She and her husband, Charles, a former high school teacher who goes by Chaz, planned to retire comfortably in the three-bedroom house where they raised their kids about 60 miles northwest of Sacramento.

But early last year, the 63-year-old became unsteady on her feet. One morning in May, she woke up with slurred speech and landed in the hospital, then rapidly lost the ability to move the right side of her body.

In August, as doctors continued to puzzle over a possible diagnosis, the couple received a notice saying that on Jan. 1 their combined health care premium payments through the state insurance exchange would shoot up from $540 a month to $3,899 a month. The reason: Federal enhanced premium subsidies expiring at the end of last year would no longer offset their payment.

They immediately canceled a monthlong cruise they’d been planning with friends and looked through their retirement accounts.

“Now, instead of thinking about where we can go in our retirement, we’re asking the question, ‘Are we still going to be able to stay where we are because of the health care costs?’” said Chaz, who retired in 2021 at age 59.

Then they received more bad news. In October, at the age of 63, Jean was diagnosed with ALS, a debilitating disease that will eventually leave her unable to speak, swallow, or breathe on her own. But Jean’s condition allowed her to enroll in Medicare, the federal health insurance program that covers adults 65 and older and people with disabilities. The diagnosis saved them roughly $1,600 a month in premiums — little comfort as Jean lost her ability to walk, bathe, and dress herself.

“It’s kind of morbid that, because of my diagnosis, I got put on Medicare right away, so at least we don’t have to pay that out-of-pocket,” Jean said, sitting in a wheelchair in her living room, a quilt draped over her legs to guard against the intense chills she now often gets. “We’re not going to get buried under this.”

Yet the premiums for Chaz’s plan and her Medicare remain a significant strain on their finances. The $2,300 a month they now owe, which includes roughly $342 in premium payments for Jean’s Medicare supplemental insurance, is higher than their monthly mortgage and eats up more than a quarter of their budget.

The Franklins are among the across the nation facing greater financial pressure after Congress chose not to extend 2021 enhanced federal subsidies. That assistance helped more than double enrollment in Obamacare plans to over 24 million.

The Congressional Budget Office estimated in 2024 that, without an extension of the tax credits, the number of uninsured Americans would climb by 2.2 million this year alone. , nationwide enrollment in ACA plans was down about 1.2 million year over year, though experts say it could be months before the full effects of rising premiums are known, as people miss payments and lose coverage.

The groups hit hardest will be , , and people living in high-cost states, said , a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. The Franklins are all three.

“They fell off what we call a subsidy cliff,” Pogue said. “It’s very, very shocking, the amount that a person would have to absorb.”

That’s because the expanded tax credits made the biggest difference for people nearing retirement age who sat just above thresholds, Pogue said. People such as the Franklins, who likely wouldn’t have qualified for financial help before expanded credits were implemented, are now losing that support at a time when insurers have responded to the uncertainty by dramatically raising rates.

Roughly half of people who were expected to lose eligibility for premium tax credits were ages 50 to 64, according to an , a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Republicans who opposed the extension have said the premium assistance went directly to insurance companies rather than consumers, incentivizing fraud and wasteful coverage. They also say the enhanced subsidies, which had no upper income limit for eligibility, were far too generous in capping premium payments at 8.5% of income, no matter how much an enrollee made.

“Most Americans would agree that taxpayers should not be subsidizing the health insurance of someone making $250,000,” U.S. Rep. , a California Republican who an extension in January, wrote in an . “I cannot accept the simple extension of a program that will line the pockets of insurers and is riddled with fraud at the expense of the American taxpayer.”

Patient advocates say the premium increases and expiration of subsidies have forced people into difficult choices. “The young people who are healthy are the first to say, I’m going to roll the dice” and forgo coverage, said , executive vice president of policy and programs at the National Patient Advocate Foundation. “Those who are remaining in the system — because they have no choice — are holding off care, they’re holding off their meds, they’re going without necessary food.”

While the Franklins are getting by, they have relied on their sons to pay for a motorized recliner to assist with lifting Jean and a handicap van to transport her. Chaz, who broke a tooth a year ago, delayed fixing it because a crown would cost him $1,000.

This year, the couple will draw $36,000 more than they had anticipated from their retirement savings, most of it to cover Chaz’s insurance premiums.

“I have a nest egg,” Chaz said. “But there’s a lot of people around here who don’t.”

For a while, he was outraged.

“I wish Congress would get off their butts and solve this issue,” said Chaz, who is a registered Republican but blames both sides of the aisle. “You’re so busy bickering over stupid crap and it’s both parties pointing fingers and blaming. Where was this discussion two years ago?”

Now, Chaz said, he’s focused on making Jean, his wife of 27 years, as comfortable as possible.

Before she got sick, they did practically everything together — hiking, traveling, tai chi, amateur photography, and bug-hunting. One of her favorite specimens was the rain beetle, a fuzzy scarab-like insect that can’t feed as an adult, relying solely on fat stores from its larval stages.

In the mornings, Chaz and their sons, Charlie and Louis, take turns lifting Jean, dressing her, and helping her use the bathroom. It’ll be fodder for the counselor, she jokes to her sons, when they inevitably need therapy later in life.

Most days, Jean’s outdoor adventures rarely extend beyond being wheeled to her back patio, where she loves to watch their backyard chickens bobble around. Chaz’s stubbornness makes him a great patient advocate. Charlie always seems to know exactly when she needs a big hug, and Louis tells jokes that can still make her snort with laughter.

“I don’t know what I would do without my boys making me laugh,” she said.

In December, Chaz will turn 65, old enough to qualify for Medicare himself. “After this year — knock on wood — we should be OK,” Jean said, before pausing and shooting her husband a wry smile.

“Well, you’re gonna be OK.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage?ÌýClick here to contact ºÚÁϳԹÏÍø News and share your story.

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TheÌýCaliforniaÌýDemocratÌýcame into office promising to fight forÌý“,”Ìýand he came close to achieving it. Really close. But as it turns out,Ìýthat’sÌýeasier said than done whenÌýyou’reÌýjugglingÌý,Ìý,ÌýandÌýshrinking federal support.Ìý

NowÌýhe’sÌýwalking the fine line betweenÌýkeepingÌýhisÌýÌýand being tarred asÌýa recklessÌýstateÌýexecutive who has stretched California’sÌýspendingÌý.Ìý

AfterÌýyears of politicalÌýinfighting,Ìý±·±ð·É²õ´Ç³¾Ìýand the Democratic-controlledÌýlegislatureÌýin 2024ÌýbroadenedÌýCalifornia’s Medicaid program, Medi-Cal, toÌýÌýregardless of immigration status.Ìý

Now,Ìýhe’sÌýrollingÌýback those expansions in the name of “fiscal prudence.”Ìý

This year, CaliforniaÌý´Ú°ù´Ç³ú±ðÌý²Ñ±ð»å¾±-°ä²¹±ôÌý±ð²Ô°ù´Ç±ô±ô³¾±ð²Ô³ÙÌýforÌýmostÌýadultsÌýwithout legal status, justÌýtwo years afterÌý. On July 1, immigrants not eligible forÌýfederal MedicaidÌý—Ìýboth legal residents and those without authorizationÌý—Ìýwill lose access toÌýstateÌýdental coverage.ÌýNext year,Ìýthey’llÌýhave to start paying monthly premiums.Ìý

Last month, Newsom proposedÌýlettingÌýroughly 200,000Ìýlegal immigrantsÌý—Ìýasylees, refugees,Ìýand othersÌý—ÌýgetÌýcutÌýoff from Medi-Cal after Sept. 30, when the federal government will stop paying for them.Ìý

Advocates are livid.Ìý

ProgressivesÌýsayÌýNewsom’s political ambitionsÌý—Ìýand perceived need to distance himself from theÌýpolarizedÌýtopic of immigrant health careÌý—Ìýgo againstÌýhis earlyÌýpledges.Ìý

“You’re clouded by what Arkansas is going to think, or Tennessee is going to think, whenÌýwhat California thinks is something completely different,” said CaliforniaÌýstate Sen. Caroline Menjivar, chairÌýof theÌýbudget subcommittee on healthÌýand human services.Ìý

Meanwhile, Republicans and fiscal hawksÌýhaveÌýpaintedÌýNewsom as aÌýÌýDemocrat prioritizingÌýuse ofÌýlimited state funds on free health care for noncitizens.ÌýAnd Newsom has taken hits fromÌýtheÌýTrump administration accusing California ofÌý“”Ìýto use federal funds for immigrant health services.Ìý

He’sÌýnot the only governor grappling with this dilemma.ÌýAnd all 50 states,ÌýwhichÌýareÌýcurrentlyÌýrequired toÌýprovide health coverage toÌýrefugees, asylees,ÌýandÌýothers,Ìýwill have toÌýdecide whether toÌýbackfill that coverage for some 1.4 million legal immigrants starting Oct. 1, whenÌýÌýofÌýthe One Big Beautiful Bill ActÌýkicks inÌýand leaves states without federal reimbursement for their care.

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Por segundo año, el demócrata pidió a los legisladores estatales que eliminen la cobertura para un sector de los inmigrantes ante los recortes federales al gasto en Medicaid y un déficit presupuestario de aproximadamente .

Muchos analistas advierten que, si estalla la burbuja de la inteligencia artificial, .

Newsom propuso que el estado no intervenga cuando, a partir de octubre, el gobierno federal deje de brindar cobertura médica a unos 200.000 residentes legales, entre ellos .

Legisladores progresistas y activistas afirmaron que esos recortes representan un alejamiento de la promesa de Newsom de garantizar “”. Por otro lado, los republicanos siguen criticándolo porque utiliza fondos públicos para cubrir a personas que no son ciudadanas.

Según el Departamento de Finanzas, la propuesta más reciente de Newsom permitiría un ahorro estimado de $786 millones en este año fiscal y de $1.100 millones anuales en los años siguientes, dentro de un presupuesto proyectado de $349.000 millones.

La senadora estatal Caroline Menjivar, una de las dos demócratas que el año pasado votaron en contra de los recortes de Newsom, dijo que le preocupa que las ambiciones políticas del gobernador estén pesando más que lo que es mejor para los californianos.

“Está pendiente de lo que van a opinar Arkansas o Tennessee, cuando lo que piensa California es algo completamente diferente”, se quejó Menjivar, quien contó que sus críticas anteriores le costaron de un subcomité clave del presupuesto. “Esa es mi perspectiva sobre lo que está ocurriendo aquí”, agregó.

Mientras tanto, el senador estatal republicano Tony Strickland criticó a Newsom por restar importancia del estado que, según funcionarios estatales, podría crecer hasta los $27.000 millones el próximo año. Además, lo acusó de seguir ofreciendo cobertura a residentes de California que viven en el país sin autorización. “Lo único que quiere es relanzarse políticamente, proyectar una nueva imagen”, dijo Strickland.

Es una cuerda floja política que se irá tensando aún más a medida que disminuya el apoyo federal y sigan aumentando los gastos en atención médica, afirmó Guian McKee, codirector del Proyecto de Políticas de Salud de la Escuela de Asuntos Públicos Miller de la Universidad de Virginia.

“Newsom tiene que hacer malabares con tres o cuatro temas delicados al mismo tiempo”, opinó ÌýMcKee. Si decide postularse, agregó: “las prioridades de los votantes demócratas en las primarias —que en gran medida reflejan estados progresistas como California— son muy distintas a las del electorado en general, que está mucho más dividido”.

En Estados Unidos, las opiniones sobre si el gobierno debería ofrecer cobertura médica a personas sin papeles están muy divididas.

En una realizada el año pasado, una pequeña mayoría —54%— se opuso a una disposición que establecía sanciones a los estados que utilizaban sus propios recursos para brindar atención médica a inmigrantes. Había grandes diferencias según la afiliación política. Finalmente, esa disposición no fue incluida en la versión final del proyecto de ley aprobado por el Congreso y promulgado por el presidente Donald Trump.

Incluso en California, la idea de ofrecer atención médica perdió apoyo a causa de los problemas presupuestarios.

En , el 41% de los adultos expresó estar de acuerdo con ofrecer cobertura médica a inmigrantes sin papeles, una caída significativa con respecto en 2023.

el vicepresidente JD Vance, y legisladores republicanos han acusado en repetidas ocasiones a California y a otros estados demócratas de usar fondos públicos para dar atención médica a inmigrantes, un tema que enardece a la base del Partido Republicano.

Mehmet Oz, administrador de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), de “” para recibir más fondos federales, liberando recursos estatales para su programa de Medicaid, conocido como Medi-Cal, que ha inscrito a cerca de 1,6 millones de inmigrantes en situación irregular.

“Si usted es un contribuyente en Texas o Florida, sus impuestos podrían haberse usado para financiar la atención médica de inmigrantes ilegales en California”, dijo en octubre.

Funcionarios de California negaron esas acusaciones y afirmaron que solo se utilizan fondos estatales para dar servicios de salud general a personas indocumentadas, ya que la ley prohíbe usar fondos federales.

Newsom ha convertido esto en un “”, ya que ampliar la cobertura a inmigrantes, según su administración, mantiene a las y ayuda a evitar costosas visitas a salas de emergencia que muchas veces se terminan pagando con dinero público.

“Ninguna administración ha hecho más que ésta para ampliar la cobertura total de Medicaid para nuestras comunidades diversas, con y sin estatus migratorio”, dijo Newsom a periodistas en enero. “Hay quienes han construido toda su carrera política criticando mi postura”.

Newsom advirtió sobre el “carnaval de caos” del gobierno federal al aprobar la ley One Big Beautiful Bill Act de Trump. Esa ley, sostuvo, pone a 1,8 millones de californianos en riesgo de perder su cobertura médica debido a la implementación de requisitos laborales, otras reglas de elegibilidad y nuevos límites al financiamiento federal para los estados.

Según la Oficina de Presupuesto del Congreso, desde ahora y hasta 2034, a nivel nacional, 10 millones de beneficiarios podrían perder su cobertura.

han señalado que un número mayor de personas sin seguro —en especial aquellas que están relativamente sanas— podría concentrar la cobertura en , lo que potencialmente elevaría los costos de las primas y los costos hospitalarios en general.

Organizaciones que trabajan con los inmigrantes señalan que es especialmente cruel dejar sin atención médica a quienes pudieron haber huido de situaciones de violencia o sobrevivido a la trata o a situaciones de abuso.

Las normas federales actuales exigen que los programas estatales de Medicaid cubran a “no ciudadanos calificados”, incluidos solicitantes de asilo y refugiados, explicó Tanya Broder, del National Immigration Law Center. Pero la One Big Beautiful Bill Act, impulsada por los republicanos, puso fin a esa cobertura, lo que afectaría a legales en todo el país.

Como muchos gobernadores estatales aún no han presentado sus propuestas de presupuesto, no está claro cómo piensan cubrir los recortes al financiamiento, dijo Broder.

Por ejemplo, funcionarios de Colorado estiman que unos 7.000 inmigrantes legales podrían perder cobertura por los cambios en la ley. En el estado de Washington, las autoridades calculan que , solicitantes de asilo y otros inmigrantes con autorización legal se quedarán sin cobertura de Medicaid.

Ambos estados, al igual que California, ampliaron la cobertura completa a todos los residentes elegibles por ingresos, sin importar su situación migratoria. Ahora, sus funcionarios electos están en la incómoda posición de tener que explicar por qué algunos inmigrantes legales podrían perder su cobertura médica mientras que otros sin estatus legal podrían conservarla.

El año pasado, el aumento de los costos en atención médica y los recortes presupuestarios llevaron a los gobernadores demócratas de —JB Pritzker y Tim Walz, dos potenciales aspirantes a la presidencia— a suspender o cancelar la cobertura para inmigrantes sin papeles.

También en 2025, legisladores de California votaron por la eliminación de la cobertura dental y congelaron nuevas inscripciones para personas sin documentos. A partir del próximo año también se cobrará una prima mensual a quienes mantengan su cobertura.

Aun así, se estima que el estado gastará $13.800 millones de su fondo general en atención médica para inmigrantes no cubiertos por el gobierno federal, según H.D. Palmer, vocero del Departamento de Finanzas.

En enero, en una conferencia de prensa en San Francisco, Newsom defendió estas medidas y dijo que eran necesarias por “prudencia fiscal”. Evitó responder preguntas sobre la cobertura para solicitantes de asilo y refugiados, y minimizó la importancia de su propuesta, al decir que podría revisarla cuando tuviera la oportunidad de actualizar el presupuesto en mayo.

Kiran Savage-Sangwan, directora ejecutiva de la California Pan-Ethnic Health Network, señaló que el estado aprobó una ley en la década de 1990 que le exige cubrir con Medi-Cal cuando los fondos federales de Medicaid no están disponibles. Esto incluye a personas con residencia permanente que aún no cumplen con el período de espera de cinco años para inscribirse en Medicaid.

Savage-Sangwan calificó la propuesta del gobernador como “arbitraria y cruel” y criticó su decisión de priorizar los depósitos del fondo de emergencia para tiempos difíciles en vez de mantener la cobertura. Agregó que culpar al gobierno federal era engañoso.

También consideró que es un gran retroceso respecto de lo que ella esperaba que California pudiera lograr el primer día de Newsom en el cargo, hace siete años, cuando el gobernador declaró su apoyo a un sistema de salud con financiamiento público integral y propuso ampliar los subsidios para pagar el seguro médico para la clase media.

“Tenía esperanza y celebramos los avances que impulsó el gobernador”, afirmó Savage-Sangwan. “Por eso estoy aún más decepcionada”.

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For a second year, the Democrat has asked state lawmakers to roll back coverage for some immigrants in the face of federal Medicaid spending cuts and a roughly that if the artificial intelligence bubble bursts. Newsom has proposed that the state not step in when, starting in October, the federal government stops providing health coverage to an estimated 200,000 legal residents — comprising .

Progressive legislators and activists said the cost-saving measures are a departure from Newsom’s , while Republicans continue to skewer Newsom for using public funds to cover any noncitizens.

Newsom’s latest move would save an estimated $786 million this fiscal year and $1.1 billion annually in future years in a proposed budget of $349 billion, according to the Department of Finance.

State Sen. Caroline Menjivar, one of two Senate Democrats who voted against Newsom’s immigrant health cuts last year, said she worried the governor’s political ambition could be getting in the way of doing what’s best for Californians.

“You’re clouded by what Arkansas is going to think, or Tennessee is going to think, when what California thinks is something completely different,” said Menjivar, who said previous criticism got her from a key budget subcommittee. “That’s my perspective on what’s happening here.”

Meanwhile, Republican state Sen. Tony Strickland criticized Newsom for glossing over the state’s , which state officials say could balloon to $27 billion the following year. And he slammed Newsom for continuing to cover California residents in the U.S. without authorization. “He just wants to reinvent himself,” Strickland said.

It’s a political tightrope that will continue to grow thinner as federal support shrinks amid ever-rising health care expenses, said Guian McKee, a co-chair of the Health Care Policy Project at the University of Virginia’s Miller Center of Public Affairs.

“It’s not just threading one needle but threading three or four of them right in a row,” McKee said. Should Newsom run, McKee added, the priorities of Democratic primary voters — who largely mirror blue states like California — look very different from those in a far more divided general electorate.

Americans are deeply divided on whether the government should provide health coverage to immigrants without legal status. In a last year, a slim majority — 54% — were against a provision that would have penalized states that use their own funds to pay for immigrant health care, with wide variation by party. The provision was left out of the final version of the bill passed by Congress and signed by President Donald Trump.

Even in California, support for the idea has waned amid ongoing budget problems. In a by the Public Policy Institute of California, 41% of adults in the state said they supported providing health coverage to immigrants who lack legal status, a sharp drop from the 55% .

, Vice President JD Vance, , and congressional Republicans have repeatedly accused California and other Democratic states of using taxpayer funds on immigrant health care, a red-meat issue for their GOP base. Centers for Medicare & Medicaid Services Administrator Mehmet Oz has of “” to receive more federal funds, freeing up state coffers for its Medicaid program, known as Medi-Cal, which has enrolled roughly 1.6 million immigrants without legal status.

“If you are a taxpayer in Texas or Florida, your tax dollars could’ve been used to fund the care of illegal immigrants in California,” he said in October.

California state officials have denied the charges, noting that only state funds are used to pay for general health services for those without legal status because the law prohibits using federal funds. Instead, Newsom has made it a “” that California has opened up coverage to immigrants, which his administration has noted and helps them avoid costly emergency room care often covered at taxpayer expense.

“No administration has done more to expand full coverage under Medicaid than this administration for our diverse communities, documented and undocumented,” Newsom told reporters in January. “People have built careers out of criticizing my advocacy.”

Newsom warns the federal government’s “carnival of chaos” passed Trump’s One Big Beautiful Bill Act, which he said puts 1.8 million Californians at risk of losing their health coverage with the implementation of work requirements, other eligibility rules, and limits to federal funding to states.

Nationally, 10 million people could lose coverage by 2034, according to the Congressional Budget Office. higher numbers of uninsured patients — particularly those who are relatively healthy — could concentrate coverage among sicker patients, potentially increasing premium costs and hospital prices overall.

Immigrant advocates say it’s especially callous to leave residents who may have fled violence or survived trafficking or abuse without access to health care. Federal rules currently require state Medicaid programs to cover “qualified noncitizens” including asylees and refugees, according to Tanya Broder of the National Immigration Law Center. But the Republican tax-and-spending law ends the coverage, affecting legal immigrants nationwide.

With many state governors yet to release budget proposals, it’s unclear how they might handle the funding gaps, Broder said.

For instance, Colorado state officials estimate roughly 7,000 legal immigrants could lose coverage due to the law’s changes. And Washington state officials refugees, asylees, and other lawfully present immigrants will lose Medicaid.

Both states, like California, expanded full coverage to all income-eligible residents regardless of immigration status. Their elected officials are now in the awkward position of explaining why some legal immigrants may lose their health care coverage while those without legal status could keep theirs.

Last year, spiraling health care costs and state budget constraints prompted the Democratic governors of , potential presidential contenders JB Pritzker and Tim Walz, to pause or end coverage of immigrants without legal status.

California lawmakers last year voted to eliminate dental coverage and freeze new enrollment for immigrants without legal status and, starting next year, will charge monthly premiums to those who remain. Even so, the state is slated to spend $13.8 billion from its general fund on immigrants not covered by the federal government, according to Department of Finance spokesperson H.D. Palmer.

At a press conference in San Francisco in January, Newsom defended those moves, saying they were necessary for “fiscal prudence.” He sidestepped questions about coverage for asylees and refugees and downplayed the significance of his proposal, saying he could revise it when he gets a chance to update his budget in May.

Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network, pointed out that California passed a law in the 1990s requiring the state to cover when federal Medicaid dollars won’t. This includes green-card holders who haven’t yet met the five-year waiting period for enrolling in Medicaid.

Calling the governor’s proposal “arbitrary and cruel,” Savage-Sangwan criticized his choice to prioritize rainy day fund deposits over maintaining coverage and said blaming the federal government was misleading.

It’s also a major departure from what she had hoped California could achieve on Newsom’s first day in office seven years ago, when he declared his support for single-payer health care and proposed extending health insurance subsidies to middle-class Californians.

“I absolutely did have hope, and we celebrated advances that the governor led,” Savage-Sangwan said. “Which makes me all the more disappointed.”

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For several years, that number has been zero in the predominantly white, largely rural county stretching from Sacramento’s eastern suburbs to the shores of Lake Tahoe.

The trend could be short-lived.

County health officials there and across the country are bracing for an newly uninsured patients over the next decade in the wake of Republicans’ One Big Beautiful Bill Act. The act, which President Donald Trump signed into law this past summer, is also expected to reduce Medicaid spending by over that period.

“This is the moment where a lot of hard decisions have to be made about who gets care and who doesn’t,” said Nadereh Pourat, director of the Health Economics and Evaluation Research Program at UCLA. “The number of people who are going to lose coverage is large, and a lot of the systems that were in place to provide care to those individuals have either gone away or diminished.”

It’s an especially thorny challenge for states and New Mexico where counties are legally required to help their poorest residents through what are known as indigent care programs. Under Obamacare, both states were to include more low-income residents, alleviating counties of patient loads and redirecting much of their funding for the patchwork of local programs that provided bare-bones services.

Placer County, which estimates that 16,000 residents could lose health care coverage by 2028, quit operating its own clinics nearly a decade ago.

“Most of the infrastructure that we had to meet those needs is gone,” said Rob Oldham, Placer County’s director of health and human services. “This is a much bigger problem than it was a decade ago and much more costly.”

In December, county officials that provides care to mostly small, rural counties, citing an expected rise in the number of uninsured residents.

New Mexico’s second-most-populous county, Doña Ana, added dental care for seniors and behavioral health benefits after many of its poorest residents qualified for Medicaid. Now, federal cuts could force the county to reconsider, said Jamie Michael, Doña Ana’s health and human services director.

“At some point we’re going to have to look at either allocating more money or reducing the benefits,” Michael said.

Straining State Budgets

Some states, such as Idaho and Colorado, abandoned laws that required counties to be providers of last resort for their residents. In other states, uninsured patients often delay care or receive it at hospital emergency rooms or community clinics. Those clinics are often supported by a mix of federal, state, and local funds, according to the National Association of Community Health Centers.

Even in states like Texas, which opted not to expand its Medicaid program and continued to rely on counties to care for many of its uninsured, rising health care costs are straining local budgets.

“As we have more growth, more people coming in, it’s harder and harder to fund things that are required by the state legislature, and this isn’t one we can decrease,” said Windy Johnson, program manager with the Texas Indigent Health Care Association. “It is a fiscal issue.”

California lawmakers face a nearly in the 2026-27 fiscal year, according to the latest estimates by the state’s nonpartisan Legislative Analyst’s Office. Gov. Gavin Newsom, who has acknowledged he is , has rebuffed to significantly raise taxes on the ultra-wealthy. Despite blasting the bill passed by Republicans in Congress as a that guts health care programs, in 2025 the Democrat rolled back state Medi-Cal benefits for seniors and for immigrants without legal status after rising costs forced the program to borrow $4.4 billion from the state’s general fund.

H.D. Palmer, a spokesperson for the state’s Department of Finance, said that the Newsom administration is still refining its fiscal projections and that it would be “premature” to discuss potential budget solutions.

Newsom will unveil his initial budget proposal in January. State officials have said California a year in federal funding for Medi-Cal under the new law, as much as 15% of the state program’s entire budget.

“Local governments don’t really have much capacity to raise revenue,” said Scott Graves, a director at the independent California Budget & Policy Center with a focus on state budgets. “State leaders, if they choose to prioritize it, need to decide where they’re going to find the funding that would be needed to help those who are going to lose health care as a result of these federal funding and policy cuts.”

Reviving county-based programs in the near term would require “considerable fiscal restructuring” through the state budget, the Legislative Analyst’s Office said in .

No Easy Fixes

It’s not clear how many people are currently enrolled in California’s county indigent programs, because the state doesn’t track enrollment and utilization. But enrollment in county health safety net programs dropped dramatically in the first full year of ACA implementation, going from about 858,000 people statewide in 2013 to roughly 176,000 by the end of 2014, at the time by Health Access California.

“We’re going to need state investment,” said Michelle Gibbons, executive director of the County Health Executives Association of California. “After the Affordable Care Act and as folks got coverage, we didn’t imagine a moment like this where potentially that progress would be unwound and folks would be falling back into indigent care.”

In November, voters in affluent Santa Clara County approved a sales tax increase, in part to backfill the loss of federal funds. But even in the home of Silicon Valley, where the median household income is about 1.7 times the , that is expected to of the $1 billion a year the county stands to lose.

Health advocates fear that, absent major state investments, Californians could see a return to the previous , with local governments choosing whom and what they cover and for how long.

In many cases, indigent programs didn’t include specialty care, behavioral health, or regular access to primary care. Counties can also exclude people or income. Before the ACA, many uninsured people who needed care didn’t get it, which could lead to them winding up in ERs with untreated health conditions or even dying, said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.

Rachel Linn Gish, interim deputy director of Health Access California, a consumer advocacy group, said that “it created a very unequal, maldistributed program throughout the state.”

“Many of us,” she said. “including counties, are reeling trying to figure out: What are those downstream impacts?”

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Sin embargo, hubo una omisión importante que, según defensores de la comunidad LGBTQ+ y estrategas políticos, forma parte de una situación cada vez más compleja que enfrenta el demócrata mientras delinea un perfil más ubicado en el centro para una posible candidatura presidencial.

±·±ð·É²õ´Ç³¾ÌýÌýque habría obligado a las aseguradoras a cubrir y a las farmacéuticas a dispensar 12 meses de terapia hormonal de una sola vez a pacientes transgénero y a otras personas.

La propuesta era para los líderes de los derechos de las personas trans, quienes afirmaron que era crucial preservar la atención médica mientras las clínicas de afirmación de género bajo la presión de la Casa Blanca.

Expertos políticos afirman que el pone de relieve la carga que ha adquirido la atención médica para las personas transgénero para y, en particular, para Newsom, quien, como alcalde de San Francisco, cometió actos de desobediencia civil al permitir que las parejas homosexuales .

El veto, junto con su tibia respuesta a la retórica antitrans, argumentan, forma parte de un patrón alarmante que podría dañar su credibilidad ante su base de votantes clave.

“Aunque no hubiera ninguna motivación política tras la decisión de Newsom, sin duda existen ramificaciones políticas de las que es muy consciente”, declaró Dan Schnur, ex estratega político republicano que ahora es profesor de política en la Universidad de California-Berkeley. “Es lo suficientemente inteligente como para saber que este es un tema que va a enojar a su base, pero que, a cambio, podría hacerlo más aceptable para un gran número de votantes indecisos”, agregó.

A principios de este año, en el podcast de Newsom, el gobernador le dijo al difunto activista conservador Charlie Kirk que la participación de atletas trans en deportes femeninos era , lo que desencadenó una reacción negativa entre la base de su partido y los líderes LGBTQ+. Y ha descrito la como un “problema grave para el Partido Demócrata”, afirmando que los anuncios de campaña de Donald Trump fueron “devastadores” para su partido en 2024.

Aun así, en una conversación con el streamer de YouTube ConnorEatsPants en octubre,Ìý: “Como alguien que ha arriesgado su vida política por la comunidad durante décadas, ha sido un defensor y un líder”.

“No quiere enfrentar las críticas como alguien que, estoy segura, intenta postularse para la presidencia, cuando la retórica antitrans actual es tan fuerte”, dijo Ariela Cuellar, vocera de la Red de Salud y Servicios Humanos LGBTQ de California.

Caroline Menjivar, la senadora estatal que presentó la medida, la describió como la “más tangible y efectiva” de este año para ayudar a las personas trans en un momento en que están siendo señaladas por lo que describió como una “discriminación selectiva”.

En una legislatura donde los demócratas cuentan con supermayoría en ambas cámaras, los legisladores enviaron el proyecto de ley a Newsom mediante una votación partidista. A principios de este año, Washington se convirtió en en promulgar una ley que extiende la cobertura de la terapia hormonal a un suministro de 12 meses.

En un sobre el proyecto de ley de California, Newsom mencionó su potencial para aumentar los costos de la atención médica, impactos que, según un , serían insignificantes.

“En un momento en que las personas se enfrentan a aumentos de dos dígitos en las tarifas de sus primas de atención médica en todo el país, debemos tener mucho cuidado de no promulgar políticas que aumenten aún más el costo de la atención médica, por muy bien intencionadas que sean”, escribió Newsom.

, se ha ordenado a las agencias federales a la atención de afirmación de género para niños, a lo que Trump se ha referido como “mutilación química y quirúrgica”, y se han a las instituciones que la brindan.

En los últimos meses, , el y han reducido o eliminado la atención médica de afirmación de género para pacientes menores de 19 años, una muestra del efecto persuasivo que las órdenes ejecutivas de Trump han tenido en la atención médica, incluso en uno de los estados más progresistas del país.

California una amplia cobertura de atención médica de afirmación de género, incluyendo la terapia hormonal, pero actualmente las farmacias solo pueden dispensar un suministro para 90 días. El proyecto de ley de Menjivar habría permitido suministros para 12 meses, siguiendo el modelo de que permitía a las mujeres recibir un suministro anual de anticonceptivos.

Luke Healy, quien en una audiencia en abril que era “un joven de 24 años que ya no se identificaba como transgénero” y que ya no se consideraba mujer, criticó el intento de aumentar la cobertura de servicios que, dijo, resultó “irreversiblemente perjudicial” para él.

“Creo que proyectos de ley como este obligan a los médicos a convertir cuerpos sanos en problemas médicos perpetuos en nombre de una ideología”, testificó Healy.

La Asociación de Planes de Salud de California se opuso al proyecto de ley debido a las disposiciones que limitarían el uso de ciertas prácticas, como la autorización previa y la terapia escalonada, que requieren la aprobación de la aseguradora antes de ofrecer la atención, y obligan a pacientes y médicos a probar primero otras terapias.

“Estas salvaguardas son esenciales para aplicar estándares de prescripción basados en la evidencia y gestionar los costos de forma responsable, garantizando que los pacientes reciban la atención adecuada y manteniendo las primas bajo control”, declaró la vocera Mary Ellen Grant.

Un análisis del Programa de Revisión de Beneficios de Salud de California, que revisa de forma independiente las facturas relacionadas con los seguros médicos, concluyó que los aumentos anuales de las primas resultantes de la implementación de la ley serían insignificantes y que no se esperaban “impactos a largo plazo en la utilización ni en los costos”.

Shannon Minter, director legal del Centro Nacional para los Derechos LGBTQ, afirmó que el argumento económico de Newsom no era plausible. Aunque afirmó considerar a Newsom un firme aliado de la comunidad transgénero, Minter señaló estar “profundamente decepcionado” al ver el veto del gobernador. “Entiendo que intenta responder a este momento político y desearía que respondiera con un lenguaje y políticas que realmente puedan impulsar el cambio”.

La oficina de prensa de Newsom no quiso hacer más comentarios.

Luego de la entrevista en el podcast de Kirk, Cuellar afirmó que los grupos de defensa que apoyaban la SB 418 comenzaron a preocuparse cada vez más por un posible veto y se esforzaron por destacar las voces de otros pacientes que se beneficiarían, como mujeres en la etapa de menopausia y pacientes con cáncer. Fue una estrategia radicalmente distinta a la que podrían haber seguido antes de que Trump asumiera el cargo.

“Si hubiéramos presentado este proyecto de ley en 2022-2023, el mensaje habría sido totalmente distinto”, dijo otro defensor queien pidió que su no se revelara su nombre por no estar autorizado a hablar públicamente sobre el tema. “Nos habría hecho estar muy orgullosos. En 2023, podríamos haber tenido una ceremonia de firma”.

Los defensores de los derechos de las personas trans se mostraron tan recelosos del clima político actual que algunos también sintieron la necesidad de evitar promover un proyecto de ley independiente que habría ampliado la cobertura de la terapia hormonal y otros tratamientos para la menopausia y la perimenopausia.

Ese , redactado por la asambleísta Rebecca Bauer-Kahan, quien ha hablado conmovedoramente sobre sus dificultades con la atención médica para la perimenopausia, .

Mientras tanto, Jovan Wolf, un hombre trans y veterano militar, dijo que pacientes como él tendrán que sufrir.

Wolf, quien había tomado testosterona durante más de 15 años, intentó reiniciar la terapia hormonal en marzo, tras una pausa de dos años en la que contempló tener hijos.

Los médicos del Departamento de Asuntos de Veteranos le dijeron que era demasiado tarde. Días antes, la administración Trump que eliminaría gradualmente la terapia hormonal y otros tratamientos para la disforia de género.

“Tener estrógeno bombeando por mi cuerpo no me hace sentir bien, ni física ni mentalmente. Y cuando tomo testosterona, me siento equilibrado”, dijo Wolf, quien finalmente recibió atención en otro lugar. “Debería ser mi decisión y solo mía”.

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

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

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

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

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

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

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

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

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

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

, federal agencies have been to gender-affirming care for children, which Trump has referred to as “chemical and surgical mutilation,” and from or of institutions that provide it.

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

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

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

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

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

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

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

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

Newsom’s press office declined to comment further.

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

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

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

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

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

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

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

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She hesitated. The procedure was part of a clinical trial, and she’d heard about a federal freeze on . She wanted to know: Would this study be at risk, potentially affecting her care?

Those worries put unnecessary pressure on a patient facing the loss of roughly 2 million nerve cells every minute that treatment was delayed, said , a neurologist and longtime stroke researcher.

“To then have to worry about what’s happening with the funding from the federal government is a needless increase in the stress patients are going through,” Saver said.

Patients and researchers such as Saver have found themselves caught in the middle as the Trump administration has accused major universities of , pulling research funds in an attempt to .

Scientists who have spent their lives developing treatments for lung cancer, brain tumors, and Alzheimer’s disease say scientific funding should not be politicized — and warn that patients waiting for lifesaving treatments stand to lose the most. They also worry that funding cuts mired in legal challenges could discourage would-be scientists from entering the field, reducing the chances for medical breakthroughs.

“I would have thought that stroke and Alzheimer’s disease and all these conditions affect Democrats and Republicans alike and would be supported by everyone,” Saver said. “The reasons for the suspension don’t seem to tie into the work we’re doing.”

In July, the National Institutes of Health, the National Science Foundation, and the Energy Department in medical and science research grants to UCLA after the Justice Department said the university had of Jewish students during pro-Palestinian protests. The Trump administration that would require UCLA to pay a $1.2 billion fine and overhaul campus policies on admissions, hiring, and gender-affirming health care to reinstate the grants.

Yet the federal government plays a crucial role in funding lifesaving research that industry has little incentive to back. Saver said treatment discoveries made in the past 15 years have been “transformative” for stroke care. To keep eight clinical trials afloat, Saver said, he and other neurology department faculty members sought outside funding and agreed to salary cuts. But they were close to running out before federal funds were restored.

In the ER, doctors told the stroke patient not to worry. Given the need to study her particular symptoms, they tapped a pot of private donations to cover the procedure. She enrolled and was treated.

Gov. Gavin Newsom, a Democrat who has been challenging President Donald Trump more directly as he builds a national profile, has likened the president’s demands .

And Newsom last week state funding from any California university that Trump put forth that prioritizes federal research funds to institutions that adhere to the administration’s definitions of gender, limit international students, and change admissions policies, among other stipulations. “California will not bankroll schools that sell out their students, professors, researchers, and surrender academic freedom,” Newsom said in a statement.

In September, U.S. District Judge Rita Lin of the Northern District of California ordered frozen NIH grants in the state to flow again, folding UCLA researchers into a lawsuit initially brought by researchers from the University of California-Berkeley and UC-San Francisco in June after federal agencies slashed hundreds of millions in grants to UC campuses.

Some private academic institutions have reclaimed their funding by agreeing to pay hefty fines and changing campus policies, including , which agreed to pay $200 million, and , which settled for $50 million. Meanwhile, last month that the administration’s cancellation of some $2.6 billion in grants to Harvard was illegal.

Still, researchers worry the relief is temporary. Even with the district court’s restoration, the case brought by UC researchers is still pending and could ultimately be decided in Trump’s favor. The White House has the ruling to restore Harvard’s funding, while of the school’s finances.

“We haven’t seen everything play out yet. Lots of scientists and researchers and people who run labs are circumspect, knowing that the near future could be a bit bumpy,” said Jessica Levinson, a constitutional law professor at Loyola Law School. “They should feel like this is a win, but it’s possible that it’s a short-lived one.”

Officials at the U.S. Department of Health and Human Services did not respond to questions about potential harm done to studies while the funds were frozen, or criticisms that they are wrongly politicizing money for potentially lifesaving research.

In a statement about the administration’s campaign targeting antisemitism, HHS spokesperson Andrew Nixon said that “we will not fund institutions that promote antisemitism. We will use every tool we have to ensure institutions follow the law.”

HHS spokesperson Emily Hilliard said in a follow-up statement that the department is “steadfast in its commitment to advancing groundbreaking biomedical research” and that it continues to “invest strategically in research that tackles today’s urgent challenges.”

Most of the UCLA funding freezes affected foundational science that doesn’t directly involve patients but has the potential to vastly improve treatment. David Shackelford, a researcher exploring novel ways to stunt the growth of therapy-resistant lung cancer, said he was nearing a potential breakthrough for treating the disease, which kills 9 in 10 patients within five years of a diagnosis.

“I’m not used to my science being politicized,” Shackelford said. “It’s cancer. We should never even be having this discussion.”

As court battles play out, Democratic state legislators are on next year’s ballot dedicating state funds to continue advances in cancer, stroke, and infectious disease research, among other scientific research. But state bond money, if approved by voters, wouldn’t come close to replacing federal grants, which traditionally finance the lion’s share of biomedical research.

In 2024 alone, for example, roughly flowed to California, with $3.8 billion of that going to universities. And the proposed bond would be broad, one-time funding that could pay for other study areas, such as climate change research, marine ecosystems, or wildfire prevention.

the possibility of even bigger federal cuts to the state’s second-largest employer would have ripple effects across California’s economy.

While other universities have sued the Trump administration, UC leaders have instead engaged in “good faith dialogue” with the Justice Department in hopes of negotiating a settlement, Milliken said.

S. Thomas Carmichael, a neurologist at UCLA, said about 55 grants totaling $23 million from the NIH, including studies of migraines, epilepsy, and autism, were frozen in his department at the David Geffen School of Medicine. As bad as funding cuts are, he warned of the Trump administration’s ability to attack a school’s accreditation, to limit visas for international students, or to launch investigations.

“It’s essentially a complete and total power mismatch to take the federal government on,” Carmichael said. “If you simply give no ground, yield nothing, you won’t win.”

Separately, in mid-September, a group of UC labor unions and faculty associations filed suit against the federal government, claiming the threat to research funds amounted to “financial coercion” to adopt campus policies that would restrict free speech. A hearing in that case is scheduled for December.

Brenda L., a UCLA patient, said she was devastated when a scan in 2021 led to her stage 4 lung cancer diagnosis at age 70. After 18 months on Tagrisso, a drug considered the gold standard for treating this particular cancer, her tumors started growing again. (Brenda declined to provide her full name because she hasn’t disclosed her diagnosis to some family members.)

“I was just feeling like, well, that’s the end of me,” said Brenda, who’s now 75 and lives in Bakersfield. She joined a clinical trial and has been taking another experimental drug alongside Tagrisso for two years. The combination has all but stopped the cancer’s progression.

“I’m the lucky one,” said Brenda, whose current trial has not been impacted. “Other patients, they should have that same chance.”

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The leadership upheavals, which he says will restore trust in federal health agencies, have shaken the confidence many states have in the CDC and led to the fracturing of a national, cohesive immunization policy that’s endured for .

States and medical societies that long worked in concert with the CDC are breaking with federal recommendations, saying they no longer have faith in them amid the turmoil and Kennedy’s criticism of vaccines. Roughly seven months after Kennedy’s nomination was confirmed, they’re rushing to draft or release their own vaccine recommendations, while new groups are forming to issue immunization guidance and advice.

How the new system will work is still being hammered out. Vaccine recommendations from states, medical societies, and other groups are likely to diverge, creating dueling guidance and requirements. Schoolchildren in New York may still generally need immunizations, for example, while others in places such as Florida may not need many vaccines.

There are potential financial ramifications too, because historically, private insurers, Medicaid, and Medicare have generally covered only vaccines recommended by the federal government. If the CDC and its advisory group, which began Sept. 18 in Atlanta, stop recommending certain vaccines, hundreds of millions of people could wind up paying for shots that previously cost them nothing. Some states are already taking steps to prevent that from happening, which means where people live could determine if they will face costs.

“You’re seeing a proliferation of recommendations, and the recommendations by everybody are different from the CDC,” said , a University of Minnesota epidemiologist who launched an ad hoc group that provides vaccine guidance. “States and medical societies are basing their recommendations on science. The recommendations out of CDC are magic, smoke, and mirrors.”

Kennedy has defended changes at the CDC and the revamping of the vaccine committee as necessary, saying previous advisory panel members had and agency leadership botched its pandemic response.

The CDC is “the most corrupt agency at HHS, and maybe the government,” Kennedy said at a . Susan Monarez, the ousted CDC director, testified Sept. 17 at another Senate hearing about how Kennedy told her to preapprove vaccine recommendations from the advisory panel or be fired.

Kennedy has said HHS also plans to investigate vaccine injuries he says are . The CDC investigates injuries that are reported by providers or patients, but Kennedy has said he wants to recast the entire program. The Food and Drug Administration is already who died following covid-19 vaccination.

HHS didn’t return an email seeking comment.

The actions by states, medical societies, and other groups reflect a mounting lack of confidence in federal leadership, public health leaders say, and the break from the CDC is happening at a rapid clip.

The Democratic governors of California, Hawaii, Oregon, and Washington — fashioning themselves as the West Coast Health Alliance — are coordinating to develop vaccine recommendations that won’t necessarily follow those from the CDC. The governors said in a that the CDC shake-up has “impaired the agency’s capacity to prepare the nation for respiratory virus season and other public health challenges” and this week for vaccination against viruses such as covid, influenza, and respiratory syncytial virus.

A group of northeastern states are exploring a similar collaborative.

“The worst thing that could happen is that we have 50 different recommendations for the covid vaccine. That will destroy public health,” said Massachusetts Public Health Commissioner Robbie Goldstein, who has been involved with the effort. He’s also spoken with leaders of the West Coast alliance. “I’m really hopeful that we do come together in larger and larger collaboratives with the same recommendations or very similar recommendations,” he said while speaking to a group of reporters this month.

And medical societies such as the American Academy of Pediatrics are releasing covid vaccine recommendations for the first time from the CDC’s guidance.

Some states are seizing on the split to ensure access to shots. Massachusetts is to cover vaccines recommended by the state health department rather than paying only for those suggested by the CDC, making it the first state to guarantee such continued coverage. AHIP, a trade group representing insurers, that health plans will cover immunizations, including updated formulations of covid and flu vaccines, that were recommended by the CDC panel as of Sept. 1 with no cost sharing through the end of 2026.

Pennsylvania is to give covid vaccines even if they’re not recommended by the federal agency. Instead, they can follow recommendations from the pediatric academy and other medical groups.

Florida, meanwhile, plans to for schoolchildren to get immunizations against chickenpox, meningitis, hepatitis B, and some other diseases. State lawmakers would need to take action to end mandates for all vaccines.

Joseph Ladapo, the state’s surgeon general, said in a that any vaccine requirement is wrong and “drips with disdain and slavery.”

Some doctors criticize the decision as a dangerous step backward.

“This is a terrifying decision that puts our children’s lives at risk,” said , former acting director of the CDC, in an emailed statement.

The first school vaccine mandate was rolled out in the , for smallpox. While all states have vaccine requirements for schoolchildren, immunization rates for kindergarten students declined while cases of vaccine-preventable in 2024 and 2025.

Rochelle Walensky, the Biden administration’s first CDC director, warned of the “polarization” of state-by-state approaches. “It’s like your head is in the oven and your feet are in the freezer and, on average, we’re at 95% vaccination. That doesn’t work in measles — every place has to be at 95% vaccination.” She was referring to the proportion of a population that needs to be vaccinated to provide herd immunity.

Kennedy’s actions have thrust vaccines center stage and made him fodder for comedy. The Marsh Family, a British musical group, on Sept. 7 of Paul Simon’s “Me and Julio Down by the Schoolyard,” with the chorus, “We’ll see measles and polio down in the schoolyard.”

HBO comedian said the CDC could be known by the title “Disease” during a recent episode of his show. And Stephen Colbert used his monologue on “The Late Show with Stephen Colbert” to weigh in on the revamped vaccine advisory group, calling its new members the “.”

President Donald Trump has defended Kennedy, telling reporters “he means very well,” even as Trump said on Sept. 5 that “you have some vaccines that are so amazing.” Trump has repeatedly expressed pride in Operation Warp Speed, a government initiative during Trump’s previous administration that rapidly developed covid vaccines. But he’s also promoted a discredited theory linking vaccines and autism.

The White House did not respond to a request for comment.

The Trump administration already narrowed recommendations for the covid vaccine despite no new safety risks with the shots, although medical societies are continuing to recommend them for most people. The gulf is expected to widen as the agency’s advisory group reviews on a number of pediatric vaccines.

Other groups are also trying to provide vaccine and public health guidance, driven in part by concerns that Kennedy and other federal health leaders will make policy decisions and statements not grounded in science. Kennedy has promoted claims that aluminum, used in many vaccines, is , despite a lack of evidence for the claims. A , in fact, found aluminum was not linked to chronic disease, but Kennedy said the study’s supplemental data indicated it caused harm. The journal that published the study .

Current and former CDC and HHS staffers, along with public health academics and retired health officials, have formed the National Public Health Coalition, a nonprofit to endorse recommendations and provide guidance on policy issues. They plan to partner with state and local health departments.

“A real benefit of the National Public Health Coalition is we are made up of current and former CDC and HHS folks, people who have deep knowledge of what government programs for public health look like, and what improvements are needed,” said Abigail Tighe, the group’s executive director.

Another new group is , which bills itself as a volunteer-led effort to raise awareness about vaccines. And the was launched in April by the University of Minnesota’s infectious disease center, to review evidence for medical societies on the safety and effectiveness of vaccines.

“We’re going to continue to help wherever we can to address misinformation,” said Osterholm, the center’s leader.

ºÚÁϳԹÏÍø 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 .

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Hasta este año.

El plan de la administración Trump de 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 , que pone en marcha gran parte de la agenda nacional del presidente Donald Trump.

Texas, por ejemplo, anticipa una reducción de hasta 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.

han bajado sus proyecciones de ingresos para el año próximo, según un informe .

“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 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 .

Otros estados recortan proyectos para enfrentar la situación.

El gobernador de Delaware, Matt Meyer, demócrata, supo en marzo que la administración Trump retiraría 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 , presidente temporal del Senado estatal.

En Nuevo México, el estado con el , un grupo bipartidista de legisladores votó a favor de crear un fondo fiduciario para reforzar el financiamiento del programa. Según , aproximadamente el 10% de los 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 .

En California, los legisladores analizaron el impacto de los recortes en 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 (CBO). Las reducciones en el gasto vienen en gran medida de la imposición de un 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 .

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 destinados a los estados durante la pandemia, lo que provocó una con una coalición de estados gobernados por demócratas. También recortó unos en 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 ºÚÁϳԹÏÍø 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 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 , vicepresidente ejecutivo de políticas de salud en KFF. (ºÚÁϳԹÏÍø 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 para , presentando demandas para intentar bloquear los recortes y reasignando fondos.

En Colorado, los legisladores 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 en los tribunales.

La legislatura de Louisiana asignó 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 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 , 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.

ºÚÁϳԹÏÍø 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 .

USE OUR CONTENT

This story can be republished for free (details).