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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“We’re going to take care of the sickest patients first,” Margo, a family medicine physician, said.

It’s not like there was space on that June afternoon anyway. A small monitor on the wall pulsed with the vitals of current patients, who filled the ER. An ambulance idled outside in the South Texas heat with a patient waiting for a bed to open up.

“Everybody shows up here,” Margo said. “When you’re overwhelmed and you’re overrun, there’s only so much you can do.”

Starr County, a largely rural, Hispanic community on the southern U.S. border, made headlines in 2024 when it voted Republican in a presidential election for the first time in more than a century. Immigration and the economy drove the flip in this community, where roughly a third of the population falls below the poverty line.

Now, recent actions by the Trump administration and the GOP-controlled Congress have triggered a new concern: the inability of doctors, hospitals, and other health providers to continue to care for uninsured patients. It’s a fear not only in Starr County, which has one of the highest uninsured rates in the nation. Communities across the U.S. with similarly high proportions of uninsured people could struggle as additional residents lose health coverage.

About 14 million fewer Americans are expected to have health insurance in a decade due to President Donald Trump’s new tax-and-spending law, which Republicans dubbed the One Big Beautiful Bill Act, and the pending expiration of enhanced subsidies that slashed the price of Affordable Care Act plans for millions of people. The new law also limits programs that send billions of dollars to help those who care for uninsured people stay afloat.

“You can’t disinsure this many people and not have, in many communities, just a collapse of the health care system,” said Sara Rosenbaum, founding chair of the Department of Health Policy and Management at George Washington University’s Milken Institute School of Public Health.

“The future is South Texas,” she said.

KFF Health News is examining the impact of national health care policy changes on uninsured people and their communities. Though the Trump administration told KFF Health News it is making “a historic investment in rural health care,” people who treat low-income patients, as well as researchers and consumer advocates, say recent policy decisions will make it harder for people to stay healthy. Doctors, hospitals, and clinics that make up the health care safety net could lose so much money they must close their doors, some of them warn.

“Because the patient’s bill is not going to get paid,” said Joseph Alpert, editor-in-chief of The American Journal of Medicine and a professor of medicine at the University of Arizona. “Uninsured patients stress the health care system.”

Starr County shows how this dynamic unfolds.

Primary care doctors in the county serve an average of just under 3,900 people each, nearly three times the U.S. average.

Margo, the family physician, said because so many people lack insurance and there are so few places to seek care, many residents treat the ER as their first stop when they’re sick.

In many cases, they have neglected their health, making them sicker and more expensive to treat. And federal law requires ERs at hospitals in the Medicare program to stabilize or transfer patients, regardless of their ability to pay.

That leaves Margo and his team to practice what he described as “disaster medicine.”

“They come in with chest pain or they stop breathing. They collapse. They’ve never seen a doctor,” Margo said. “They’re literally dying.”

Health Systems in ‘Survival Mode’

When people are uninsured or on Medicaid, they tend to rely on a safety net of doctors, hospitals, clinics, and community health centers, which offer services free of charge or absorb getting reimbursed at lower rates than they do treating patients on commercial insurance.

Those providers’ financial situations can often be precarious, leading them to rely on myriad federal supports. The Trump administration’s cuts to health care and Medicaid in the name of eliminating “waste, fraud, and abuse” have many concerned they won’t weather the additional financial strain.

Trump’s new law funds his priorities, like extending tax cuts that mainly benefit wealthier Americans and expanding immigration enforcement. Those costs are covered in part by a nearly $1 trillion reduction in federal health spending for Medicaid within the next decade and changes to the ACA, such as requiring additional paperwork and shortening the time for people to sign up.

Many Republicans have argued Medicaid has gotten too large and strayed from the state-federal program’s core mission of covering those with low incomes and disabilities. And the GOP has fought to roll back the ACA since its passage.

Kush Desai, a spokesperson for the White House, said projections from the nonpartisan Congressional Budget Office about how many people could lose health insurance are an “overestimate.” He did not provide an estimate the administration sees as more accurate.

Supporters of the “One Big Beautiful Bill” say those who need health coverage can still get it if they meet new requirements such as working in exchange for Medicaid coverage.

And Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, said even with the legislation, Medicaid spending will grow, just not as quickly.

The budget law won’t cause “the sky to fall,” Cannon said. “The inefficient providers should be shutting down.”

A recent survey from AMGA, formerly the American Medical Group Association, which represents health systems across the country, found nearly half of rural facilities could close or restructure due to Medicaid cuts. Nearly three-quarters of respondents said they anticipated layoffs or furloughs, including of front-line clinicians.

Public health departments, which often fill gaps in care, also face federal funding cuts that have reduced their capacity. In South Texas’ Cameron County, the health department has eliminated nearly a dozen positions, said agency head Esmer Guajardo. In neighboring Hidalgo County, the health department has laid off more than 30 people, said Ivan Melendez, who helps oversee its operations.

In July, the Texas Department of State Health Services canceled Operation Border Health, a massive annual event that last year provided free health services to nearly 6,000 South Texas residents.

Gateway Community Health Center in Laredo, a border city north of the Rio Grande Valley, is in “survival mode,” with about a third of patients already lacking insurance and even more who will struggle to afford health care if the ACA subsides aren’t renewed, said David Vasquez, its director of communications and public affairs. The center is looking for other forms of funding to avoid layoffs or cuts to services, and its expansion and hiring plans are on hold, Vasquez said.

That downsizing is happening as more people lose health insurance and need free or reduced-cost care.

Esther Rodriguez, 39, of McAllen has been out of work for two years and her husband makes $600 a week working in construction. Neither of them has health insurance.

Medicaid covered the bills for the births of her five children. Now, she depends on a mobile health clinic run by a local medical school, where she can pay out-of-pocket for routine checkups and drugs to control her Type 2 diabetes. If she needed more care, Rodriguez said, she would go to the ER.

“You have to adapt,” she said in Spanish.

‘Death by a Thousand Cuts’

People’s inability to pay results in uncompensated care, or services that hospitals, doctors, and clinics don’t get paid for, which, under an earlier version of the megabill, was projected to increase by $204 billion over the next decade, according to the Urban Institute, a nonprofit think tank.

But the Trump administration is also cutting other support that helped offset the cost of care for people who can’t pay. The new law caps federal programs that many health providers for low-income people have come to depend on, especially in rural areas, to shore up their budgets. These include taxes on hospitals, health plans, and other providers that states use to help fund their Medicaid programs. Such provider taxes are a “financial gimmick,” Desai said.

While the law creates a temporary $50 billion fund to support rural doctors and hospitals, that’s a little over a third of estimated Medicaid funding losses in rural areas, according to KFF, a health information nonprofit that includes KFF Health News. Desai called the analysis “flawed.”

Any loss in revenue could spell financial ruin, especially for small rural hospitals, said Quang Ngo, president of the Texas Organization of Rural & Community Hospitals Foundation.

“It’s kind of like death by a thousand cuts,” he said. “Some will probably not make it.”

And the hits could keep coming. The Trump administration’s budget request for the coming fiscal year calls for cuts to multiple rural health programs operated through the Health Resources and Services Administration. Desai said the spending law’s investment in rural health “dwarfs” the cuts.

In February, the Trump administration announced funding cuts of 90% to the ACA navigator program, which helps people find health insurance. That program has been “historically inefficient,” Desai said.

In December 2023, nearly 3 million of Texas’ uninsured were eligible for ACA subsidies, Medicaid, or the Children’s Health Insurance Program, according to Texas 2036, a public policy think tank.

Maria Salgado spends her workdays tabling at community events, dropping off flyers at doctors’ offices, and holding one-on-one meetings with clients of MHP Salud, a nonprofit that connects residents to Medicaid and ACA coverage.

She worried funding cuts would really set the organization’s efforts back: “A lot of community members here, they’re going to be left behind,” said Salgado, a community health worker, or promotora.

Chris Casso, a primary care physician who grew up in McAllen and now practices there, held back tears as she described treating patients who have put off seeing a doctor because of an inability to pay, only to have their preventable conditions deteriorate.

She worries about the future of her community as physician shortages worsen, potentially leaving few providers to treat uninsured people.

“It’s heartbreaking,” she said, sitting in a small back room in her office in a suburban strip mall, wedged between a Kohl’s and a Shoe Carnival. “These are hardworking people,” she said. “They try their best to take care of themselves.”

Casso said her own sister, who worked as a medical biller in a physician’s office, couldn’t afford health insurance. She delayed care and died at age 45 of complications from diabetes and heart disease. Casso worries the future will find more people in similar situations.

“Our population is going to suffer,” she said. “It’s going to be devastating.”

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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“Vamos a atender primero a los pacientes más graves”, dijo Margo, que es médica de familia.

De todas formas, esa tarde de junio no quedaba espacio disponible. Un pequeño monitor en la pared mostraba los signos vitales de los pacientes que ya llenaban la sala de emergencias. Y afuera, bajo el calor del sur de Texas, una ambulancia esperaba a que se liberara una cama para el paciente que había traído.

“Aquí viene todo el mundo”, dijo Margo. “Pero cuando estás abrumado y sobrepasado, hay un límite a lo que puedes hacer”.

El condado de Starr, una comunidad rural y mayoritariamente hispana en la frontera sur de Estados Unidos, fue noticia en 2024 al votar, por primera vez en más de un siglo, por un candidato republicano en una elección presidencial.

La inmigración y la economía fueron los temas que impulsaron el cambio político en esta comunidad, donde aproximadamente un tercio de la población vive bajo la línea de la pobreza.

Ahora, las medidas que adoptaron recientemente la administración Trump y el Congreso controlado por el Partido Republicano han despertado una nueva preocupación: la creciente dificultad para que médicos, hospitales y otros proveedores de salud puedan seguir atendiendo a personas sin seguro médico.

Este es un temor que va más allá del condado de Starr, una localidad que tiene una de las tasas más altas de población sin seguro del país. Comunidades de todo Estados Unidos que tienen números similares de personas sin seguro podrían verse en serios problemas a medida que más residentes pierden su cobertura médica.

Se calcula que, en 10 años, 14 millones de personas se quedarán sin seguro médico en Estados Unidos como consecuencia de la ley fiscal y de presupuesto del presidente Donald Trump, a la que los republicanos llaman One Big Beautiful Bill Act.

A esto se agrega la eliminación de los subsidios extraordinarios que redujeron el costo de los planes a partir de la Ley de Cuidado de Salud a Bajo Precio (ACA).

La nueva ley también limita programas que otorgan miles de millones de dólares a los hospitales y clínicas que atienden a personas sin seguro, lo que complica aún más su supervivencia.

“No se puede dejar sin cobertura a tanta gente sin que, en muchas comunidades, el sistema de salud colapse”, afirmó Sara Rosenbaum, presidenta y fundadora del Department of Health Policy and Management de la George Washington University’s Milken Institute School of Public Health.

“El futuro es el sur de Texas”, pronosticó.

KFF Health News está examinando el impacto de los cambios en la política nacional de salud en las personas sin seguro y sus comunidades.

Aunque la administración Trump respondió a KFF Health News que está haciendo “una inversión histórica en la atención médica rural”, quienes tratan a pacientes de bajos ingresos, así como investigadores y defensores de los consumidores, aseguran que las recientes decisiones políticas harán más difícil que las personas permanezcan saludables.

Algunos médicos, hospitales y clínicas que conforman la red de seguridad sanitaria han advertido que podrían perder tanto dinero que se verían obligados a cerrar.

“Porque la factura del paciente no se va a pagar”, dijo Joseph Alpert, editor en jefe de The American Journal of Medicine y profesor de Medicina en la Universidad de Arizona. “Los pacientes sin seguro saturan el sistema de salud”, añadió.

El condado de Starr es un ejemplo de esta situación.

Los médicos de atención primaria del condado reciben algo menos de 3.900 personas cada uno, casi tres veces el promedio nacional.

Margo, la médica de familia, explicó que como hay tantas personas sin seguro y son tan pocos los lugares donde los atienden, cuando se sienten mal muchas van directamente a la sala de emergencias.

Además, muchos de esos pacientes han descuidado su salud y por eso llegan más enfermos y necesitan tratamientos más costosos. La ley federal exige que las salas de emergencia de los hospitales que participan en Medicare atiendan o transfieran a los pacientes, sin tomar en cuenta si pueden pagar o no.

Esto obliga a Margo y a su equipo a practicar lo que describió como “medicina de desastre”.

“Llegan con dolor en el pecho o no pueden respirar. Se desmayan. Nunca han visto a un médico”, dijo. “Están literalmente muriendo”.

Sistemas de salud en “modo de supervivencia”

Cuando alguien no tiene seguro o depende de Medicaid, suele recurrir a una red de seguridad sanitaria: médicos, hospitales, clínicas y centros comunitarios que ofrecen servicios gratuitos o reciben reembolsos muy bajos si se los compara con los seguros comerciales.

Estas instituciones muchas veces funcionan con un financiamiento muy precario y dependen de innumerables ayudas federales. Los recortes impulsados por la administración Trump, con el argumento de eliminar el “desperdicio, fraude y abuso”, generaron dudas respecto de si estos proveedores podrán soportar todavía mayor presión financiera.

La nueva ley de Trump financia las prioridades del gobierno. Entre ellas están la ampliación de los recortes fiscales que benefician principalmente a los estadounidenses de mayores ingresos y el refuerzo de los controles a los inmigrantes.

Esos costos se cubren en parte con una reducción de casi $1.000 millones en el gasto federal en salud para Medicaid durante la próxima década. Y, también, con cambios en los mercados de seguros establecidos por ACA, como la exigencia de trámites adicionales y la reducción de los plazos para inscribirse.

Muchos republicanos argumentan que Medicaid ha crecido demasiado y se ha desviado de su misión original de cubrir a personas de bajos recursos y con discapacidades. El Partido Republicano ha tratado de revertir ACA desde que se aprobó.

Kush Desai, vocero de la Casa Blanca, dijo que las proyecciones sobre cuántas personas podrían perder el seguro médico de la no partidista Congressional Budget Office son “exageradas”. No ofreció una cifra que la administración considere más precisa.

Los que apoyan la One Big Beautiful Bill aseguran que quienes necesitan cobertura médica pueden obtenerla si cumplen con los nuevos requisitos, como trabajar para recibir Medicaid.

Michael Cannon, director de estudios de políticas de salud del Cato Institute, un centro de pensamiento libertario, sostuvo que incluso con esta ley el gasto en Medicaid seguirá creciendo, aunque más lentamente.

“Los proveedores ineficientes deberían cerrar”, dijo Cannon. “La ley no provocará un colapso”, aseguró.

Una encuesta reciente de la AMGA, una asociación que representa a los sistemas de salud de todo el país y antes era conocida como American Medical Group Association, reveló que casi la mitad de los centros de salud rurales podrían cerrar o reestructurarse por los recortes de Medicaid.

Casi tres cuartas partes de los encuestados afirmaron que preveían despidos o licencias, incluso de profesionales de salud de primera línea.

Los departamentos de salud pública, que a menudo cubren las carencias en la atención médica, también se enfrentan a recortes en el financiamiento federal que redujeron su capacidad operativa.

En el condado de Cameron, al sur de Texas, el Departamento de Salud ha eliminado casi una docena de puestos, según afirmó su directora, Esmer Guajardo.

En el condado vecino de Hidalgo han despedido a más de 30 empleados, según Iván Meléndez, que colabora en la supervisión de la administración.

En julio, el Departamento de Servicios de Salud de Texas canceló  Operation Border Health, un multitudinario evento anual que el año anterior había brindado servicios de salud gratuitos a casi 6.000 residentes en el sur de Texas.

El Gateway Community Health Center, un centro de salud comunitario de Laredo, una ciudad fronteriza al norte del Valle del Río Grande, está en “modo de supervivencia”, según David Vásquez, su director de comunicaciones.

Aproximadamente un tercio de sus pacientes ya no tienen seguro médico, y muchos más tendrán dificultades para pagar la atención sanitaria si no se renuevan las subvenciones de ACA.

El centro está buscando otras formas de financiamiento para evitar despidos o recortes en los servicios, y ha suspendido todos los planes de expansión y contratación, agregó Vásquez.

Este achicamiento ocurre justo cuando más personas pierden su seguro y necesitan atención médica gratuita o a bajo costo.

Esther Rodríguez, de 39 años, residente de McAllen, lleva dos años sin empleo y su esposo gana $600 por semana trabajando en la construcción. Ninguno de los dos tiene seguro médico.

Medicaid cubrió los gastos del parto de sus cinco hijos. Ahora depende de una clínica móvil gestionada por una facultad de medicina local, donde debe pagar de su bolsillo las revisiones rutinarias y los medicamentos para controlar su diabetes tipo 2. Si necesitara más atención, dijo Rodríguez, iría a una sala de emergencias.

“Hay que saber adaptarse”, dijo.

Muerte por mil recortes

Que muchas personas no estén en condiciones de pagar genera una atención médica no remunerada, es decir, servicios por los que los hospitales, los médicos y las clínicas no reciben ningún pago. Estaba previsto, según una versión anterior del megaproyecto de ley, que esto aumentara en $204.000 millones durante la próxima década. La estimación es del Urban Institute, un grupo de expertos sin fines de lucro.

Pero la administración Trump también está recortando otras formas de ayuda que contribuían a compensar el costo de la atención médica de las personas que no pueden pagarla.

La nueva ley impone límites a programas federales que muchos prestadores de salud para personas de bajos ingresos han utilizado para equilibrar sus presupuestos, especialmente en áreas rurales.

Entre ellos se incluyen los impuestos a los hospitales, los planes de salud y otros proveedores que los estados utilizan para ayudar a financiar sus programas de Medicaid. Estos impuestos a los proveedores son un “truco financiero”, afirmó Desai.

Si bien la ley crea un fondo temporario de $50.000 millones para apoyar a médicos y hospitales rurales, esa cifra representa poco más de un tercio de las pérdidas estimadas en fondos de Medicaid en estas zonas, según la organización sin fines de lucro KFF.

Desai calificó el análisis como “defectuoso”.

Cualquier pérdida de ingresos podría suponer la ruina financiera, especialmente para los pequeños hospitales rurales, afirmó Quang Ngo, presidente de la Texas Organization of Rural & Community Hospitals Foundation.

“Es como si te fueran matando de a poquito con tantos recortes”, dijo. “Algunos probablemente no lo resistan”.

Todo indica que los golpes podrían continuar. La propuesta presupuestaria de la administración Trump para el próximo año fiscal contempla recortes a múltiples programas de salud rural ejecutados por la Health Resources and Services Administration (HRSA).

Desai aseguró que la inversión de la nueva ley en salud rural “supera por mucho” esos recortes.

En febrero, la administración Trump anunció un recorte del 90% al programa de navegadores de ACA, que ayuda a las personas a encontrar seguro médico.

Desai afirmó que ese programa ha sido “históricamente ineficiente”.

En diciembre de 2023, en Texas, casi tres millones de personas sin seguro médico reunían los requisitos para recibir subsidios de ACA, Medicaid o el Programa de Seguro Médico Infantil (CHIP), según Texas 2036, un grupo de expertos en políticas públicas.

María Salgado es una trabajadora de salud comunitaria, o promotora de salud, que pasa sus días laborales en eventos comunitarios, repartiendo volantes en consultorios médicos y reuniéndose con personas para ayudarlas a inscribirse en Medicaid o en planes de ACA a través de MHP Salud, una organización sin fines de lucro.

Salgado tiene miedo de que los recortes de fondos realmente frenen los esfuerzos de la organización: “Muchos miembros de nuestra comunidad van a quedar rezagados”, dijo.

Chris Casso, una médica de atención primaria que creció y ahora ejerce en McAllen, contuvo las lágrimas mientras hablaba de los pacientes que habían dejado de ir al médico porque no lo podían pagar, y eso había hecho que sus enfermedades prevenibles se volvieran más graves.

A Casso le preocupa el futuro de su comunidad, ya que se acentúa la escasez de médicos y podrían quedar pocos profesionales de salud para tratar a quienes han quedado sin cobertura.

“Parte el alma”, dijo, sentada en un pequeño cuarto detrás de su consultorio, ubicado en un centro comercial suburbano, entre una tienda Kohl’s y una Shoe Carnival. “Son personas muy trabajadoras”, afirmó. “Hacen todo lo posible para cuidarse”.

Casso contó que su propia hermana, que trabajaba como facturadora médica en un consultorio, no tenía seguro. Postergó la atención y murió a los 45 años por complicaciones de la diabetes y una enfermedad cardíaca. Casso teme que ese sea el destino de muchas otras personas en el futuro.

“Nuestra comunidad la va a pasar mal”, aseguró. “Va a ser un desastre”.

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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Hasta este año.

El plan de la administración Trump de retirar más de $550 millones en fondos federales para salud pública y pandemias en Texas hizo que se cancelara el evento, justo antes de su inicio programado para el 21 de julio.

“Hay personas que vienen todos los años y dependen de este evento”, dijo Dairen Sarmiento Rangel, directora del Departamento de Salud y Servicios Humanos del condado de Hidalgo. “Algunas personas incluso acampan afuera de Operación Salud Fronteriza para ser las primeras en recibir servicios. Este evento es muy importante para nuestra comunidad”.

Los gobiernos estatales y locales ya han tenido que hacer dolorosos recortes a sus programas, luego de importantes reducciones en la financiación federal para salud que ya han entrado en vigor. Ahora, se preparan para enfrentar los golpes financieros que están por venir —algunos no ocurrirán hasta finales del próximo año o incluso después— como resultado de la ley fiscal y de gasto aprobada por los republicanos en el Congreso en julio, conocida como la One Big Beautiful Bill, que pone en marcha gran parte de la agenda nacional del presidente Donald Trump.

Texas, por ejemplo, anticipa una reducción de hasta $39.000 millones en fondos federales para Medicaid durante los próximos 10 años debido a nuevas barreras para la inscripción, como revisiones de elegibilidad más frecuentes, según un análisis publicado en julio por KFF.

En conjunto, estas reducciones representan un cambio radical en la forma en que se financian y se ofrecen los programas estatales de salud. En la práctica, la administración está trasladando una parte importante de los costos de salud a los estados. Esto obligará a sus líderes a tomar decisiones difíciles, ya que muchos presupuestos estatales ya están presionados por la disminución en la recaudación de impuestos, la desaceleración del gasto federal por covid y la incertidumbre económica.

Más de una docena de estados han bajado sus proyecciones de ingresos para el año próximo, según un informe publicado en junio por Pew.

“Es casi inevitable que los estados recorten varios servicios de salud debido a la presión fiscal”, dijo Wesley Tharpe, asesor principal en política fiscal estatal del Centro para Prioridades Presupuestarias y Políticas (CBPP), una organización de tendencia progresista.

Algunos estados tratan de suavizar el impacto de forma proactiva.

En Hawaii, los legisladores se han propuesto ayudar a organizaciones sin fines de lucro que ya enfrentan disminución en fondos federales. Repartirán $50 millones en subvenciones a organizaciones de salud, servicios sociales y otras que hayan sufrido recortes. Para acceder a los fondos, deben demostrar que su financiación fue eliminada, reducida o afectada por los recortes.

“No es justo que organizaciones dedicadas a ayudar al pueblo de Hawaii se vean obligadas a reducir sus servicios por los recortes federales”, declaró el gobernador demócrata Josh Green en un comunicado.

Otros estados recortan proyectos para enfrentar la situación.

El gobernador de Delaware, Matt Meyer, demócrata, supo en marzo que la administración Trump retiraría $38 millones en fondos de salud pública al estado. Como consecuencia, un mes después, los líderes legislativos estatales frenaron un proyecto para renovar y ampliar el complejo del Capitolio estatal.

“Reconocimos que los recortes federales irresponsables a la red de protección social de miles de habitantes de Delaware nos obligaban a ahorrar recursos para proteger a los más vulnerables”, dijo David Sokola, presidente temporal del Senado estatal.

En Nuevo México, el estado con el mayor porcentaje de residentes inscritos en Medicaid, un grupo bipartidista de legisladores votó a favor de crear un fondo fiduciario para reforzar el financiamiento del programa. Según algunas estimaciones, aproximadamente el 10% de los más de 800.000 residentes que están cubiertos por Medicaid y el Programa de Seguro Médico para Niños (CHIP, en inglés) podrían perder su cobertura bajo esta nueva ley federal.

Algunos líderes estatales advierten a sus comunidades que lo peor está por venir.

En un evento realizado el 18 de agosto en un hospital del sur del Bronx, en la ciudad de Nueva York, la gobernadora demócrata Kathy Hochul subió al escenario junto a trabajadores de salud para criticar la nueva ley de Trump.

“Lo que los republicanos en Washington han hecho con la ‘Ley Más Horrible’ que he visto es, literalmente, perjudicar a los neoyorquinos”, dijo. El sistema de salud del estado se prepara para enfrentar recortes cercanos a los $13.000 millones al año.

En California, los legisladores analizaron el impacto de los recortes en una audiencia del comité de la Asamblea General el 20 de agosto, donde algunos legisladores demócratas señalaron que programas estatales como los de salud reproductiva estaban en peligro.

“Nos hemos preparado para esta realidad: la llamada ‘Big Beautiful Bill’ del presidente Trump ahora es ley”, dijo el legislador demócrata Gregg Hart durante la audiencia, calificándola como “un ataque directo a los programas fundamentales de California y a nuestros valores”.

“Lamentablemente, la realidad es que el estado no tiene la capacidad para compensar todos estos recortes federales draconianos con el presupuesto actual”, agregó. “No podemos simplemente firmar un cheque y hacer que esto desaparezca”.

La radical ley presupuestaria, que fue aprobada sin apoyo demócrata, reducirá el gasto federal en Medicaid en aproximadamen $1.000 millones durante la próxima década, según estimaciones de la Oficina de Presupuesto del Congreso (CBO). Las reducciones en el gasto vienen en gran medida de la imposición de un requisito laboral para las personas que obtuvieron Medicaid con la expansión promovida por la Ley de Cuidado de Salud a Bajo Precio (ACA), además de otras nuevas barreras para acceder a la cobertura.

Según la CBO, más de 7,5 millones de personas perderán la cobertura de Medicaid y quedarán sin seguro, mientras se extienden recortes fiscales para personas ricas que, según los demócratas, no los necesitan.

Por su parte, los republicanos y el presidente Trump afirman que el paquete fiscal y los recortes en los programas son necesarios para evitar el fraude y el despilfarro, y para garantizar la sostenibilidad de Medicaid, un programa federal-estatal que brinda cobertura a personas con discapacidades y de bajos ingresos.

“La One Big Beautiful Bill elimina a los inmigrantes ilegales, aplica requisitos laborales y protege a Medicaid para los verdaderamente vulnerables”, anunció la Casa Blanca en un comunicado del 29 de junio.

Los recortes a Medicaid no comenzarán hasta después de las elecciones legislativas de mitad de mandato en noviembre de 2026, pero ya se han aplicado otros recortes.

La administración Trump ha intentado recuperar $11.000 millones en fondos federales de salud pública destinados a los estados durante la pandemia, lo que provocó una batalla legal con una coalición de estados gobernados por demócratas. También recortó unos $1.000 millones en subvenciones federales para servicios de salud mental en las escuelas y detuvo los fondos de los Institutos Nacionales de Salud (NIH) que financiaban a más de 90 universidades públicas.

Un análisis de KFF Health News demuestra que las cancelaciones han afectado a todo el país, sin importar la afiliación política o la ubicación geográfica. De las organizaciones que sufrieron recortes en el primer mes, aproximadamente el 40% se encuentran en estados que Trump ganó en noviembre.

La secretaria de prensa del Departamento de Salud y Servicios Humanos (HHS), Emily Hilliard, dijo que la agencia prioriza las inversiones que respalden el mandato de Trump de enfrentar las enfermedades crónicas. Defendió algunos de los recortes y afirmó, erróneamente, que la nueva ley no reduce Medicaid.

“La pandemia de covid-19 ya terminó, y el HHS no seguirá desperdiciando miles de millones de dólares de los contribuyentes en una crisis que los estadounidenses superaron hace años”, dijo.

Líderes estatales señalan que los fondos federales por la pandemia, que la administración busca recuperar, se habían destinado a otras medidas de salud pública, como la vigilancia de enfermedades emergentes, la respuesta ante brotes y la contratación de personal. En mayo, fiscales estatales ganaron una orden de restricción temporal contra la administración.

“Lo que estamos viendo ahora es que los estados anticipan grandes recortes a Medicaid, pero también enfrentan una serie de recortes federales más pequeños, pero significativos, en programas de salud pública”, dijo Larry Levitt, vicepresidente ejecutivo de políticas de salud en KFF. (KFF Health News es uno de los programas de KFF)

Parte del desafío para los estados es simplemente entender los cambios.

“Creo que es justo decir que hay preocupación, confusión e incertidumbre”, afirmó Kathryn Costanza, experta en Medicaid en la Conferencia Nacional de Legislaturas Estatales.

Los estados intentan entenderlo todo, creando grupos asesores para seguir los cambios federales, presentando demandas para intentar bloquear los recortes y reasignando fondos.

En Colorado, los legisladores aprobaron una ley que permite que fondos estatales de Medicaid se usen para servicios de salud —excluyendo abortos— en clínicas de Planned Parenthood of America, después de que la nueva ley de Trump prohibiera la financiación federal para este tipo de atención. Aún está por verse si esa prohibición se mantiene en los tribunales.

La legislatura de Louisiana asignó $7,5 millones a universidades estatales para compensar los recortes en financiación federal para la investigación, gran parte de ella relacionada con temas de salud.

Y en Dakota del Sur, el banco de alimentos más grande del estado pidió a los legisladores que destinen $3 millones para compensar recortes en fondos del Departamento de Agricultura de Estados Unidos.

Los estados deben equilibrar sus presupuestos cada año, por lo que los recortes ponen en riesgo muchos servicios si los legisladores no están dispuestos a aumentar impuestos. El trabajo comenzará en serio en enero, cuando muchos estados inicien sus nuevas sesiones legislativas.

Y es probable que las decisiones difíciles continúen. Los republicanos en la Cámara de Representantes del Congreso consideran nuevas leyes que podrían traer más recortes, como la reducción al generoso financiamiento federal que actualmente reciben 20 millones de adultos inscritos en Medicaid gracias a la expansión de ACA.

Como resultado, algunos estados revertirán sus expansiones de Medicaid y recortarán aún más programas de salud.

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Until this year. The Trump administration’s plan to strip more than $550 million in federal public health and pandemic funds from Texas helped prompt cancellation of the event just before its scheduled July 21 start.

“Some people come every year and rely on it,” said Hidalgo County Health and Human Services Director Dairen Sarmiento Rangel. “Some people even camp out outside of Border Health so they can be the first in line to receive services. This event is very important to our community.”

States and local governments have made painful program cuts in the wake of major reductions in federal health funding that have already taken effect. Now, they’re sizing up the financial hits to come — some not until late next year or beyond — from the “One Big Beautiful Bill Act,” the tax and spending law congressional Republicans passed in July that enacts much of President Donald Trump’s domestic agenda.

Texas, for instance, expects to see its federal Medicaid funds reduced by as much as $39 billion over 10 years due to new barriers for enrollment, such as more frequent eligibility checks, according to a July analysis by KFF.

Taken together, the reductions amount to a seismic shift in how state health programs are provided and paid for. The administration is, in effect, pushing a significant amount of health costs to states. That will force their leaders to make difficult choices, as many state budgets are already strained by declining tax revenues, a slowdown in federal pandemic spending, and economic uncertainty.

Revenue forecasters in more than a dozen states have lowered expectations for the coming year, according to a June report by Pew.

“It’s almost inevitable that states will enact a number of cuts to health services because of the fiscal pressure,” said Wesley Tharpe, senior adviser for state tax policy at the left-leaning Center on Budget and Policy Priorities.

Some are proactively trying to stanch the impact.

Hawaii lawmakers are looking to aid nonprofits that are already contending with federal funding cuts. They’re doling out $50 million in grants to health, social service, and other nonprofits hit by federal funding cuts. To get the money, nonprofits must show a termination or drop in funding, or that they have otherwise been harmed by the cuts.

“It is not fair that organizations dedicated to supporting the people of Hawaii are being forced to scale back due to federal funding cuts,” Democratic Gov. Josh Green said in a statement.

Other states are scaling back projects to contend with cuts. Delaware Gov. Matt Meyer, a Democrat, received notice in March that the Trump administration was cutting $38 million in public health funding from the state. The next month, state legislative leaders halted a planned project to upgrade and expand the Capitol complex as a result.

“We recognized that the reckless federal cuts to the social safety nets of thousands of Delawareans called for us to hold back resources to protect our most vulnerable,” said David Sokola, president pro tempore of the Delaware Senate.

In New Mexico, the state with the highest percentage of residents enrolled in Medicaid, a bipartisan group of lawmakers voted to create a trust fund to boost funding for the program. About 10% of the more than 800,000 state residents covered by Medicaid and the related Children’s Health Insurance Program could lose their health coverage under the federal spending law, based on some estimates.

Some state leaders are warning constituents that the worst may be yet to come.

At an Aug. 18 event at a hospital in the South Bronx section of New York City, New York Gov. Kathy Hochul, a Democrat, stood on stage among health care workers in white coats to skewer Trump’s new law.

“What Republicans in Washington have done through the ‘Big Ugliest Bill’ I’ve ever seen is literally screwing New Yorkers,” she said. The state’s health system is bracing for nearly $13 billion in annual cuts.

And in California, lawmakers weighed the impact of the coming cuts from the federal law at a general assembly committee hearing on Aug. 20, where some Democratic legislators said state efforts to protect reproductive health services and other programs were in jeopardy.

“We’ve been bracing for this reality: President Trump’s so-called ‘Big, Beautiful Bill’ is now law,” Democratic lawmaker Gregg Hart said at the hearing, calling it a “direct assault on California’s core programs and our values.”

“Sadly, the reality is, the state does not have the capacity to backfill all of these draconian federal funding cuts in the current budget,” Hart said. “We cannot simply write a check and make this go away.”

The sweeping budget law, which passed without any Democratic support, will reduce federal spending on Medicaid by about $1 trillion over the next decade, based on estimates from the Congressional Budget Office. The spending reductions largely come from the imposition of a work requirement on people who’ve obtained Medicaid under the Affordable Care Act’s expansion, as well as other new barriers to coverage.

The law will mean more than 7.5 million people will lose Medicaid coverage and become uninsured, according to the Congressional Budget Office, while extending tax cuts for wealthy people who, Democrats say, don’t need them. Republicans and Trump have said the spending package and its accompanying program cuts were necessary to prevent fraud and waste, and to sustain Medicaid, a state-federal program for people with disabilities and lower incomes.

“The One Big Beautiful Bill removes illegal aliens, enforces work requirements, and protects Medicaid for the truly vulnerable,” the White House said in a June 29 statement.

The Medicaid cuts won’t begin until after the midterm elections in November 2026, but other cuts have already hit.

The Trump administration has sought to claw back $11 billion in federal public health funds earmarked to states because of the pandemic, spurring a legal fight with a coalition of Democratic-led states. It also cut about $1 billion in federal grants for mental health services in schools, and halted grants from the National Institutes of Health that provided money to more than 90 public universities.

HHS press secretary Emily Hilliard said the agency is prioritizing investments that advance Trump’s mandate to confront chronic disease. She defended some of the cuts and said, erroneously, that the spending law doesn’t cut Medicaid.

“The covid-19 pandemic is over, and HHS will no longer waste billions of taxpayer dollars responding to a crisis that Americans moved on from years ago,” she said.

State leaders say the pandemic funding the administration wants returned was earmarked for other public health measures, such as tracking emerging diseases, outbreak responses, and staffing. State attorneys general in May won a temporary restraining order against the administration.

“What we’re seeing now is states anticipating big cuts in Medicaid coming, but they’re also dealing with a whole variety of federal cutbacks in public health programs that are smaller but still quite meaningful,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News.

Part of the challenge for states is simply understanding the changes.

“I think it’s fair to say there is concern, confusion, and uncertainty,” said Kathryn Costanza, a Medicaid expert at the National Conference of State Legislatures.

States are struggling to sort it all out, forming advisory groups that are tracking federal changes, suing to try to block the cuts, and reallocating funding.

In Colorado, lawmakers passed a bill to let state Medicaid dollars pay for non-abortion care at Planned Parenthood of America clinics after Trump’s law banned federal funding for such care. Whether the ban holds up in court remains to be seen.

The Louisiana Legislature sent $7.5 million to state universities to make up for cuts to federal research funding, much of which goes to health-related research.

And in South Dakota, the state’s largest food bank has asked lawmakers to spend $3 million to make up for funding cuts to the U.S. Department of Agriculture.

States must balance their budgets every year, so cuts put many services at risk if state lawmakers are unwilling to raise taxes. The work will begin in earnest in January, when many states begin new legislative sessions.

And the tough choices are likely to continue. Congressional House Republicans are considering legislation that could bring more cuts, including by slashing the generous cost sharing the federal government provides for 20 million adults who enrolled in Medicaid under the ACA’s Medicaid expansion.

Some states will roll back their Medicaid expansions and cut more health programs as a result.

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MIAMI — GOP lawmakers in the 10 states that refused the Affordable Care Act’s Medicaid expansion for over a decade have argued their conservative approach to growing government programs would pay off in the long run.

Instead, the Republican-passed budget law that includes many of President Donald Trump’s priorities will pose at least as big a burden on patients and hospitals in the expansion holdout states as in the 40 states that have extended Medicaid coverage to more low-income adults, hospital executives and other officials warn.

For instance, Georgia, with a population of just over 11 million, will see as many people lose insurance coverage sold through ACA marketplaces as will California, with more than triple the population, according to estimates by KFF, a health information nonprofit that includes KFF Health News.

The new law imposes additional paperwork requirements on Obamacare enrollees, slashes the time they have each year to sign up, and cuts funding for navigators who help them shop for plans. Those changes, all of which will erode enrollment, are expected to have far more impact in states like Florida and Texas than in California because a higher proportion of residents in non-expansion states are enrolled in ACA plans.

The budget law, which Republicans called the “One Big Beautiful Bill,” will cause sweeping changes to health care across the country as it trims federal spending on Medicaid by more than $1 trillion over the next decade. The program covers more than 71 million people with low incomes and disabilities. Ten million people will lose coverage over the next decade due to the law, according to the nonpartisan Congressional Budget Office.

Many of its provisions are focused on the 40 states that expanded Medicaid under the ACA, which added millions more low-income adults to the rolls. But the consequences are not confined to those states. A proposal from conservatives to cut more generous federal payments for people added to Medicaid by the ACA expansion didn’t make it into the law.

“Politicians in non-expansion states should be furious about that,” said Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank.

The number of people losing coverage could accelerate in non-expansion states if enhanced federal subsidies for Obamacare plans expire at the end of the year, driving up premiums as early as January and adding to the rolls of uninsured. KFF estimates as many as 2.2 million people could become uninsured just in Florida, a state where lawmakers refused to expand Medicaid and, partly as a result, now leads the nation in ACA enrollment.

For people like Francoise Cham of Miami, who has Obamacare coverage, the Republican policy changes could be life-altering.

Before she had insurance, the 62-year-old single mom said she would donate blood just to get her cholesterol checked. Once a year, she’d splurge for a wellness exam at Planned Parenthood. She expects to make about $28,000 this year and currently pays about $100 a month for an ACA plan to cover herself and her daughter, and even that strains her budget.

Cham choked up describing the “safety net” that health insurance has afforded her — and at the prospect of being unable to afford coverage if premiums spike at the end of the year.

“Obamacare has been my lifesaver,” she said.

If the enhanced ACA subsidies aren’t extended, “everyone will be hit hard,” said Cindy Mann, a health policy expert with Manatt Health, a consulting and legal firm, and a former deputy administrator for the Centers for Medicare & Medicaid Services.

“But a state that hasn’t expanded Medicaid will have marketplace people enrolling at lower income levels,” she said. “So, a greater share of residents are reliant on the marketplace.”

Though GOP lawmakers may try to cut Medicaid even more this year, for now the states that expanded Medicaid largely appear to have made a smart decision, while states that haven’t are facing similar financial pressures without any upside, said health policy experts and hospital industry observers.

KFF Health News reached out to the governors of the 10 states that have not fully expanded Medicaid to see if the budget legislation made them regret that decision or made them more open to expansion. Spokespeople for Republican Gov. Henry McMaster of South Carolina and Republican Gov. Brian Kemp of Georgia did not indicate whether their states are considering Medicaid expansion.

Brandon Charochak, a spokesperson for McMaster’s office, said South Carolina’s Medicaid program focuses on “low-income children and families and disabled individuals,” adding, “The state’s Medicaid program does not anticipate a large impact on the agency’s Medicaid population.”

Enrollment in ACA marketplace plans nationwide has more than doubled since 2020 to 24.3 million. If enhanced subsidies expire, premiums for Obamacare coverage would rise by more than 75% on average, according to an analysis by KFF. Some insurers are already signaling they plan to charge more.

The CBO estimates that allowing enhanced subsidies to expire will increase the number of people without health insurance by 4.2 million by 2034, compared with a permanent extension. That would come on top of the coverage losses caused by Trump’s budget law.

“That is problematic and scary for us,” said Eric Boley, president of the Wyoming Hospital Association.

He said his state, which did not expand Medicaid, has a relatively small population and hasn’t been the most attractive for insurance providers — few companies currently offer plans on the ACA exchange — and he worried any increase in the uninsured rate would “collapse the insurance market.”

As the uninsured rate rises in non-expansion states and the budget law’s Medicaid cuts loom, lawmakers say state funds will not backfill the loss of federal dollars, including in states that have refused to expand Medicaid.

Those states got slightly favorable treatment under the law, but it’s not enough, said Grace Hoge, press secretary for Kansas Gov. Laura Kelly, a Democrat who favors Medicaid expansion but who has been rebuffed by GOP state legislators.

“Kansans’ ability to access affordable healthcare will be harmed,” Hoge said in an email. “Kansas, nor our rural hospitals, will not be able to make up for these cuts.”

For hospital leaders in other states that have refused full Medicaid expansion, the budget law poses another test by limiting financing arrangements states leveraged to make higher Medicaid payments to doctors and hospitals.

Beginning in 2028, the law will reduce those payments by 10 percentage points each year until they are closer to what Medicare pays.

Richard Roberson, president of the Mississippi Hospital Association, said the state’s use of what’s called directed payments in 2023 helped raise its Medicaid reimbursements to hospitals and other health institutions from $500 million a year to $1.5 billion a year. He said higher rates helped Mississippi’s rural hospitals stay open.

“That payment program has just been a lifeline,” Roberson said.

The budget law includes a $50 billion fund intended to insulate rural hospitals and clinics from its changes to Medicaid and the ACA. But a KFF analysis found it would offset only about one-third of the cuts to Medicaid in rural areas.

Trump encouraged Florida, Tennessee, and Texas to continue refusing Medicaid expansion in his first term, when his administration gave them an unusual 10-year extension for financing programs known as uncompensated care pools, which generate billions of dollars to pay hospitals for treating the uninsured, said Allison Orris, director of Medicaid policy for the left-leaning think tank Center on Budget and Policy Priorities.

“Those were very clearly a decision from the first Trump administration to say, ‘You get a lot of money for an uncompensated care pool instead of expanding Medicaid,’” she said.

Those funds are not affected by Trump’s new tax-and-spending law. But they do not help patients the way insurance coverage would, Orris said. “This is paying hospitals, but it’s not giving people health care,” she said. “It’s not giving people prevention.”

States such as Florida, Georgia, and Mississippi have not only turned down the additional federal funding that Medicaid expansion brings, but most of the remaining non-expansion states spend less than the national average per Medicaid enrollee, provide fewer or less generous benefits, and cover fewer categories of low-income Americans.

Mary Mayhew, president of the Florida Hospital Association, said the state’s Medicaid program does not adequately cover children, older people, and people with disabilities because reimbursement rates are too low.

“Children don’t have timely access to dentists,” she said. “Expectant moms don’t have access nearby to an OB-GYN. We’ve had labor and delivery units close in Florida.”

She said the law will cost states more in the long run.

“The health care outcomes for the individuals we serve will deteriorate,” Mayhew said. “That’s going to lead to higher cost, more spending, more dependency on the emergency department.”

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Alexander tried signing up for Pathways, the state’s limited Medicaid expansion, multiple times and got denied each time, he said, even though he met the qualifying terms because he’s a full-time student.

Georgia is one of 10 states that haven’t expanded Medicaid health coverage to a broader pool of low-income adults. Instead, it offers coverage to those who can prove they’re working or completing 80 hours a month of other qualifying activities, like going to school or volunteering. And it is the only state currently doing so.

“Why is this marketing out here?” said the 20-year-old, who lives in Conyers, east of Atlanta. “It’s truly not accessible.”

Each denial used the same boilerplate language, Alexander said, and his calls to caseworkers were not returned. State offices couldn’t connect him with caseworkers assigned to him from the same state agency. And when he requested contact information for a supervisor to appeal his denial, he said, the number rang to a fax machine.

“It’s impenetrable,” Alexander said. “I’ve literally tried everything, and there’s no way.”

Millions of Americans trying to access Medicaid benefits could soon find themselves navigating similar byzantine state systems and work rules. Legislation signed into law by President Donald Trump on July 4 allocates $200 million to help states that expanded Medicaid create systems by the end of next year to verify whether some enrollees are meeting the requirements.

Conservative lawmakers have long argued that public benefits should go only to those actively working to get off of government assistance. But the nation’s only Medicaid work requirement program shows they can be costly for states to run, frustrating for enrollees to navigate, and disruptive to other public benefit systems. Georgia’s budget for marketing is nearly as much as it has spent on health benefits. Meanwhile, most enrollees under age 65 are already working or have a barrier that prevents them from doing so.

What Georgia shows is “just how costly setting up these administrative systems of red tape can be,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

Over the past two years, KFF Health News has documented the issues riddling Georgia’s Pathways program, launched in July 2023. More than 100,000 Georgians have applied to the program through March. Just over 8,000 were enrolled at the end of June, though about 300,000 would be eligible if the state fully expanded Medicaid under the terms of the Affordable Care Act.

The program has cost more than $100 million, with only $26 million spent on health benefits and more than $20 million allocated to marketing contracts, according to a KFF Health News analysis of state reports.

“That was truly a pretty shocking waste of taxpayer dollars,” Alker said.

The Government Accountability Office is investigating the costs of the program after a group of Democratic senators — including both members of the Georgia delegation — asked the government watchdog to look into the program. Findings are expected this fall.

A state report to the federal government from March said Georgia couldn’t effectively determine if applicants meet the qualifying activities criteria. The report also said the state hadn’t suspended anyone for failing to work, a key philosophical pillar of the program. Meanwhile, as of March, more than 5,000 people were waiting to have their eligibility verified for Pathways.

The Pathways program has strained Georgia’s eligibility system for other public benefits, such as food stamps and cash assistance.

In April, the state applied to the federal government to renew Pathways. In its application, officials scaled back key elements, such as the requirement that enrollees document work every month. Critics of the program also say the red tape doesn’t help enrollees find jobs.

“Georgia’s experience shows that administrative complexity is the primary outcome, not job readiness,” said Natalie Crawford, executive director of Georgia First, which advocates for fiscal responsibility and access to affordable health care.

Despite the struggles, Garrison Douglas, a spokesperson for Georgia’s Republican governor, Brian Kemp, defended the program. “Georgia Pathways is doing what it was designed to do: provide free healthcare coverage to low-income, able-bodied Georgians who are willing to engage in one of our many qualifying activities,” he said in an emailed statement.

New federal requirements in the tax and spending legislation mean that the 40 states (plus Washington, D.C.) that expanded Medicaid will need to prepare technology to process the documentation some Medicaid recipients will now have to regularly file.

The federal law includes exemptions for people with disabilities, in addiction treatment, or caring for kids under 14, among others.

The Trump administration said other states won’t face a bumpy rollout like Georgia’s.

“We are fully confident that technology already exists that could enable all parties involved to implement work and community engagement requirements,” said Mehmet Oz, head of the Centers for Medicare & Medicaid Services, in an emailed statement.

In a written public comment on Georgia’s application to extend the program, Yvonne Taylor of Austell detailed the difficulties she faced trying to enroll.

She said she tried to sign up several times but that her application was not accepted. “Not once, not twice,  but 3 times. With no response from customer service,” she wrote in February. “So now I am without coverage.”

Victoria Helmly of Marietta wrote in a January comment that she and her family members take care of their dad, but the state law doesn’t exempt caregivers of older adults.

“Georgia should recognize their sacrifices by supporting them with health insurance,” she wrote. “Let’s simplify this system and in the end, save money and lives.”

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So began the stress of trying to pay for tens of thousands of dollars in treatment — without health insurance.

“I’ve never been sick in my life, so I’ve never needed insurance before,” said Fry, a 54-year-old self-employed masonry contractor who restores old buildings in the rural Appalachian community he’s called home nearly all his life.

Making sure he had insurance was the last thing on his mind, until recently, Fry said. He had been rebuilding his life after a prison stay, maintaining his sobriety, restarting his business, and remarrying his wife. “Things got busy,” he said.

Now, with a household income of about $48,000, Fry and his wife earn too much to qualify for Georgia’s limited Medicaid expansion. And he said he found that the health plans sold on the state’s Affordable Care Act exchange were too expensive or the coverage too limited.

In late April, a friend launched a crowdfunding campaign to help Fry cover some of the costs. To save money, Fry said, he’s taking a less aggressive treatment route than his doctor recommended.

“There is no help for middle-class America,” he said.

More than 26 million Americans lacked health insurance in the first six months of 2024, according to the Centers for Disease Control and Prevention.

The uninsured are mostly low-income adults under age 65, and people of color, and most live in the South and West. The uninsured rate in the 10 states that, like Georgia, have not expanded Medicaid to nearly all low-income adults was 14.1% in 2023, compared with 7.6% in expansion states, according to KFF, a health information nonprofit that includes KFF Health News.

Health policy researchers expect the number of uninsured to swell as the second Trump administration and a GOP-controlled Congress try to enact policies that explicitly roll back health coverage for the first time since the advent of the modern U.S. health system in the early 20th century.

Under the “One Big Beautiful Bill Act” — budget legislation that would achieve some of President Donald Trump’s priorities, like extending tax cuts mainly benefiting the wealthy — some 10.9 million Americans would lose health insurance by 2034, according to estimates by the nonpartisan Congressional Budget Office based on a House version of the budget bill.

A Senate version of the bill could result in more people losing Medicaid coverage, with reductions in federal spending and rules that would make it harder for people to qualify. But that bill suffered a major blow June 26 when the Senate parliamentarian, a nonpartisan official who enforces the chamber’s rules, rejected several health provisions — including the proposal to gradually reduce provider taxes, a mechanism that nearly every state uses to increase its federal Medicaid funding.

The number could rise to 16 million if proposed rule changes to the ACA take effect and tax credits that help people pay for ACA plans expire at the end of the year, according to the CBO. In KFF poll results released in June, nearly two-thirds of people surveyed viewed the bill unfavorably and more than half said they were worried federal funding cuts would hurt their family’s ability to obtain and afford health care.

Like Fry, more people would be forced to pay for health expenses out-of-pocket, leading to delays in care, lost access to needed doctors and medications, and poorer physical and financial health.

“The effects could be catastrophic,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.

The House-passed bill would represent the largest reduction in federal support for Medicaid and health coverage in history, she said. If the Senate approves it, it would be the first time Congress moved to eliminate coverage for millions of people.

“This would take us back,” Tolbert said.

A Patchwork System

The United States is the only wealthy country where a substantial number of citizens lack health insurance, due to nearly a century of pushback against universal coverage from doctors, insurance companies, and elected officials.

“The complexity is everywhere throughout the system,” said Sherry Glied, dean of New York University’s Wagner School of Public Service, who worked in the George H.W. Bush, Clinton, and Obama administrations. “The big bug is that people fall between the cracks.”

This year, KFF Health News is speaking to Americans about the challenges they face in finding health insurance and the effects on their ability to get care; to providers who serve the uninsured; and to policy experts about why, even when the nation hit its lowest recorded uninsured rate in 2023, nearly a tenth of the U.S. population still lacked health coverage.

So far, the reporting has found that despite decades of policies designed to increase access to care, the very structure of the nation’s health insurance system creates the opposite effect.

Government-backed universal coverage has eluded U.S. policymakers for decades.

After lobbying from physician groups, President Franklin D. Roosevelt abandoned plans to include universal health coverage in the Social Security Act of 1935. Then, because of a wage and salary cap used to control inflation during World War II, more employers offered health insurance to lure workers. In 1954, health coverage was formally exempted from income tax requirements, which led more employers to offer the benefit as part of compensation packages.

Insurance coverage offered by employers came to form the foundation of the U.S. health system. But eventually, problems with linking health insurance to employment emerged.

“We realized, well, wait, not everybody is working,” said Heidi Allen, an associate professor at the Columbia School of Social Work who studies the impact of social policies on access to care. “Children aren’t working. People who are elderly are not working. People with disabilities are not working.”

Yet subsequent efforts to expand coverage to all Americans were met with backlash from unions who wanted health insurance as a bargaining chip, providers who didn’t want government oversight, and those who had coverage through their employers.

That led policymakers to add programs piecemeal to make health insurance accessible to more Americans.

There’s Medicare for older adults and Medicaid for people with low incomes and disabilities, both created in 1965; the Children’s Health Insurance Program, created in 1997; the ACA’s exchange plans and Medicaid expansion for people who can’t access job-based coverage, created in 2010.

As a result, the U.S. has a patchwork of health insurance programs with numerous interest groups vying for dollars, rather than a cohesive system, health policy researchers say.

Falling Through the Cracks

The lack of a cohesive system means that, even though Americans are eligible for health insurance, they struggle to access it, said Mark Shepard, an associate professor of public policy at the Harvard Kennedy School of Government. No central entity exists in the U.S. to ensure that all people have a plan, he said.

Over half of the uninsured might qualify for Medicaid or subsidies that can help cover the costs of an ACA plan, according to KFF. But many people aren’t aware of their options or can’t navigate overlapping programs — and even subsidized coverage can be unaffordable.

Those who have fallen through the cracks said it feels like the system has failed them.

Yorjeny Almonte of Allentown, Pennsylvania, earns about $2,600 a month as an inspector in a cabinet warehouse. When she started her job in December 2023, she didn’t want to spend nearly 10% of her income on health insurance.

But, last year, her uninsured mom chose to fly to the Dominican Republic to get care for a health concern. So Almonte, 23, who also needed to see a doctor, investigated her employer’s health offerings. By then she had missed the deadline to sign up.

“Now I have to wait another year,” she said.

In January, Camden, Alabama, resident Kiana George, who’s uninsured, landed in an intensive care unit months after she stopped seeing a nurse practitioner and taking blood pressure medications — an ordeal that saddled her with nearly $7,000 in medical bills.

George, 30, was kicked off Medicaid in 2023 after she got hired by an after-school program. It pays $800 a month, an income too high to qualify her for Medicaid in Alabama, which hasn’t expanded to cover most low-income adults. She also doesn’t make enough for a free or reduced-cost ACA plan.

George, who has a 9-year-old daughter, said she “has no idea” how she can repay the debt from the emergency room visit. And because she fears more bills, she has given up on treatment for ovarian cysts.

“It hurts, but I’m just gonna take my chances,” she said.

Widening the Gaps

Health insurance is fundamentally a financial product, intended to protect the policyholder’s pocketbook from accidents or illnesses.

Researchers have known for decades that a lack of insurance coverage leads to poor access to health care, said Tom Buchmueller, a health economist at the University of Michigan Ross School of Business.

“It’s only more recently we’ve had really good, strong evidence that shows that health insurance really does improve health outcomes,” Buchmueller said.

Research released this spring by the National Bureau of Economic Research found that expanding Medicaid reduced low-income adults’ chances of dying by 2.5%. In 2019, a separate study published by that nonpartisan think tank provided experimental evidence that health insurance coverage reduced mortality among middle-aged adults.

In late May, the House narrowly advanced the budget legislation that independent government analysts said would result in millions of Americans losing health insurance coverage and reduce federal spending on programs like Medicaid by billions of dollars.

A key provision would require some Medicaid enrollees to work, volunteer, or complete other qualifying activities for 80 hours a month, starting at the end of 2026. Most Medicaid enrollees already work or have some reason they can’t, such as a disability, according to KFF.

House Speaker Mike Johnson has defended the requirement as “moral.”

“If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system,” he told CBS News in the wake of the bill’s passage.

A Senate version of the bill also includes work requirements and more frequent eligibility checks for Medicaid recipients.

Fiscal conservatives argue a solution is needed to curb health care’s rising costs.

The U.S. spends about twice as much per capita on health care as other wealthy nations, and that spending would grow under the GOP’s budget bill, said Michael Cannon, director of health policy studies at the Cato Institute, a think tank that supports less government spending on health care.

But the bill doesn’t address the root causes of administrative complexity or unaffordable care, Cannon said. To do that would entail, for instance, doing away with the tax break for employer-sponsored care, which he said fuels excessive spending, raises prices, and ties health insurance to employment. He said the bill should cut federal funding for Medicaid, not just limit its growth.

The bill would throw more people into a high-cost health care landscape with little protection, said Aaron Carroll, president and CEO of AcademyHealth, a nonpartisan health policy research nonprofit.

“There’s a ton of evidence that shows that if you make people pay more for health care, they get less health care,” he said. “There’s lots of evidence that shows that disproportionately affects poor, sicker people.”

Labon McKenzie, 45, lives in Georgia, the only state that requires some Medicaid enrollees to work or complete other qualifying activities to obtain coverage.

He hasn’t been able to work since he broke multiple bones after he fell through a skylight while on the job three years ago. He got fired from a county road and bridge crew after the accident and hasn’t been approved for Social Security or disability benefits.

“I can’t stand up too long,” he said. “I can’t sit down too long.”

In February, McKenzie started seeing double, but canceled an appointment with an ophthalmologist because he couldn’t come up with the $300 the doctor wanted in advance. His cousin gave him an eye patch to tide him over, and, in desperation, he took expired eye drops his daughter gave him. “I had to try something,” he said.

McKenzie, who lives in rural Fort Gaines, wants to work again. But without benefits, he can’t get the care he needs to become well enough.

“I just want my body fixed,” he said.

Have you recently lost your health insurance coverage? Have you been uninsured for a while? Click here to contact KFF Health News and share your story.

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 new members of the Advisory Committee on Immunization Practices began their tenure Wednesday by shifting the posture of the 60-year-old panel from support for vaccine advancement to doubt about the safety and efficacy of well-established and widely administered inoculations.

Their discussions and votes this week paled in significance, however, in comparison with Health and Human Services Secretary Kennedy’s announcement Tuesday that he would withdraw a $1.2 billion U.S. commitment to global immunization.

That decision will kill children in the world’s poorest countries, critics said.

The new ACIP, meanwhile, recommended that newborn Americans get a newly licensed shot to protect them against a respiratory virus. The panel also urged doctors to stop administering influenza vaccine that contains a mercury-based preservative called thimerosal. That decision, in keeping with Kennedy’s disproven claim that thimerosal helped cause an autism epidemic, will have relatively little effect, since only about 4% of flu vaccines currently contain the preservative.

More worrying to vaccine advocates, the committee’s plans to review the government’s childhood vaccine schedule could undermine long-accepted consensus and public confidence, since at least three of the seven committee members have been outspoken opponents of current vaccines. The federal government is legally bound by ACIP’s decisions to provide vaccines it recommends to lower-income children and other groups, and states also follow ACIP’s advice.

Former Harvard University epidemiologist Martin Kulldorff, ACIP’s new chair, set the tone in his opening remarks. “Secretary Kennedy has given this committee a clear mandate to use evidence-based medicine when making vaccination recommendations, and that’s what we will do,” he said.

He added, “There are no wrong questions,” and he announced that a new working group would investigate whether children and adolescents are getting too many vaccines. Another will consider whether to continue ACIP’s 34-year-old recommendation of a birth dose of hepatitis B vaccine, a practice that has dramatically reduced liver disease.

Kulldorff, a covid-19 contrarian and biostatistician who said he was fired by Harvard for refusing a covid vaccination after suffering a severe case of the disease, said the reputations of science and public health have fallen to all-time lows. But scientists and public health officials disagree on who’s to blame.

The biggest cause is “fearmongering and pseudoscience that has overtaken our country,” Caroline Brown, a pediatrician outside Winston-Salem, North Carolina, said during the remote public comment session. She noted that her state’s first measles case of the year was reported this week, panicking many of the families she treats.

Measles was declared eliminated in the United States 25 years ago. It “is back now because of declining rates of vaccination fueled by misinformation that is not only allowed but amplified by some of you sitting on this very committee,” Brown said.

The American Academy of Pediatrics declined to send official liaisons to the meeting and announced on Thursday that it would continue to publish “its own evidence-based recommendations and schedules” for vaccines, blasting Kennedy’s panel.

“What we heard in this meeting was really a false narrative that the current vaccine policies are flawed and that they need fixing,” Sean O’Leary, a physician who chairs the AAP Committee on Infectious Diseases, said in a statement. “That’s completely false. These policies have saved millions of lives, trillions of dollars.”

The CDC’s immunization safety office has conducted studies of the entire vaccine schedule and found no harms, although a 2023 study indicated a possible link between aluminum salts used in some shots and asthma.

Within the CDC conference room, there was a striking contrast between ACIP members and the CDC officials who briefed the panel. While the CDC scientists presented studies showing the safety and value of covid and RSV (respiratory syncytial virus) vaccines, for example, many of the panel members expressed skepticism.

Biochemist Robert Malone and Massachusetts Institute of Technology management professor Retsef Levi — two panelists who have called for banning the mRNA technology used for covid vaccines — were frequently dismissive of the CDC analysis and data.

Malone, Levi, and Vicky Pebsworth — a longtime foe of school vaccination requirements — suggested hidden harms such as “hot lots” of dangerous shots, residual spike protein in the blood from mRNA shots, and inadequate vaccine safety monitoring.

CDC scientists rebutted most of the critiques. But final recommendations on policy will be made by the committee.

Standing along a busy suburban thoroughfare outside the CDC’s headquarters in Atlanta as the meeting rolled on, people critical of the new ACIP were dressed in costumes representing vaccine-preventable diseases — measles, HPV, chickenpox. A small cadre carried balloon letters spelling “R-E-S-T-O-R-E A-C-I-P.” One held a leg splint, commonly used to stabilize the limbs of people with polio, a disease driven to near-extinction by vaccination. Many drivers honked in support as they drove by.

Casey Boudreau, who recently retired from a career working on vaccine-preventable diseases at the CDC, said she was upset by Kennedy’s insistence that the verdict was still out on the safety of some vaccines and by his calls for them to be studied further.

“You’re focusing on reinventing the wheel,” she said. “Do we need to go back and test air bags again? Or do we know they work?”

Tony Fiore, who served as a liaison to ACIP during some of his time at the CDC before retiring, said he was “greatly concerned” that the committee’s words and actions would “reduce the confidence people have in vaccines and hurt our immunization programs.”

HHS spokesperson Andrew Nixon, who hovered briefly at the edge of rally as people began to gather, dismissed it as “nothing more than a dog and pony show with a lack of serious credibility, evidenced by their Halloween costumes,” in a statement later sent by text message.

At the meeting inside, Kennedy and his agenda loomed in the background, especially after the HHS secretary announced the abandonment of Gavi, an international group that estimates its vaccine programs have saved 18 million lives, mostly in the world’s poorest countries.

The United States has provided 13% of Gavi’s budget, and President Joe Biden had promised an additional $1.2 billion over four years before he left office. Kennedy’s action means that children “will miss lifesaving vaccines” against diseases causing pneumonia, diarrhea, measles, polio, and other diseases, former CDC official Deblina Datta said in an interview.

“There will be deaths,” said Datta, who retired in 2023 after 24 years at the agency. “I am not being hyperbolic. This is a big blow for children worldwide.”

Kennedy said Gavi had not done enough to promote vaccine safety. He also accused the group of complicity in censoring vaccine skeptics like him during the pandemic.

Before Kennedy intervened, the ACIP had been preparing to propose giving children one less shot. The committee was to have voted on reducing vaccinations against HPV, which causes cervical cancer, from two doses to one — because a single shot has proved so effective.

Kennedy has earned hundreds of thousands of dollars in fees from a pending lawsuit against Merck over alleged injuries from one of the HPV vaccines.

While it will have little actual impact, the vote on thimerosal also frustrated vaccine proponents. Public health agencies removed the substance from nearly all childhood vaccines beginning in 1999, out of concern that the accumulation of even tiny amounts of mercury could harm children’s brains and, some believed, cause autism.

Removal of thimerosal from childhood vaccines had no impact on autism rates, however.

But on Thursday, one of the earliest anti-thimerosal activists, nurse Lyn Redwood, presented a paper to ACIP on its dangers. Her arguments were nearly identical to a paper she co-wrote on the subject in 2001.

A summary of the evidence on thimerosal produced by CDC staff was posted online next to Redwood’s slides on Tuesday, but it was removed before the ACIP meeting began. The CDC paper concluded the evidence did not link thimerosal in vaccines to autism or other developmental issues.

According to The Washington Post, Kennedy has appointed Redwood to a position in the CDC’s immunization safety office.

“Removing thimerosal from vaccines didn’t make them safer, just more expensive,” Elias Kass, a naturopathic physician in Seattle, told the committee during a public comment session. “Re-litigation of questions already answered, like the safety of thimerosal, is not advancing radical transparency — it is an insidious attempt to suggest that something was missed or hidden previously.”

Removal of thimerosal from all flu vaccines may have drawbacks.

Two companies — Seqirus and Sanofi — still sell multi-dose flu vaccine vials that contain thimerosal as a preservative. A single vaccination from these 10-dose vials costs 10 to 40 times less than a single-shot prepackaged syringe, according to a CDC price list.

Seqirus will have no trouble replacing its remaining multi-dose vials with single syringes in time for the flu season, spokesperson Melanie Kerin said.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

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Party members argue Medicaid, a taxpayer-funded program for people with low incomes and disabilities, shouldn’t cover Americans who aren’t actively trying to improve their financial situations. And Republicans are closer than ever to achieving a national work requirement, after winning the White House and both chambers of Congress, and unlocking a fast-track process to secure big spending cuts. 

A national Medicaid work requirement would slash spending by reducing the number of people covered. About 5 million adults could lose Medicaid coverage in 2026 if Congress imposes one. 

But here’s the thing: Most adults with Medicaid who can work are already working, or have some reason they can’t (such as they’re full-time caregivers). And the experiences of two states that have implemented work requirements reveal the hidden costs of adding those layers of bureaucracy.  

The nonpartisan U.S. Government Accountability Office confirmed last week that, at the request of three Democratic senators, it’ll examine the costs of running a work requirement program that Georgia spent millions of dollars to establish. 

The GAO investigation comes at a critical time, said Leo Cuello, a research professor at Georgetown University’s Center for Children and Families. 

“Congress seems to be pursuing cuts in Medicaid in a frenetic and rushed manner,” he said. The GAO report could outline for Congress the full extent of problems with work requirements “before they rush forward and do this without thinking.” 

The GAO previously found that work requirement programs can be extremely expensive for states to run — hundreds of millions of dollars, in some cases — and that federal officials failed to consider those costs when approving the programs, which are not allowed to increase Medicaid spending. 

States must introduce new technology and have enough staffers to verify whether enrollees meet complex eligibility requirements and to monitor their continued compliance. 

When Arkansas tried its work requirement program, which applied to those covered by Medicaid expansion, 18,000 people lost coverage in less than a year before a federal judge stopped it. 

So, yeah, a work requirement would cut federal spending, but potentially also anger voters. 

New polling released Thursday by KFF, a nonprofit health policy organization that includes KFF Health News, shows a majority of Americans — regardless of party — oppose funding cuts to Medicaid. 

Moderate Republicans are showing trepidation about changes to the program: House Republican Don Bacon, a key centrist from Nebraska, said this week he wouldn’t support more than half a trillion dollars in cuts to Medicaid over a decade. The House-passed version of a congressional budget resolution called for as much as $880 billion. 

While Donald Trump has emphasized his goal of rooting out waste in federal programs, he’s also asking Congress to extend his 2017 tax cuts and spend more on border security. 

That the opinion of one House member from Nebraska could draw so much attention this week underlines the hard math House Speaker Mike Johnson faces in passing those pricey priorities; he can’t lose more than a handful of GOP votes to get it done.

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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