no cost, and may cover some doctor visits before the deductible.

“In most cases, it makes more sense to have a bronze plan than to be uninsured,” she said.

The Trump administration has been promoting catastrophic plans as a more affordable option for people who face financial hardship, including those who don’t qualify for subsidies because their incomes are either less than 100% or more than 400% of the federal poverty level.

Similar to bronze plans, catastrophic plans cover a set of essential health benefits, provide free preventive care, and must cover at least three doctor visits before people reach their deductible. But catastrophic plan deductibles are the highest of any type of marketplace plan: $10,600 for individuals and $21,200 for families in 2026.

“They are expensive relative to what they cover,” said Jennifer Sullivan, director of health coverage access at the Center on Budget and Policy Priorities, noting premiums can cost several hundred dollars.

5. Come Back, Check, and Recheck

If you’re dismayed at premium prices on your first pass, “don’t slam the computer shut and decide that there are no options for you,” Sullivan said. “Congress might still act and things might change radically.”

Lawmakers could restore the enhanced premium tax credits right up to the end of the year, or later.

In a majority of states, including the 28 that use the federal government’s centralized marketplace, open enrollment lasts until Jan. 15. There are also other key dates to remember.

In most states, people must enroll by Dec. 15 for coverage starting Jan. 1, and by Jan. 15 for coverage starting Feb. 1, though some states have later deadlines.

6. Wait To Pay Your Premium

Premium payments are generally due before the plan takes effect, although marketplaces and insurers have flexibility to extend deadlines, Corlette said.

They might allow people extra time to make a first payment, for example. “We’ve seen that in the past. State officials and insurance companies have gotten creative to try and keep people in coverage,” she said.

But if there is a last-minute deal and someone has already paid their premium for January coverage and received a lower tax credit than the deal provides, they should still be able to receive the higher credit.

“There are ways to make people whole,” Corlette said, although how that might happen this enrollment period is unclear.

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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Después de un verano confuso, cuando las autoridades federales anunciaron cambios en las recomendaciones sobre la vacuna contra covid, que luego anularon, los Centros para el Control y la Prevención de Enfermedades (CDC) anunciaron a principios de octubre los calendarios de vacunación actualizados para el otoño, que no difieren mucho de los del año pasado.

Según expertos en salud pública, eso debería facilitar que la mayoría de las personas que quieren vacunarse puedan hacerlo.

“Desde la experiencia del paciente, no debería haber nada diferente a lo que ya han vivido, salvo quizás que el farmacéutico les dé un poco más de información”, explicó Hannah Fish, directora de iniciativas estratégicas en la Asociación Nacional de Farmacéuticos Comunitarios.

Esto es lo que necesitas saber:

VACUNA CONTRA COVID

Este otoño, se recomienda esta vacuna para todas las personas de 6 meses en adelante, con una salvedad: se requiere primero una conversación con el proveedor de salud, un modelo llamado “toma de decisiones clínicas compartida”.

El proveedor puede ser tu doctor, un farmacéutico u otro profesional que administre vacunas. En el caso de las personas menores de 65 años, el Comité Asesor sobre Prácticas de Vacunación de los CDC enfatizó que la vacunación suele ser más beneficiosa para quienes tienen mayor riesgo de presentar covid grave.

Aunque las recomendaciones de edad no han cambiado respecto al año pasado, hay algunos matices. Si bien la aprobación de los CDC es amplia —y eso significa que los planes de salud deben cubrir la vacuna sin costo para el paciente—, algunos proveedores podrían mostrarse reacios a administrar la vacuna a personas menores de 65, a menos que tengan una afección médica que las exponga a un mayor riesgo de sufrir covid grave si se infectan. Esa es la recomendación que figura en la etiqueta de la vacuna, aprobada por la Administración de Alimentos y Medicamentos (FDA).

“Es un detalle que podría surgir en la interacción entre un proveedor y un paciente”, dijo Jen Kates, vicepresidenta y directora de políticas de salud pública y global en KFF.

Sin embargo, si un proveedor se niega a vacunar a una persona sana por considerarlo un uso no recomendado en la etiqueta de la vacuna, otro proveedor probablemente sí estaría dispuesto a administrarla, dijeron expertos.

“Podrían ir a otra farmacia”, señaló Kates.

Según un análisis de KFF, muchos estados han intervenido para garantizar que las personas puedan acceder a las vacunas si así lo desean. Veintiún estados y el Distrito de Columbia han adoptado recomendaciones más amplias que las del gobierno federal, explicó Kates.

Sin embargo, el porcentaje de personas que optan por recibir la vacuna contra covid sigue bajando. A fines de abril, solo 23% de los adultos había recibido la vacuna actualizada, según los CDC.

Con una aceptación tan baja, es posible que menos farmacias y médicos decidan tener la vacuna disponible este año, comentó Jeff Levin-Scherz, médico de atención primaria, líder de salud poblacional en la consultora WTW y profesor adjunto en la Facultad de Salud Pública Chan de la Universidad de Harvard.

Cadenas grandes como CVS y Walgreens afirman que tienen suficiente suministro para cubrir la demanda.

Aun así, los obstáculos adicionales que las personas podrían enfrentar —como tener que buscar otra farmacia o proveedor— podrían afectar el interés en vacunarse contra covid.

“Para que más personas se vacunen, la clave es que el proceso sea lo más fácil posible y reducir la cantidad de pasos”, dijo Levin-Scherz.

VACUNA CONTRA LA GRIPE

Más personas buscan la vacuna contra la gripe que la de covid, pero aun así, solo el 47% de los adultos se vacunó durante la temporada pasada.

Los CDC recomiendan que prácticamente todas las personas de 6 meses en adelante se vacunen contra la gripe cada año. Este año no hay cambios. Las vacunas estarán ampliamente disponibles en farmacias y consultorios médicos, y los planes de salud las cubrirán sin costo para el paciente.

El Departamento de Salud y Servicios Humanos (HHS) anunció en julio que las vacunas contra la gripe no deben contener timerosal, un conservante que evita el crecimiento de bacterias en las vacunas.

Según investigadores especializados en el tema, no hay pruebas de que este aditivo, que contiene mercurio y se ha utilizado durante décadas, sea dañino. El año pasado, los CDC estimaron que solo el 6% de las vacunas contra la gripe contenía timerosal.

VACUNA CONTRA EL VRS

Esta vacuna protege contra el virus respiratorio sincitial (VRS), un virus estacional altamente contagioso que afecta los pulmones y las vías respiratorias. Aunque los síntomas suelen ser leves, el VRS puede causar infecciones pulmonares graves, especialmente en personas mayores.

Se aprobó una vacuna en 2023. Los CDC la recomiendan para todas las personas de 75 años o más, y para quienes tienen entre 50 y 74 años con afecciones médicas que las expongan a un mayor riesgo de desarrollar una forma grave de la enfermedad.

Las personas que cumplan con estos criterios deberían poder vacunarse en su farmacia, explicó Fish.

La vacuna contra el VRS no es anual. Según la normativa vigente, si ya la recibiste, no necesitas volver a vacunarte.

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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Following several confusing months this summer when federal officials announced and then retreated from changes to covid vaccine recommendations, the Centers for Disease Control and Prevention on Oct. 6 announced updated fall immunization schedules that are not that different from last year’s. That should clear the way for most people who want shots this fall to get them, public health experts say.

“From a patient’s experience, there shouldn’t be anything different from what they’ve experienced in the past, except maybe they’ll get a little more information from the pharmacist,” said Hannah Fish, senior director of strategic initiatives at the National Community Pharmacists Association.

Here’s what you need to know:

Covid Vaccine

This fall, the covid vaccine is recommended for everyone 6 months or older, with one caveat. People need to have a conversation with their provider first, a model called “shared clinical decision-making.” Providers can be doctors, pharmacists, or the health professionals giving the shots. For people younger than 65, the CDC’s Advisory Committee on Immunization Practices emphasized that vaccination is generally more beneficial for those who are at higher risk for severe covid.

Although the shots are recommended for the same age range as last year, there are a few possible wrinkles. Even though the CDC’s approval is broad and means that health plans have to cover the shot without charging consumers for it, some providers may balk at giving the vaccine to people under 65 unless they have an underlying condition that puts them at risk for severe covid if they get infected. That’s what the Food and Drug Administration’s label for the covid vaccine advises.

“It’s a nuance that could occur in an interaction between a provider and a patient,” said Jen Kates, a senior vice president and the director of global and public health policy at KFF, a health information nonprofit that includes KFF Health News.

However, if a provider refused to administer the shot to a healthy person because doing so would be “off-label,” another provider would probably be willing to give someone the jab, experts said.

“They could go to a different pharmacy,” Kates said.

Many states have stepped in to ensure that people can get vaccines if they want them, according to a KFF analysis. Twenty-one states and the District of Columbia have adopted recommendations that are broader than those of the federal government, Kates said.

However, the percentage of people opting to get the covid vaccine continues to drop. At the end of April, 23% of adults said they had received the current vaccine, according to the CDC.

With uptake so low, fewer pharmacies and doctors may choose to stock the shot this year, said Jeff Levin-Scherz, a primary care doctor who is the population health leader for the management consultancy WTW and an assistant professor at Harvard’s Chan School of Public Health.

Large chains, including CVS and Walgreens, say they have enough supply available to meet demand.

The additional hoops people might have to go through — such as having to find a different pharmacy or physician — could have an impact on uptake of the covid shot, though.

“To get more people to get vaccines, the key is making vaccination really easy and to take steps out,” Levin-Scherz said.

Influenza Vaccine

More people seek out the flu vaccine than the covid vaccine, but even so, only 47% of adults got a shot last flu season.

The CDC recommends that virtually everyone 6 months or older get a flu shot annually. This year is no different. The shots should be widely available at pharmacies and physician offices, and health plans will cover the shots without charging people for them.

The federal Department of Health and Human Services announced in July that flu vaccines must not contain thimerosal, a preservative that prevents bacterial growth in vaccines. There is no evidence that the mercury-based additive, which has been used for decades, is harmful, according to vaccine researchers. Last year, the CDC estimated that only 6% of flu vaccines use thimerosal as a preservative.

RSV Vaccine

This vaccine protects against respiratory syncytial virus, a highly contagious seasonal virus that infects the lungs and respiratory tract. Although symptoms are typically mild, RSV can lead to serious lung infections, particularly in older people.

A vaccine was approved in 2023. The CDC recommends it for everyone 75 or older and for people 50 to 74 who have medical conditions that put them at risk for severe disease.

People who meet the criteria should be able to get the RSV vaccine at their local pharmacy, Fish said.

The RSV vaccine is not an annual vaccine. If you’ve already received it, you don’t need to get it again, according to current guidelines.

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 two hospitals that treated Cochran-Zipp at the time determined that she qualified for 100% financial assistance, since her income as a college student was extremely low. Not having to worry about the roughly $100,000 in bills she racked up for her care was an enormous relief, she said.

Then she started receiving unexpected bills from doctors who worked at the hospitals but, because they weren’t on staff there, didn’t have to abide by the facilities’ financial assistance policies.

Those bills, which came from specialists in emergency medicine, anesthesiology, and radiology who treated her, totaled more than $5,000. Although it was a fraction of the total cost of her care, to Cochran-Zipp it was an enormous amount. She went on payment plans and used scholarship and covid stimulus money to help cover the bills.

Cochran-Zipp, now 25 and working at a community health center, is applying to medical schools and hopes to enroll next fall. Her experience as a patient has shaped how she thinks about becoming a doctor.

“I don’t think that I could be a provider that, in good conscience, charges patients money in addition to the hospital fees,” she said.

Hospital financial assistance programs are commonplace, and many patients rely on them. Most offer varying amounts of financial help to uninsured and lower-income people. Eligibility is typically based on a sliding income scale. Some hospitals apply other tests, such as residency.

But even if people qualify for assistance, they may not get discounts. That’s because many physicians working at but not for a hospital aren’t bound by its financial assistance policies. Hospitals themselves might limit the types of services eligible for discounted or “charity care,” as it’s sometimes called.

“It’s a hole in the system,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that helps patients with serious illnesses cover their medical bills. Case managers who work with patients report that they’ve seen these problems repeatedly, Donovan said.

In the coming years, more patients will encounter difficulties as demand for financial assistance grows. More than 14 million people are projected to lose health insurance over the next decade, primarily because of changes to the federal Medicaid program and state insurance marketplaces in recently passed tax and spending legislation championed by the Trump administration. Some of these people will likely qualify for discounted care.

Nonprofit hospitals do not pay taxes on the money they make, but to maintain that tax-exempt status, they are required to have policies to help patients pay for emergency and other medically necessary care. For-profit hospitals are not required to offer financial assistance to needy patients, but many do.

However, physicians and other providers who work in a hospital as independent contractors rather than as employees are often not subject to a hospital’s financial assistance policy. According to an analysis by the Lown Institute, a health care think tank, physician services in the emergency, radiology, anesthesia, and pathology specialties are commonly excluded from hospital charity care.

For example, at Hartford HealthCare, a large nonprofit health system serving Connecticut, Massachusetts, and Rhode Island, services performed by physicians, nurse practitioners, and physician assistants employed by HHC, including emergency department physicians at four of its hospitals, are covered by its financial assistance policy. But treatment by emergency physicians at three HHC hospitals is not covered by the financial assistance policy, since they are not employees. Care by doctors working in radiology, pathology, and anesthesia isn’t covered by the financial assistance policy at any HHC facility.

Hartford HealthCare declined to comment on the record for this article.

Health system researchers have identified another potential barrier to patients’ receiving help from hospital financial assistance policies. IRS rules require that nonprofit hospitals include emergency and medically necessary care in their charity care policies, but they give hospitals substantial leeway to define what “medically necessary” care means.

Historically, excluded care has been limited to services that insurance doesn’t typically cover, like cosmetic surgery or experimental treatment. But in recent years, hospitals appear to be defining medically necessary care more narrowly, eliminating financial assistance for care that is needed but not urgently required. Care that might fall into this category could be a kidney stone removal, a cancer biopsy, or a cardiac valve replacement, according to a study published this year in The New England Journal of Medicine.

Although the study of 209 nonprofit hospitals with more than 200 beds found only isolated examples of hospitals — about 6% of them — that substantially excluded medically necessary care, researchers are concerned that it could be the leading edge of a larger trend, said Mark Hall, a professor of law and public health at Wake Forest University, who co-authored the study.

“There’s not really much in the way of regulatory guidance in what should be in or out” of a financial assistance policy, said Christopher Goodman, a clinical assistant professor at the University of South Carolina School of Medicine, who has published several studies examining hospital financial assistance policies.

The American Hospital Association declined to comment for this article. American Medical Association spokesperson Robert Mills said that the AMA doesn’t have a position on whether all contracted physicians should be required to participate in hospital financial assistance policies.

For-profit hospitals have more latitude to fashion their financial assistance policies as they wish.

At HCA Healthcare, one of the country’s largest for-profit health care systems, with nearly 200 hospitals in 20 states and the United Kingdom, discounted or free care is available only for “emergent or non-elective services.”

“Facility charity policies and uninsured discounts are typically specific to emergency services” at HCA Healthcare, said Harlow Sumerford, an HCA Healthcare spokesperson. “Any third-party providers are independent and would have their own financial policies.”

In recent years, several states have passed medical debt protection laws. A few apply to some doctors and other health care providers who practice at health care facilities and bill patients separately for their care.

Colorado’s is the most expansive. Under its Hospital Discounted Care law that took effect in September 2022, covered hospitals have to screen all uninsured people and others who request it for eligibility for Medicaid and other health programs, and provide discounted care to people whose income is up to 250% of the federal poverty level (about $80,000 for a family of four). There are limits on how much qualifying patients can be billed each month and, after three years, their debt is retired.

Under the Colorado law, licensed health care professionals who work at a covered hospital can charge qualified patients no more than the rates set by the state.

“This rule has been a game changer for folks in Colorado,” said Melissa Duncan, consumer assistance program manager at the Colorado Consumer Health Initiative, which helps patients access health care and cover their bills.

Unfortunately, the law didn’t pass in time to help Cochran-Zipp.

As hospitals grapple with the changes expected under the federal health care legislation passed this summer, discounted care programs may make a tempting target, say some health care financing experts. Facing higher rates of uncompensated care and trouble collecting payments from patients, facilities may reduce the financial assistance that they offer.

Hospitals may say “we are going to do all we can to protect our spending,” said Ge Bai, a professor of accounting and health policy and management at Johns Hopkins University. “In that environment, charity care will be a burden.”

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Health and Human Services Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist, has upended the way covid vaccines are approved and for whom they’re recommended, creating uncertainty where coverage was routine.

Agencies within HHS responsible for spelling out who should get vaccinated aren’t necessarily in sync, issuing seemingly contradictory recommendations based on age or risk factors for serious disease.

But the ambiguity may not affect your coverage, at least this year.

“I think in 2025 it’s highly likely that the employer plans will cover” the covid vaccines, said Jeff Levin-Scherz, a primary care doctor who is the population health leader for the management consultancy WTW and an assistant professor at Harvard’s T.H. Chan School of Public Health. They’ve already budgeted for it, “and it would be a large administrative effort to try to exclude coverage for those not at increased risk,” he said.

With so much in flux, it’s important to check with your employer or insurer about coverage policies before you roll up your sleeve.

Here’s what we know so far, and what remains unclear.

Q: How have the recommendations changed?

What used to be straightforward is now much murkier. Last year, the Moderna and Pfizer-BioNTech covid vaccines were recommended for anyone at least 6 months old.

This year, the recommendation by the Centers for Disease Control and Prevention is narrower. Although the vaccines are broadly recommended for adults 19 and older, they are no longer recommended for healthy pregnant people or for healthy children 6 months through 17 years old.

Kennedy announced the changes in a video in May, citing safety risks for young people and pregnant people as justification.

But his claims have been widely disputed by experts in vaccines, pediatrics, and women’s health. An analysis by FactCheck.org found that the secretary “misrepresented scientific research to make unfounded claims about vaccine safety for pregnant people and children.”

In addition, recently announced changes to the vaccine approval framework have further chipped away at eligibility.

Moderna announced July 10 that the FDA had fully approved its Spikevax covid vaccine — but approval is restricted to adults 65 and older, and for people from 6 months through 64 years old who are at increased risk of developing a serious case of covid.

Two other covid vaccines expected to be available this fall, Novavax’s Nuvaxovid and Moderna’s mNexspike, are also restricted. They are approved for people 65 or older and those 12 to 64 who have underlying health conditions that put them at higher risk of developing severe covid.

Notably, Pfizer’s Comirnaty covid vaccine is still approved or authorized for people 6 months of age and older without any restrictions based on risk factors for covid — at least for now. But the FDA could change that at any time, experts said.

Increasing restrictions “is definitely the direction they are moving,” said Jen Kates, a senior vice president at KFF who authored a KFF analysis of vaccine insurance coverage rules. KFF is a health information nonprofit that includes KFF Health News.

HHS did not provide an on-the-record comment for this article.

Q: How might these changes alter my insurance coverage for the vaccine?

That’s the big question, and the answer is uncertain. Without insurance coverage, people could owe hundreds of dollars for the shot.

Most private health plans are required by law to cover recommended vaccines, whether for covid, measles, or the flu, without charging their members. But that requirement kicks in after the shots are recommended by a federal panel — the Advisory Committee on Immunization Practices — and adopted by the CDC director, according to the KFF analysis. The committee hasn’t yet voted on covid vaccine recommendations for this fall. Its next meeting is expected to occur in August or September.

Still, employers and insurers can opt to cover the vaccines on their own, as many did before the law required them to do so. But they may require people to pay something for it.

In addition, the narrower recommendations from different HHS agencies might result in some health plans declining to pay for certain categories of people to get certain vaccines, experts said.

“I don’t think an employer or insurer would deny coverage,” Kates said. “But they could say: You have to get this product.”

That could mean a 45-year-old with no underlying health conditions raising their covid risk might have to get the Pfizer shot rather than the Moderna version if they want their health plan to pay for it, experts said.

In addition, up to 200 million people may qualify for the vaccines because they have health conditions such as asthma or diabetes that increase their risk of severe disease, according to a commentary published by FDA officials in the New England Journal of Medicine.

Health care professionals can help people determine whether they qualify for the shot based on health conditions.

Tina Stow, a spokesperson for AHIP, which represents health plans, said in a statement that plans will continue to follow federal requirements for vaccine coverage.

Q: What are the options for people who are pregnant or have children they want to have vaccinated?

Many parents are confused about getting their kids vaccinated, according to a KFF poll released on Aug. 1. About half said they don’t know whether federal agencies recommend healthy children get the vaccine this fall. Among the other half, more said the vaccine is not recommended than recommended.

Meanwhile, Kennedy’s recommendation that healthy children not get vaccinated has a notable caveat: If a parent wishes a child to get a covid vaccine and a health care provider recommends it, the child can receive it under the “shared clinical decision-making” model, and it should be covered without cost sharing.

Some policy experts point out that this is the way care for kids is typically provided anyway.

“Outside of any requirements, vaccines have always been provided through shared decision-making,” said Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America.

There’s no similar allowance for pregnant people. However, even though Kennedy has stated that covid vaccines are no longer recommended for healthy pregnant people, pregnancy is one of the underlying medical conditions that put people at high risk for getting very sick from covid, according to the CDC. That could make pregnant people eligible for the shot.

Depending on the stage of someone’s pregnancy, it could be difficult to know whether someone should be denied the shot based on their condition. “This is uncharted territory,” said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms.

Q: How will these changes affect access to the vaccine? Will I still be able to go to the pharmacy for the shot?

“If far fewer are expected to be vaccinated, fewer sites will offer the vaccinations,” Levin-Scherz said. This could be an especially notable hurdle for people looking for pediatric doses of a covid vaccine, he said.

In addition, pharmacists’ authority to administer vaccines depends on several factors. For example, in some states they can administer shots that have been approved by the FDA, while in others the shots must have been recommended by the ACIP, said Hannah Fish, senior director of strategic initiatives at the National Community Pharmacists Association. Since ACIP hasn’t yet recommended covid shots for the fall, that could create a speed bump in some states.

“Depending on the rules, you still may be able to get the shot at the pharmacy, but they might have to call the physician to send over a prescription,” Fish said.

Q: What do these changes mean long-term?

It’s impossible to know. But given Kennedy’s vocal skepticism of vaccines and his embrace of long-disproven theories about connections between vaccines and autism, among other things, medical and public health professionals are concerned those views will shape future policies.

“The recommendation changes that were made with respect to children and pregnant women were not necessarily made in good science,” Corlette said.

It’s already a challenge to convince people they need annual covid shots, and shifting guidelines may make it tougher, some public health experts warn.

“What’s concerning is that this could even further depress the uptake of the covid vaccines,” Jezek said.

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El secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., un veterano activista antivacunas, ha modificado radicalmente la forma en que se aprueban estas vacunas, y para quiénes se recomiendan, creando incertidumbre cuando la cobertura era rutinaria.

Las agencias dentro del Departamento de Salud y Servicios Sociales (HHS)  responsables de especificar quién debe vacunarse no están necesariamente sincronizadas, emitiendo recomendaciones en apariencia contradictorias basadas en la edad o los factores de riesgo de enfermedades graves.

Pero la ambigüedad podría no afectar tu cobertura, al menos este año.

“Creo que en 2025 es muy probable que los planes de las empresas cubran las vacunas contra covid-19”, afirmó Jeff Levin-Scherz, médico de atención primaria, líder de salud poblacional de la consultora de gestión WTW y profesor adjunto de la Escuela de Salud Pública T.H. Chan de la Universidad de Harvard.

Ya lo han presupuestado, “y sería un gran esfuerzo administrativo intentar excluir la cobertura para quienes no tienen mayor riesgo”, dijo.

Con tantos cambios, es importante consultar con tu empleador o aseguradora sobre las políticas de cobertura antes de arremangarte la camisa.

Esto es lo que sabemos hasta ahora y lo que aún no está claro.

¿Cómo han cambiado las recomendaciones?

Lo que antes era sencillo ahora es mucho más confuso. El año pasado, las vacunas contra covid de Moderna y Pfizer-BioNTech se recomendaron para cualquier persona a partir de los 6 meses de edad.

Este año, la recomendación de los Centros para el Control y Prevención de Enfermedades (CDC) es más restringida. Aunque las vacunas se recomiendan ampliamente para adultos mayores de 19 años, ya no para embarazadas sanas ni para niños y adolescentes sanos de 6 meses a 17 años.

Kennedy anunció los cambios en un video en mayo, citando como justificación los riesgos de seguridad para los jóvenes y las embarazadas.

Sin embargo, sus afirmaciones han sido ampliamente cuestionadas por expertos en vacunas, pediatría y salud femenina. Un análisis de FactCheck.org reveló que el secretario “tergiversó la investigación científica para hacer afirmaciones infundadas sobre la seguridad de las vacunas para embarazadas y niños”.

Además, los cambios anunciados recientemente en el marco de aprobación de vacunas han reducido aún más la elegibilidad.

Moderna anunció el 10 de julio que la Administración de Drogas y Alimentos (FDA) había aprobado completamente su vacuna contra covid Spikevax, pero la aprobación está restringida a adultos mayores de 65 años y a personas de entre 6 meses y 64 años que tienen un mayor riesgo de desarrollar un caso grave de covid.

Otras dos vacunas contra covid que se espera estén disponibles este otoño, Nuvaxovid de Novavax y mNexspike de Moderna, también tienen restricciones. Están aprobadas para personas mayores de 65 años y para aquellas de entre 12 y 64 años que tienen afecciones subyacentes que las aumentan el riesgo de desarrollar covid grave.

Por ahora,  la vacuna contra covid Comirnaty de Pfizer sigue aprobada o autorizada a partir de los 6 meses sin ninguna restricción basada en factores de riesgo para covid.

Sin embargo, la FDA podría cambiar esto en cualquier momento, según expertos. El aumento de las restricciones “es definitivamente la dirección en la que se están moviendo”, afirmó Jen Kates, vicepresidenta sénior de KFF, autora de un análisis sobre las normas de cobertura del seguro de vacunas.

El HHS no ofreció comentarios oficiales para este artículo.

¿Cómo podrían estos cambios afectar mi cobertura para la vacuna?

Esa es la gran pregunta, y la respuesta es incierta. Sin cobertura, las personas podrían deber cientos de dólares por la vacuna.

La mayoría de los planes de salud privados están obligados por ley a cubrir las vacunas recomendadas, ya sea para covid, el sarampión o la gripe, sin cobrarles a sus miembros. Sin embargo, según el análisis de KFF, este requisito entra en vigencia después que un panel federal —el Comité Asesor sobre Prácticas de Inmunización (ACIP)— recomiende las vacunas y las adopte el director de los CDC.

El comité aún no ha votado sobre las recomendaciones de la vacuna contra covid para este otoño. Se espera que su próxima reunión sea en agosto o septiembre. Aun así, los empleadores y las aseguradoras pueden optar por cubrir las vacunas por su cuenta, como muchos lo hacían antes de que la ley los obligara. Sin embargo, podrían exigir a las personas que pagaran algo de sus bolsillos.

Además, las recomendaciones más restrictivas de las diferentes agencias del HHS podrían resultar en que algunos planes de salud se nieguen a pagar a ciertas categorías de personas para que reciban ciertas vacunas, según expertos.

“No creo que un empleador o una aseguradora nieguen la cobertura”, dijo Kates. “Pero podrían decir: debes tener este producto”.

Eso podría significar que una persona de 45 años sin afecciones subyacentes que aumenten su riesgo de covid podría tener que recibir la vacuna de Pfizer en lugar de la de Moderna si quiere que su plan de salud la cubra, dicen expertos.

Además, hasta 200 millones de personas podrían calificar para las vacunas porque tienen afecciones como asma o diabetes que aumentan su riesgo de enfermedad grave, según un comentario publicado por funcionarios de la FDA en el New England Journal of Medicine.

Profesionales de atención médica pueden ayudar a las personas a determinar si califican para la vacuna según sus afecciones de salud.

Tina Stow, vocera del America’s Health Insurance Plans (AHIP), que representa a los planes de salud, declaró que los planes seguirán cumpliendo con los requisitos federales para la cobertura de la vacuna.

¿Cuáles son las opciones para las personas embarazadas o con hijos que quieran vacunar?

Según una encuesta de KFF publicada el 1 de agosto, muchos padres tienen dudas sobre la vacunación de sus hijos. Aproximadamente la mitad afirmó desconocer si las agencias federales recomiendan que los niños sanos se vacunen este otoño. Entre la otra mitad, la mayoría dijo que no se recomienda la vacuna.

Mientras tanto, la recomendación de Kennedy de no vacunar a los niños sanos tiene una salvedad importante: si un padre quiere que su hijo se vacune contra covid y un profesional de salud lo recomienda, el niño puede recibirla bajo el modelo de “toma de decisiones clínicas compartidas” y debería estar cubierta sin costos compartidos.

Algunos expertos en políticas señalan que, de todos modos, esta es la forma en que se suele brindar atención a los niños. “Más allá de cualquier requisito, las vacunas siempre se han proporcionado con decisiones compartida”, afirmó Amanda Jezek, vicepresidenta sénior de políticas públicas y relaciones gubernamentales de la Infectious Diseases Society of America.

No existe una asignación similar para las personas embarazadas. Sin embargo, aunque Kennedy ha declarado que las vacunas contra covid ya no se recomiendan para embarazadas sanas, el embarazo es una de las afecciones médicas subyacentes que aumentan el riesgo de enfermarse gravemente por covid, según los CDC. Esto podría hacer que las embarazadas sean elegibles para la vacuna.

Dependiendo de la etapa del embarazo, podría ser difícil saber si se debe negar la vacuna a alguien debido a su condición. “Esto es un territorio desconocido”, afirmó Sabrina Corlette, codirectora del Center on Health Insurance Reforms de la Universidad de Georgetown.

¿Cómo afectarán estos cambios el acceso a la vacuna? ¿Podré seguir yendo a la farmacia para vacunarme?

“Si se espera que se vacunen muchas menos personas, menos centros ofrecerán las vacunas”, afirmó Levin-Scherz. Esto podría ser un obstáculo especialmente importante para quienes buscan dosis pediátricas de la vacuna contra covid.

Además, la autoridad de los farmacéuticos para administrar vacunas depende de varios factores. Por ejemplo, en algunos estados pueden administrar vacunas aprobadas por la FDA, mientras que en otros deben haber sido recomendadas por el ACIP, explicó Hannah Fish, directora sénior de iniciativas estratégicas de la National Community Pharmacists Association. Dado que el ACIP aún no ha recomendado las vacunas contra covid para el otoño, esto podría suponer un obstáculo en algunos estados.

“Dependiendo de las normas, es posible que aún se pueda obtener la vacuna en una farmacia, pero es posible que tengan que llamar al médico para que envíe una receta”, explicó Fish.

¿Qué significan estos cambios a largo plazo?

Es imposible saberlo. Pero dado el escepticismo sonoro de Kennedy sobre las vacunas y su aceptación de teorías refutadas desde hace tiempo sobre la conexión entre las vacunas y el autismo, entre otras cosas, a los profesionales médicos y de salud pública les preocupa que estas opiniones influyan en las políticas futuras.

“Los cambios en las recomendaciones que se hicieron con respecto a los niños y las mujeres embarazadas no se basaron necesariamente en una buena base científica”, dijo Corlette.

Convencer a la gente de que necesita la vacuna contra covid anualmente ya es un desafío, y los cambios en las directrices podrían dificultarlo aún más, advierten algunos expertos en salud pública.

“Lo preocupante es que esto podría reducir aún más la vacunación contra covid”, dijo Jezek.

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The real estate lawyer, now 67, was eligible for Medicare at the time but hadn’t enrolled. Since she was still working, she thought her employer health insurance plan would cover her.

That misunderstanding has had financial repercussions that she continues to deal with today.

More than a year after her riding accident, Diamond was back at the emergency room after she tripped on a step while entering a New York restaurant. Her face covered in blood, Diamond was examined by staff, who did multiple CT scans. The bill for that care: $12,000.

This time, though, the insurance coverage wasn’t routine. Nearly all her claims were denied.

Diamond was caught in a fairly common coverage snag: People who have group health insurance when they become eligible for Medicare sometimes find themselves on the hook for their medical bills because their group plan stops paying.

Diamond contacted several people at UnitedHealthcare before she found out why the insurer refused to pay her claims.

When Diamond turned 65 in 2022, Medicare — unbeknownst to her — became the “primary payer” for her claims, meaning the federal health program for older or disabled people was supposed to take the lead in covering her medical bills, before other insurers paid anything. (As secondary payer, Diamond’s employer policy picked up 20% of what Medicare would have paid.)

Had she signed up for the government insurance plan when she turned 65, Diamond could have avoided a financially perilous situation that left her unexpectedly responsible for the medical costs she incurred during that time.

She began to understand what had happened as she made inquiries about the denied claims.

Diamond said she was told that UnitedHealthcare audited her claims last year and determined it had been improperly paying for her care, perhaps because her pricey medical claims after her fall from the horse raised a red flag.

The insurer not only stopped paying current claims but also moved to claw back tens of thousands of dollars it had paid to providers in the two years since she turned 65. Some of those providers are now seeking payment from her.

“It’s horrifying,” she said. “For about two months I was devastated. I thought, ‘Where am I going to get the money to pay all these people? There goes my retirement.’”

The mistake has already cost her $25,000 and may cost her much more if providers continue to bill her for amounts that UnitedHealthcare has clawed back for care she received before signing up for Medicare in February.

A UnitedHealthcare spokesperson declined to provide an on-the-record statement, citing safety concerns.

Patient advocates say they frequently hear from people who, like Diamond, thought they didn’t need to sign up for Medicare upon turning 65 because they had group health coverage.

That assumption is generally correct if they or their spouse is working at a company with at least 20 employees. In that case, employer coverage is considered primary and they can delay signing up for Medicare as long as they or their spouse continues to be employed there.

But if someone has employer coverage through a company with fewer than 20 workers, Medicare generally becomes the primary payer when they turn 65. The real estate law firm at which Diamond is a partner has a handful of employees.

Similarly, if someone is older than 65 and has retiree health coverage or has left their job and opted to continue their employer coverage under the Consolidated Omnibus Budget Reconciliation Act, also known as COBRA, Medicare pays first. The issue can also arise for people who are younger than 65 if they are eligible for Medicare because of a disability. In those instances, Medicare pays first if they or their family member works at a company with fewer than 100 employees.

If people in these groups don’t sign up for Medicare when they become eligible, they can find themselves responsible for all their medical bills for years. (They may also owe a penalty for late enrollment in the Medicare program.)

“It’s very alarming and there’s no current fix to the situation,” said Fred Riccardi, president of the New York-based Medicare Rights Center, a national patient advocacy organization.

The Centers for Medicare & Medicaid Services did not respond to a request for comment.

Mark Scherzer, a lawyer in Germantown, New York, who helps people with insurance problems, and who advised Diamond, said he gets calls a couple of times a month from people who face this issue.

“What I see constantly now is that insurers go back and they claw back the money from the doctor and the doctor then claws the money back from the patient,” he said.

Costly claims may trigger an insurer to examine someone’s coverage.

Those big claims “seem to get on the insurer’s radar,” said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center.

UnitedHealthcare has recouped over $50,000 in medical bills from some of the providers who treated Diamond in New York after her riding accident. She’s paid them about $25,000 so far. Some have agreed to let her pay the amount Medicare would have paid.

But there may be more bills to come. Under New York law, health plans have two years after claims are paid to claw back payments from providers, and providers have three years to sue patients for medical debt. So, while there is still time for Diamond to be billed, the clock will eventually run out.

Diamond plans to sue the broker who manages her company’s health plan and other benefits for negligence.

“The Medicare secondary payment rules basically say that if you didn’t sign up because you didn’t know Medicare was supposed to be primary, that’s on you,” said Melanie Lambert, senior Medicare advocate at the Center for Medicare Advocacy in Connecticut.

Lambert said she has seen the issue “many, many times.” In some instances, if a beneficiary can demonstrate they were misled by an employer or a federal employee, they may qualify for relief or a special enrollment period, she said.

In a 2023 letter to the acting secretary of the Department of Labor, the National Association of Insurance Commissioners advocated applying a “commonsense rule to COBRA plans, individual health insurance, and other coverage sources: those entitled to Medicare Part B but not enrolled in it should not lose benefits they pay for from a non-Medicare coverage source.”

The Department of Labor didn’t respond to a request for comment.

In earlier times, people started collecting Social Security benefits then automatically got Medicare when they turned 65.

Now, enrolling in Medicare is more complicated for many people, said Tricia Neuman, a senior vice president and the executive director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

“As more people are delaying going on Social Security and delaying going on Medicare, there’s more opportunities for people to make mistakes, and those mistakes are costly,” Neuman said.

Coverage experts say there are no clear requirements for insurers, employers, or the federal government to notify people about how the payment rules governing coordination of benefits between health plans may change when they become eligible for Medicare.

The information appears in a chart in the government’s “Medicare & You” handbook, if someone knows to look for it. But it is not easy to find.

A straightforward fix could solve many of the problems people face in this area, Scherzer said. Since every health plan knows its enrollees’ ages, why not require them to notify people approaching 65 of possible benefit coordination issues with Medicare? “It’s so simple and such a no-brainer.”

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But the area housing the regional office of the Department of Health and Human Services was eerily quiet.

In March, HHS announced it would close five of its 10 regional offices as part of a broad restructuring to consolidate the department’s work and reduce the number of staff by 20,000, to 62,000. The HHS Region 2 office in New York City, which has served New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands, was among those getting the ax.

Public health experts and advocates say that HHS regional offices, like the one in New York City, form the connective tissue between the federal government and many locally based services. Whether ensuring local social service programs like Head Start get their federal grants, investigating Medicare claims complaints, or facilitating hospital and health system provider enrollment in Medicare and Medicaid programs, regional offices provide a key federal access point for people and organizations. Consolidating regional offices could have serious consequences for the nation’s public health system, they warn.

“All public health is local,” said Georges Benjamin, executive director of the American Public Health Association. “When you have relative proximity to the folks you’re liaising to, they have a sense of the needs of those communities, and they have a sense of the political issues that are going on in these communities.”

The other offices slated to close are in Boston, Chicago, San Francisco, and Seattle. Together, the five serve 22 states and a handful of U.S. territories. Services for the shuttered regional offices will be divvied up among the remaining regional offices in Atlanta, Dallas, Denver, Kansas City, and Philadelphia.

The elimination of regional HHS offices has already had an outsize impact on Head Start, a long-standing federal program that provides free child care and supportive services to children from many of the nation’s poorest families. It is among the examples cited in the lawsuit against the federal government challenging the HHS restructuring brought by New York, 18 other states, and the District of Columbia, which notes that, as a result, “many programs are at imminent risk of being forced to pause or cease operations.”

The HHS site included a regional Head Start office that was closed and laid off staff last month. The Trump administration had sought to wipe out funding for Head Start, according to a draft budget document that outlines dramatic cuts at HHS, which Congress would need to approve. Recent news reports indicate the administration may be stepping back from this plan; however, other childhood and early-development programs could still be on the chopping block.

Bonnie Eggenburg, president of the New Jersey Head Start Association, said her organization has long relied on the HHS regional office to be “our boots on the ground for the federal government.” During challenging times, such as the covid-19 pandemic or Hurricanes Sandy and Maria, the regional office helped Head Start programs design services to meet the needs of children and families. “They work with us to make sure we have all the support we can get,” she said.

In recent weeks, payroll and other operational payments have been delayed, and employees have been asked to justify why they need the money as part of a new “Defend the Spend” initiative instituted by the Elon Musk-led Department of Government Efficiency, created by President Donald Trump through an executive order.

“Right now, most programs don’t have anyone to talk to and are unsure as to whether or not that notice of award is coming through as expected,” Eggenburg said.

HHS regional office employees who worked on Head Start helped providers fix technical issues, address budget questions, and discuss local issues, like the city’s growing population of migrant children, said Susan Stamler, executive director of United Neighborhood Houses. Based in New York City, the organization represents dozens of neighborhood settlement houses — community groups that provide services to local families such as language classes, housing assistance, and early-childhood support, including some Head Start programs.

“Today, the real problem is people weren’t given a human contact,” she said of the regional office closure. “They were given a website.”

To Stamler, closing the regional Head Start hub without a clear transition plan “demonstrates a lack of respect for the people who are running these programs and services,” while leaving families uncertain about their child care and other services.

“It’s astonishing to think that the federal government might be reexamining this investment that pays off so deeply with families and in their communities,” she said.

Without regional offices, HHS will be less informed about which health initiatives are needed locally, said Zach Hennessey, chief strategy officer of Public Health Solutions, a nonprofit provider of health services in New York City.

“Where it really matters is within HHS itself,” he said. “Those are the folks that are now blind — but their decisions will ultimately affect us.”

Dara Kass, an emergency physician who was the HHS Region 2 director under the Biden administration, described the job as being an ambassador.

“The office is really about ensuring that the community members and constituents had access to everything that was available to them from HHS,” Kass said.

At HHS Region 2, division offices for the Administration for Community Living, the FDA’s Office of Inspections and Investigations, and the Substance Abuse and Mental Health Services Administration have already closed or are slated to close, along with several other division offices.

HHS did not provide an on-the-record response to a request for comment but has maintained that shuttering regional offices will not hurt services.

Under the reorganization, many HHS agencies are either being eliminated or folded into other agencies, including the recently created Administration for a Healthy America, under HHS Secretary Robert F. Kennedy Jr.

“We aren’t just reducing bureaucratic sprawl. We are realigning the organization with its core mission and our new priorities in reversing the chronic disease epidemic,” Kennedy said in a press release announcing the reorganization.

Regional office staffers were laid off at the beginning of April. Now there appears to be a skeleton crew shutting down the offices. On a recent day, an Administration for Children and Families worker who answered a visitor’s buzz at the entrance estimated that only about 15 people remained. When asked what’s next, the employee shrugged.

The Trump administration’s downsizing effort will also eliminate six of 10 regional outposts of the HHS Office of the General Counsel, a squad of lawyers supporting the Centers for Medicare & Medicaid Services and other agencies in beneficiary coverage disputes and issues related to provider enrollment and participation in federal programs.

Unlike private health insurance companies, Medicare is a federal health program governed by statutes and regulations, said Andrew Tsui, a partner at Arnall Golden Gregory who has co-written about the regional office closings.

“When you have the largest federal health insurance program on the planet, to the extent there could be ambiguity or appeals or grievances,” Tsui said, “resolving them necessarily requires the expertise of federal lawyers, trained in federal law.”

Overall, the loss of the regional HHS offices is just one more blow to public health efforts at the state and local levels.

State health officials are confronting the “total disorganization of the federal transition” and cuts to key federal partners like the Centers for Disease Control and Prevention, CMS, and the FDA, said James McDonald, the New York state health commissioner.

“What I’m seeing is, right now, it’s not clear who our people ought to contact, what information we’re supposed to get,” he said. “We’re just not seeing the same partnership that we so relied on in the past.”

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“I don’t want to ever feel helpless,” said Clough, who had flown to Buffalo that evening on a work trip for his engineering job in Denver. After an incident several years earlier in which he was unsure how to help a woman who collapsed at his gym, he took a college course to get certified as an emergency medical responder, who can provide basic life support interventions.

The woman who collapsed was lucky: She lost consciousness in a public place where bystanders knew how to help her. Most people aren’t so fortunate. In the United States, a lack of training and readiness to deal with this relatively common medical emergency contributes to thousands of deaths a year.

More than 350,000 cardiac arrests occur outside of a hospital setting in the United States annually, according to the American Heart Association. In 9 of 10 cases, the person dies because help doesn’t arrive quickly enough. Every minute that passes without intervention reduces the odds of survival by 10%. But if someone immediately receives cardiopulmonary resuscitation and an AED shock, if needed, their survival odds can double or even triple.

Fewer than half of people get that immediate help, according to the heart association. A cardiac arrest occurs when the heart stops suddenly, often because the heart’s electrical system malfunctions. About 70% of cardiac arrests occur at home. But even if someone collapses in a public place and an ambulance is called immediately, it takes roughly eight minutes, on average, for emergency personnel to arrive. In rural areas it can take much longer.

When someone has a cardiac arrest, they often require an electric shock from an AED to get their heart started again. These portable devices analyze the heart’s rhythm and instruct the user to deliver a shock, if necessary, through pads placed on the victim’s chest.

But although many states require that AEDs be available in public places such as airports, malls, and schools, they often aren’t easy to spot. A study of data from 2019 to 2022 found that after a cardiac arrest in a public place, bystanders used an AED 7% of the time and performed CPR 42% of the time.

The most comprehensive resource for identifying AEDs is a nonprofit foundation called PulsePoint, which has registered 185,000 AEDs in 5,400 communities in the United States, according to Shannon Smith, vice president of communications at PulsePoint. If requested, the organization will help a community build its AED registry and connect it to the area’s 911 service free of charge.

PulsePoint recently launched a national AED registry to further this effort.

Through a companion app, users trained in CPR can volunteer to be alerted to potential cardiac arrests within roughly a quarter-mile when calls come into a community’s emergency response dispatch service. The app also identifies registered AEDs nearby.

“PulsePoint is the closest thing we have to a national registry,” said Elijah White, president of the acute care technology division at Zoll, a leading AED manufacturer. The company has provided location information for all its AEDs to PulsePoint. Still, PulsePoint has registered only a fraction of AEDs in the country. “It’s just a start,” White said.

Other factors may also keep bystanders from stepping in to help. They may lack CPR training or confidence, or fear liability if something goes wrong.

Liability shouldn’t be a concern, in general. All 50 states and Washington, D.C., have “good Samaritan” laws that protect bystanders from legal liability if they intervene in a medical emergency in good faith.

But training can be a serious barrier. One study found that only 18% of people reported that they’d received CPR training within the previous two years, a key time frame for skills maintenance. Two-thirds of people reported having been trained at some point.

One way to boost training is to make it mandatory, and many states require that students receive CPR training to graduate. But even though 86% of high school students reported having received some training, only 58% said they knew how to apply their skills, and a similar proportion said they knew how to use an AED.

“We’ve got some work to do,” said Dianne Atkins, a pediatric cardiologist and longtime AHA volunteer, who said ensuring high school training is a top priority for the AHA.

Other countries have prioritized training their residents in AED use and CPR for many years, with some success.

In Denmark, such training has been required to get a driver’s license since the 2000s, and middle schoolers are also required to be trained. And in a survey, 45% of the population reported having received training through their workplace. In the study, 81% of respondents in the general public reported having been trained in CPR and 54% in how to use an AED.

Norway has provided first-aid training in primary schools since 1961 and mandates CPR training to receive a driver’s license. Ninety percent of the population reported they are trained in CPR.

In the United States,  many training courses are available, online and in person, that take only a few hours to complete. For someone who’s never learned basic life-support skills, the training can be eye-opening. This previously untrained reporter was taken aback to discover how forcefully and rapidly someone must press on a mannequin’s chest to do CPR correctly: 100 to 120 compressions a minute to a depth of at least 2 inches.

The most important thing is for ordinary people to know the basics well enough that “they would feel confident to call 911 and push hard and fast on someone’s chest,” said Audrey Blewer, an assistant professor of family medicine and community health at Duke University School of Medicine who has published numerous studies on bystander CPR and AED use. “That doesn’t require a certification card and recent training.”

During an emergency, 911 dispatchers can also play a crucial role in walking people through doing CPR and operating an AED, said David Hiltz, volunteer program director of the HeartSafe Communities program at the Citizen CPR Foundation, a nonprofit that works to improve cardiac arrest survival through training and education.

Phil Clough has stayed in touch with Rebecca Sada, the woman who collapsed at the Buffalo airport that June day as she was coming home from a trip to visit her daughter. Sada, who had no history of heart trouble before her cardiac arrest, now has an automated defibrillator implanted in her chest to stabilize a previously undiagnosed electrical problem with her heart. She and her husband have had Clough over for dinner, and they are friends for life, she said.

One other change that occurred as a result of Sada’s cardiac arrest: She and her husband got certified in CPR and AED.

“Now, if we needed to help someone down the road, we’d be able to,” Sada 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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