Pero eso no ha detenido a legisladores de Florida que, de todos modos, están tratando de imponer requisitos de trabajo para acceder a Medicaid. Hasta ahora, es la única Legislatura de un estado que no ha ampliado el programa que está considerando una medida de esa naturaleza.

“Tienes que ir a trabajar si quieres que tus amigos y vecinos paguen tu atención médica”, sentenció el , impulsor de la propuesta de imponer requisitos laborales para Medicaid que se debate en la Legislatura estatal.

La medida desconcierta a defensores de la atención médica y a expertos en Medicaid. Algunos dudan, incluso, que sea legal bajo la principal ley de política interna del presidente Donald Trump.

“No se pueden cambiar los términos del requisito de trabajo”, afirmó , abogado y profesor de la Escuela McCourt de Políticas Públicas de la Universidad de Georgetown, emitidas por los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés).

Para Cuello, la situación es clara: “Es un no rotundo”.

Los requisitos de trabajo de Medicaid afectan a Washington, D.C., y a los 40 estados que ampliaron la elegibilidad a todos los adultos sin discapacidad entre 19 y 64 años con ingresos de hasta el 138% del nivel federal de pobreza, como establece la Ley de Cuidado de Salud a Bajo Precio (ACA). Eso equivale a un ingreso de $22.025 al año para una persona sola.

A partir de enero de 2027, esos estados deberán exigir a las personas beneficiadas por la ampliación que informen por lo menos 80 horas de trabajo mensuales, educación o servicio comunitario para calificar y mantener la cobertura de Medicaid.

Alrededor de 4 millones de personas están inscritas en el programa de Florida y Gaetz calcula que unas 147.000 son adultos que “podrían y deberían trabajar”.

“Son personas sanas, no tienen niños pequeños en casa y no están cuidando a una persona mayor o a alguien con discapacidad”, dijo. “Sin embargo, reciben beneficios de Medicaid”.

por el proyecto de ley del Senado serían principalmente padres de niños de 14 años o más, así como algunos jóvenes de 19 y 20 años, explicó. Un en la Cámara de Representantes de Florida impondría los requisitos de trabajo de Medicaid a padres de niños de 6 años en adelante.

Para calificar para Medicaid en Florida, un adulto en edad laboral sin discapacidad generalmente debe estar cuidando a un niño o a un familiar mayor o con discapacidad, y no puede ganar más del 26% del nivel federal de pobreza, o unos $592 mensuales para una familia integrada por tres personas.

La mayoría de los adultos que no tienen discapacidad y reciben Medicaid ya trabajan, y muchas personas con empleos mal pagados no reciben seguro de salud a través de un empleador, , una organización sin fines de lucro de información sobre salud que incluye a ºÚÁϳԹÏÍø News.

En Florida, en 2024, entre los adultos solteros de 19 a 64 años que ganaron menos de $15.000 al año, tenía seguro de salud a través del trabajo.

Los críticos dicen que la propuesta de Florida probablemente dejaría a algunas personas sin seguro, aunque cumplan con el requisito laboral. Esto se debe a que el límite de ingresos para acceder a Medicaid en ese estado es tan bajo que trabajar las 80 horas mensuales exigidas probablemente haría que esas personas superaran el tope permitido y perdieran el derecho a la cobertura.

Sin embargo, tampoco ganarían lo suficiente como para poder acceder a un plan subsidiado en el mercado de ACA.

Michelle Mastrototaro dijo que perdió su cobertura de Medicaid en noviembre del año pasado después de aceptar un trabajo de medio tiempo como asistente de maestra en una escuela primaria de Tampa. Mastrototaro, de 47 años, cuida a un hijo adolescente con discapacidad y probablemente no tendría que cumplir con el requisito de trabajo propuesto en Florida.

Pero dijo que su salario quincenal por trabajar unas 17 horas a la semana la hizo superar el límite de ingresos de Medicaid. Desde entonces ha tenido dificultades para pagar sus medicamentos recetados.

“Lo que estoy ganando es casi nada”, contó Mastrototaro. “Estoy rebuscándomelas como puedo para apenas llegar a fin de mes”.

La propuesta liderada por Gaetz ignora “las duras realidades de lo que implica calificar para Medicaid en Florida”, dijo , director ejecutivo de Florida Voices for Health, una organización sin fines de lucro que promueve la ampliación de Medicaid. “A simple vista no tiene sentido”, señaló.

Expertos en Medicaid dicen que la establece que los estados que no han ampliado Medicaid no pueden exigir requisitos de trabajo.

Un estado que no ha agregado más adultos de bajos ingresos a su programa de Medicaid no puede imponer requisitos laborales a quienes ya tienen cobertura, ratificó Cuello.

Los estados deben cubrir categorías específicas de personas de bajos ingresos —como niños, mujeres embarazadas, algunos padres, adultos mayores y personas con discapacidad— para recibir financiamiento federal para sus programas.

Los estados que han ampliado Medicaid a un grupo limitado de adultos de bajos ingresos, específicamente Georgia y Wisconsin, están obligados a imponer requisitos de trabajo a los nuevos beneficiarios.

El , lanzado en julio de 2023, ya incluye un requisito para que los adultos que ahora son elegibles demuestren al menos 80 horas de trabajo o participación comunitaria. La aprobación federal para el programa expira a finales de diciembre y el estado ha solicitado . El deberá implementar los requisitos laborales antes del 1 de enero.

Carolina del Sur solicitó en junio la aprobación federal para ampliar la a padres y cuidadores sin discapacidad de entre 19 y 64 años que ganen entre el 67% y el 100% del nivel federal de pobreza. Eso equivale aproximadamente a entre $18.300 y $27.300 al año para una familia de tres miembros. La solicitud del estado está pendiente ante los CMS y, si se aprueba, implementaría requisitos de trabajo para los adultos que cumplan con las nuevas condiciones.

Gaetz dijo que, si la legislación de Florida se aprueba, el estado desarrollaría un “plan de negocios” para implementar los requisitos de trabajo y luego solicitaría la aprobación de los CMS.

No está claro cuánto costaría, pero la experiencia en estados que ya han aplicado requisitos laborales en Medicaid sugiere que la implementación demandaría un gasto elevado. Los estados deben actualizar sus sistemas de elegibilidad e inscripción, contratar personal adicional e informar al público sobre las nuevas exigencias.

Georgia, por ejemplo, gastó en cambios administrativos alrededor de $54,2 millones, de un total de $80,3 millones destinados al programa entre octubre de 2020 y marzo de 2025, de la Oficina de Rendición de Cuentas del Gobierno de EE.UU. (GAO, por sus siglas en inglés). La mayor parte del gasto administrativo —unos $47,4 millones, o 88%— provino del gobierno federal.

La experiencia de Georgia refleja la de otros estados, según sobre estados que recibieron la aprobación para implementar requisitos de trabajo de Medicaid durante la primera administración de Trump.

Ese informe se centró en cinco estados —Arkansas, Indiana, Kentucky, New Hampshire y Wisconsin— y estimó que los costos totales serían de $408 millones. Oscilaban entre $6 millones en New Hampshire y más de $270 millones en Kentucky, aunque esas cifras no incluían todos los costos estatales.

“La infraestructura informática de Florida para la recopilación y verificación de información, así como para determinar la elegibilidad, tiene más de 30 años de antigüedad y está siendo reemplazada. Se espera que el proceso se complete en 2028 y que cueste más de $180 millones.

Un análisis legislativo del proyecto de Gaetz estimó que, si 1 de cada 4 personas afectadas por el requisito de trabajo propuesto perdiera la cobertura de Medicaid, el estado podría ahorrar unos $80 millones al año.

Darius, de Florida Voices for Health, dijo que esos posibles ahorros difícilmente parezcan justificar el esfuerzo.

“Requiere que el estado construya este enorme marco regulatorio y reconstruya sistemas y contrate a numeroso personal para perseguir al pequeño número de personas que finalmente se verían afectadas por esto”, explicó.

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That’s not stopping Florida lawmakers from trying to adopt Medicaid work requirements anyway. It’s the only legislative body in a nonexpansion state to even consider it so far.

“You need to go to work if you want your friends and neighbors to pay for your health care,” said , the Republican sponsor of a Medicaid work requirement proposal making its way through the legislature.

The move baffles health care advocates and Medicaid experts. Some doubt it’s even legal under President Donald Trump’s signature domestic policy law.

“You cannot change the terms of the work requirement,” said , an attorney and a professor at Georgetown University’s McCourt School of Public Policy, issued by the Centers for Medicare & Medicaid Services. For Cuello, the answer is clear: “It’s a pretty easy no.”

would primarily be parents of children 14 and older, and some 19- and 20-year-olds, he said. A in the Florida House would apply Medicaid work requirements to parents of children ages 6 and older.

To qualify for Medicaid in Florida, a working-age adult without a disability must generally be caring for a child or an older or disabled family member and cannot earn more than 26% of the federal poverty level, or about $592 a month for a family of three.

Most adults who are not disabled and receive Medicaid already work, and many people in low-paying jobs do not receive health insurance through an employer, , a health information nonprofit that includes ºÚÁϳԹÏÍø News. Among single adults ages 19 to 64 in Florida who made under $15,000 a year in 2024, through work.

Critics say Florida’s proposal would likely force some people to become uninsured, even if they meet the work requirement. That’s because the state’s Medicaid income limit is so low that working the mandated 80 hours a month would likely cause those individuals to exceed the income eligibility limit but also leave them earning too little to qualify for subsidized coverage on the Affordable Care Act marketplace.

Michelle Mastrototaro said she lost her Medicaid coverage in November after taking a part-time job as a teaching assistant at a Tampa elementary school last year. Mastrototaro, 47, cares for a disabled teenage son and likely would not need to meet Florida’s proposed work requirement.

But she said her biweekly wages from working about 17 hours a week pushed her past the Medicaid income limit. She has struggled to afford her prescription medications since.

“What I’m making is nothing,” Mastrototaro said. “I am scavenging just to make ends meet.”

The Gaetz-led proposal ignores “the hard realities of what it takes to be qualifying for Medicaid in Florida,” said , executive director of Florida Voices for Health, a nonprofit that advocates for Medicaid expansion. “On its face,” he said, “it doesn’t make sense.”

Medicaid experts say the holds that nonexpansion states cannot adopt work requirements.

A state that hasn’t added more low-income adults to its Medicaid program can’t impose work requirements on those who are already covered, Cuello said. States must cover specific categories of low-income people — such as children, pregnant women, some parents, older adults, and people with disabilities — to receive federal funding for their programs.

States that have expanded Medicaid eligibility to a limited group of low-income adults, namely Georgia and Wisconsin, will be required to impose work requirements on those enrollees.

, launched in July 2023, already includes a requirement that newly eligible adults report at least 80 hours of work or community engagement. Federal approval for the program expires at the end of December, and the state . will have to implement a work requirement by Jan. 1.

South Carolina applied in June for federal approval to to nondisabled parents and caregivers ages 19 to 64 who earn 67-100% of the federal poverty level. That’s about $18,300 to $27,300 a year for a family of three. The state’s application is pending with CMS, and if approved would implement work requirements for those newly eligible adults.

Gaetz said if the Florida legislation were approved, the state would develop a “business plan” for implementing work requirements and seek CMS approval.

It is unclear how much it would cost, but experience in states with Medicaid work requirements suggests that implementation would be expensive. States must upgrade their eligibility and enrollment systems, hire additional staff, and inform the public of the new mandate.

For its program, Georgia spent about $54.2 million on administrative changes out of $80.3 million in total spending for the program from October 2020 to March 2025, according to from the U.S. Government Accountability Office. Most of the administrative spending — about $47.4 million, or 88% — came from the federal government.

Georgia’s experience echoes others’, according to a 2019 of states that received approval to implement Medicaid work requirements during the first Trump administration. That report focused on five states — Arkansas, Indiana, Kentucky, New Hampshire, and Wisconsin — and estimated costs would total $408 million. They ranged from $6 million in New Hampshire to more than $270 million in Kentucky, though those figures did not reflect all the state costs.

Florida’s computer infrastructure for collecting and verifying information and determining eligibility is more than 30 years old and is being replaced. That is anticipated to be completed in 2028 and cost more than $180 million.

A legislative analysis of Gaetz’s bill estimated that if 1 in 4 people affected by the proposed work requirement were to lose Medicaid coverage, the state could save about $80 million a year.

Darius, with Florida Voices for Health, said those potential savings hardly seem worth the effort.

“It requires the state to build this giant regulatory-like framework and to rebuild systems, and to employ a whole set of people to chase down the very small number of folks who would ultimately be touched by this,” he said.

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“Cuando te disparan, dejas de pensar en el futuro”, dijo.

Su esposa, su hijo y su fe son su gran apoyo. En el pasado quiso trabajar como operador de montacargas, pero logró desarrollar una carrera estable en tecnología de la información. Hoy en día se rodea de otras personas sobrevivientes de heridas de bala y se enfoca en el activismo.

Aun así, el trauma permanece en su vida cotidiana. Cuando la violencia por armas de fuego aumentó durante la pandemia de covid, sacudió su frágil sentido de seguridad. Mudó a su familia de Philadelphia a un suburbio arbolado en Delaware. Pero el miedo constante al crimen persiste.

Ahora está considerando comprar un arma.

Harris es una de las decenas de miles de personas que mueren o resultan heridas cada año por un arma de fuego, una crisis de salud pública que se intensificó durante la pandemia y que lleva a a la sala de emergencias cada media hora.

En las últimas dos décadas, la industria de armas de fuego y ha intensificado sus campañas de ventas a través de influencers en redes sociales, presentaciones en conferencias y .

Una organización del sector reconoció que su cliente tradicional era , por lo que en años recientes comenzó a dirigir su mercadeo hacia y otras comunidades de color, , que se ven afectadas de forma desproporcionada por la violencia de las armas.

La administración Trump redujo la supervisión federal sobre las empresas de armas, que la Oficina de Alcohol, Tabaco, Armas de Fuego y Explosivos (ATF, por sus siglas en inglés) “caracterizada por la transparencia, la responsabilidad y la colaboración con la industria de las armas de fuego”.

El dolor causado por esta forma de violencia atraviesa divisiones políticas, culturales y geográficas, pero ningún grupo ha sufrido tanto como las personas afroamericanas, como Harris. citados por investigadores, en 2021 las personas negras tenían casi 14 veces más probabilidades de morir por homicidio con arma de fuego que las personas blancas. Los hombres y niños negros representan el 6% de la población, pero son de las víctimas de homicidio.

Washington ha ofrecido poco alivio: las armas siguen siendo uno de los pocos productos de consumo que el gobierno federal en cuanto a salud y seguridad.

“La política de las armas en Estados Unidos está tremendamente desalineada con las prioridades correctas, que deberían centrarse en la salud, la seguridad y el derecho fundamental a vivir”, dijo el abogado Jon Lowy, fundador de , quien ayudó a representar a México en una demanda —sin éxito— contra Smith & Wesson y otros fabricantes de armas que llegó hasta la Corte Suprema. “Estados Unidos permite y respalda prácticas de la industria armamentista que serían totalmente inaceptables en cualquier otra parte del mundo”.

ºÚÁϳԹÏÍø News llevó a cabo una investigación sobre la violencia por armas de fuego durante la pandemia, período en el que las muertes por estas armas alcanzaron su nivel más alto en la historia.

Los periodistas revisaron investigaciones académicas, informes del Congreso y datos de hospitales, y entrevistaron a decenas de expertos en salud pública y en este tipo de violencia, personas dueñas de armas y víctimas o sus familiares.

La investigación encontró que, mientras los funcionarios imponían restricciones para frenar la propagación de covid, las decisiones políticas y regulatorias impulsaron las ventas de armas y, con ello, otra crisis de salud pública.

Mientras los gobiernos estatales y locales escuelas, pedían a la población que se quedara en casa y suspendían actividades en gimnasios, teatros, centros comerciales y otros espacios, el entonces presidente Donald Trump mantuvo abiertas las tiendas de armas, considerándolas para el funcionamiento de la sociedad.

Kush Desai, vocero de la Casa Blanca, no respondió a solicitudes de entrevista ni a preguntas sobre los esfuerzos de la administración Trump para reducir la regulación de la industria de armas.

Durante la pandemia, el gobierno federal entregó más de $150 millones en asistencia financiera a empresas y grupos del sector de las armas a través del Programa de Protección de Cheques de Pago (Paycheck Protection Program), incluso cuando algunas empresas reportaban fuertes ventas, según del grupo de defensa Comunidades por la Seguridad de las Armas (Everytown for Gun Safety).

Funcionarios federales dijeron que el programa tenía como objetivo mantener empleos, pero millones de dólares fueron a parar a empresas de armas que no declararon si esos fondos ayudarían a conservar puestos de trabajo, según el informe.

Alrededor de en Estados Unidos compró un arma durante los dos primeros años de la pandemia, incluidos millones de compradores primerizos, según datos de encuestas de NORC en la Universidad de Chicago.

Harris comprende claramente lo que impulsa esa demanda.

“Las armas no van a desaparecer a menos que abordemos la raíz de los miedos de las personas”, dijo.

muestran que la mayoría de los que poseen un arma creen que les brinda mayor seguridad. Pero los datos de salud pública indican que tener un arma en casa de homicidio y triplica las probabilidades de suicidio.

“No hay pruebas de que las armas aumenten la protección”, señaló Kelly Drane, directora de investigación del Centro Legal Giffords para Prevenir la Violencia por Armas de Fuego ().

“Nos han contado una mentira fundamental”, añadió.

Muertes récord

Menos de un año después del inicio de la pandemia, Jacquez Anlage, de 20 años, fue asesinado a tiros en un apartamento en Jacksonville, Florida. Cinco años después, el crimen sigue sin resolverse.

Su madre, Crystal Anlage, dijo que cayó de rodillas y gritó de dolor en su jardín cuando la policía le dio la noticia.

Contó que Jacquez superó años en el sistema de cuidado temporal —pasó por 36 hogares— antes de que ella y su esposo, Matt, lo adoptaran a los 16 años.

Jacquez acababa de mudarse a su propio apartamento cuando lo mataron. Amaba a los animales y quería convertirse en técnico veterinario. Era amable y afectuoso, dijo Crystal de su hijo adoptivo, medía 6’4” y pesaba 215 libras, propias de ser un ex jugador de fútbol americano y baloncesto.

“Recién comenzaba a sentirse seguro en la vida”, añadió Crystal Anlage.

Investigadores afirman que padres como Crystal Anlage cargan un trauma que destruye su sentido de seguridad.

Anlage contó que padece trastorno de estrés postraumático y ansiedad. Le aterran las armas y los fuegos artificiales.

Pero ha logrado darle un propósito al asesinato de su hijo: cofundó la organización Fundación de Sobrevivientes de Jacksonville (Jacksonville Survivors Foundation), que busca concientizar sobre el impacto del homicidio y apoyar a madres y padres en duelo.

“La muerte de Jacquez no puede ser en vano”, dijo. “Quiero que su legado sea el amor”.

Ese legado y el de muchos otros jóvenes asesinados a tiros quedan opacados por el poderoso mensaje de miedo que difunden los fabricantes de armas.

Durante la pandemia, las campañas publicitarias del sector le decían a la población que necesitaba armas para defenderse de criminales, manifestantes, policías poco confiables y durante , según presentada por grupos que abogan por el control de armas ante la Comisión Federal de Comercio (Federal Trade Commission, FTC).

En una del 18 de junio de 2020, de la empresa Lone Wolf Arms, un fabricante con sede en Idaho, se mostraba a un manifestante ante policías antidisturbios entre las palabras “¿Retirar la financiación a la policía? Defiéndete tú mismo”. El pie de foto ofrecía “entre 10% y 25% de descuento en armas demo y pistolas completas”.

Impact Arms, una tienda de armas en línea, publicó el 3 de agosto de 2020 en Instagram una imagen de una persona guardando un rifle en una mochila, señala el documento. El mensaje decía: “El mundo está bastante loco ahora mismo. No es mala idea llevar algo más eficiente que una pistola”.

La Asociación Nacional del Rifle (National Rifle Association, NRA) publicó en 2020 de cuatro minutos en YouTube donde una mujer negra sostiene un rifle y le dice a la audiencia que necesitan un arma durante la pandemia. “Tal vez estés almacenando comida para superar esta crisis”, dijo, “pero si no te estás preparando para defender tu propiedad cuando todo salga mal, en realidad estás almacenando para otra persona”.

El mensaje fue efectivo. Las verificaciones de antecedentes para comprar armas aumentaron 60% , año en que el gobierno federal declaró la emergencia sanitaria.

Ese mismo año, más de murieron en Estados Unidos, la cifra más alta hasta entonces. En 2021, se volvió a romper .

Las armas vendidas al inicio de la pandemia tenían más probabilidades de terminar en escenas de un crimen al año siguiente, según del Comité Económico Conjunto del Congreso, de mayoría demócrata, que citaba datos de la ATF.

Los fabricantes de armas “utilizaron tácticas de ventas preocupantes” tras tiroteos masivos en Buffalo, Nueva York, y Uvalde, Texas, “sin tomar siquiera medidas básicas para monitorear la violencia y destrucción que sus productos generan”, de acuerdo con un hecho público por los demócratas del Congreso en 2022, después de conocerse una investigación sobre prácticas y beneficios de la industria llevada a cabo por el Comité de Supervisión y Reforma de la Cámara de Representantes (House Oversight and Reform Committee).

Según esta investigación del Congreso, la industria ha publicitado las armas “entre organizaciones supremacistas blancas y extremistas durante años, apelando al miedo a la represión gubernamental contra propietarios de armas y fomentando tensiones raciales”.

“El aumento de la violencia con motivación racial también ha impulsado la compra de armas entre personas negras, lo que permite a la industria lucrar tanto con los supremacistas blancos como con sus objetivos”, señala el informe del Congreso.

En 2024, el entonces gobierno del presidente Joe Biden, a través del Departamento del Interior, otorgó una a la Fundación Nacional de Tiro Deportivo (National Shooting Sports Foundation, NSSF), un importante , para ayudar a las empresas a comercializar armas entre la población negra.

La Comisión Federal de Comercio (FTC, en inglés) es la agencia responsable de proteger a los consumidores de prácticas comerciales engañosas o injustas, y tiene poder para sancionar. Por ejemplo, emitió advertencias a empresas que hicieron afirmaciones falsas sobre productos que supuestamente prevenían o curaban covid.

Pero cuando en 2022, durante el gobierno de Joe Biden, familiares de víctimas de violencia por armas de fuego, legisladores y grupos defensores cómo se promocionaban las armas entre menores, personas de color y grupos supremacistas blancos, la agencia no anunció ninguna acción pública.

Este verano, la NSSF presentó y calificó los intentos de los grupos de control de armas como parte de una “campaña coordinada de guerra legal” contra la publicidad de las armas de fuego, “que está protegida constitucionalmente”.

Mitchell Katz, vocero de la FTC, se negó a comentar, señalando por correo electrónico que la agencia no confirma ni niega la existencia de investigaciones.

Serena Viswanathan, quien se retiró en junio como directora asociada de la FTC, dijo a ºÚÁϳԹÏÍø News que la agencia perdió al menos una cuarta parte del personal de su división de publicidad desde la llegada de Trump a la presidencia en enero.

Las empresas de armas Smith & Wesson, Lone Wolf Arms e Impact Arms no respondieron a solicitudes de comentarios. Tampoco lo hicieron la NSSF ni la Asociación Nacional del Rifle (NRA, en inglés).

En una de agosto de 2022, el presidente y CEO de Smith & Wesson, Mark Smith, dijo que algunos políticos estaban culpando erróneamente a los fabricantes de armas por el aumento de la violencia durante la pandemia, argumentando que las ciudades con altos índices de crimen habían “promovido políticas irresponsables y blandas con el crimen, que a menudo tratan a los criminales como víctimas y a las víctimas como criminales”.

“Ahora algunos buscan prohibir que fabricantes y defensores de la Segunda Enmienda anuncien productos de una manera que recuerde a los ciudadanos respetuosos de la ley que tienen un derecho constitucional a portar armas para defenderse a sí mismos y a sus familias”, añadió Smith.

Armas y raza

En 2015, la NSSF reunió a simpatizantes en una conferencia en Savannah, Georgia, e instó a la industria a diversificar su base de clientes, según un y reportes de y del (Violence Policy Center, VPC).

Chris Cheng, especialista en tiro deportivo, dio una presentación titulada “Diversidad: la próxima gran oportunidad”. Imágenes de la conferencia muestran gráficas que describen la “demografía” y “tecnografía” de tiradores negros e hispanos.

Las gráficas describían a los tiradores negros como “expresivos y seguros socialmente, en el grupo” y “menos propensos a estar casados o a haber terminado la universidad”. A los tiradores hispanos se les consideraba “mucho más confiados en la publicidad y en las celebridades”.

Nick Suplina, vicepresidente de políticas públicas de Comunidades por la Seguridad de las Armas, dijo que el mercadeo de la industria cambió en la segunda mitad del siglo XX, cuando el interés por la caza comenzó a disminuir. El nuevo enfoque: armas para la seguridad personal.

“Dijeron: ‘Necesitamos entrar a nuevos mercados’”, explicó Suplina. “Identificaron a mujeres y personas de color. No tuvieron mucho éxito hasta la pandemia, el movimiento Black Lives Matter y la muerte de George Floyd. El mensaje es: ‘Tú también mereces la Segunda Enmienda’. Están vendiendo el producto como un antídoto al miedo y la ansiedad”.

La investigación del Comité de Supervisión de 2022 criticó duramente a las compañías por promocionar sus productos entre personas de color, mientras la violencia armada sigue siendo una de las principales causas de muerte entre jóvenes afroamericanos e hispanos.

Al mismo tiempo, algunas empresas también promovieron rifles de asalto entre grupos supremacistas blancos que creen que se avecina una guerra racial, según la investigación. Una compañía incluso vendía un rifle tipo AK-47 llamado “Big Igloo Aloha”, en referencia a un movimiento antigubernamental.

Aun así, Philip Smith quiere que más personas negras compren armas para protegerse.

Smith dijo que trabajaba como consultor de recursos humanos cuando se le ocurrió crear la (National African American Gun Association, NAAGA) que ayudó a la Fundación Nacional de Tiro Deportivo (NSSF, en inglés) a preparar su informe sobre cómo comunicarse con consumidores afroamericanos.

Smith alienta a las personas negras a comprar armas para defensa personal y a recibir capacitación adecuada sobre su uso.

Tras 10 años, dijo que su organización tiene cerca de 45.000 miembros en todo el país. La membresía individual cuesta $39 anuales y la de parejas $59, lo que brinda acceso a descuentos de socios corporativos, incluidas empresas fabricantes de armas, y sorteos de armas, según su sitio web.

El asesinato policial de Michael Brown en Ferguson, Missouri, y la muerte a tiros del adolescente Trayvon Martin en Florida impulsaron el interés inicial entre doctores, abogados y otros profesionales, dijo Smith. Pero el verdadero crecimiento se dio durante la pandemia, incluso entre personas demócratas que antes se oponían a tener un arma.

“Cientos de personas me llamaban y decían: ‘No estoy de acuerdo con nada de lo que dices, pero ¿qué tipo de arma debo comprar?’”, recordó Smith.

Smith, que se describe como “callado, nerd y afrocentrista”, dijo que criticar las armas es perder la perspectiva.

“Mis ancestros dieron su sangre para que tengamos este derecho”, afirmó. “¿Hay personas blancas racistas? Sí. Pero deberíamos comprar armas porque hay una necesidad. No porque nos obligan”.

“Amnesia estadounidense”

Durante la pandemia, la violencia con armas de fuego afectó más gravemente a vecindarios racialmente segregados en ciudades como Philadelphia, donde aproximadamente vive en la pobreza.

Un informe de la ciudad indicó que durante un período de un año en la pandemia se registraron más de 2.300 tiroteos, unos seis por día. Muchos por la policía.

Funcionarios de la ciudad señalaron el auge en la venta de armas: en el año 2000 hubo menos de 400.000 ventas en Pennsylvania; en 2020, más de un millón.

Las ventas de armas desde el fin de la pandemia, pero el daño causado persiste.

En una conferencia realizada el año pasado en el estadio del equipo de fútbol americano Eagles, víctimas de esta violencia y sus familiares se reunieron con activistas para compartir relatos de experiencias cercanas a la muerte y del dolor de perder a seres queridos.

Pinturas alrededor del escenario conmemoraban a personas jóvenes, casi todas de color, asesinadas a tiros. Los mensajes decían: “Siempre te amaremos y extrañaremos” y “Los que amamos nunca se van”.

Marion Wilson, activista comunitario, dijo que cree que el país ha olvidado el sufrimiento que ciudades como Philadelphia vivieron durante la pandemia.

“Padecemos la enfermedad de la amnesia estadounidense”, señaló.

Harris regresaba a casa tras su trabajo en Burlington Coat Factory hace casi dos décadas cuando unos asaltantes lo siguieron desde la parada del autobús y le exigieron dinero. Dijo que no tenía y le dispararon.

Harris pasó su infancia arreglando autos con su abuelo, cuando no estaba en la escuela o en la iglesia. Recuerda estar acostado en la cama del hospital, sintiéndose completamente impotente.

“Tuve que volver a aprender a alimentarme solo”, dijo. “Era como un bebé. Tuve que aprender a sentarme para poder usar una silla de ruedas. La única manera en que salí adelante fue con mi fe en Dios”.

Harris pasó años en rehabilitación y recibió terapia por estrés postraumático. Ahora, en silla de ruedas, a veces teme por su seguridad y cree que tener un arma podría ser una de las pocas maneras de protegerse a sí mismo y a su familia.

“Lo estoy pensando”, dijo. “Me da miedo que mi trauma pueda dañar a otra persona. Esa es la única razón por la que aún no la he comprado”.

Si tú mismo o alguien que conoces ha sufrido el dolor de una herida de bala y está dispuesto a hablar sobre la experiencia médica, por favor, completa .

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“When you get shot,” he said, “you stop thinking about the future.”

He is anchored by his wife and child and faith. He once wanted to work as a forklift driver but has built a stable career in information technology. He finds camaraderie with other gunshot survivors and in advocacy.

Still, trauma remains lodged in his daily life. As gun violence surged in the shadows of the covid pandemic, it shook Harris’ fragile sense of security. He moved his family out of Philadelphia to a leafy suburb in Delaware. But a nagging fear of crime persists.

Now he is thinking about buying a gun.

Harris is one of tens of thousands of Americans killed or injured each year by gun violence, a public health crisis that escalated in the pandemic and churns a into a hospital emergency room every half hour.

Over the past two decades, the firearm industry has and stepped up sales campaigns through social media influencers, conference presentations, . An industry trade group acknowledged that its traditional customer was “” and in recent years began targeting and who are disproportionately victimized by gun violence.

The Trump administration has moved to reduce federal oversight of gun businesses, announced by the Bureau of Alcohol, Tobacco, Firearms and Explosives as “marked by transparency, accountability, and partnership with the firearms industry.”

The pain of gun violence crosses political, cultural, and geographic divides — but no group has suffered as much as Black people, such as Harris. They were nearly 14 times as likely to die by gun homicide than white people in 2021, , citing federal data. Black men and boys are 6% of the population but of homicide victims.

Washington has offered little relief: Guns remain one of few consumer products the federal government for health and safety.

“The politics of guns in the U.S. are so out of whack with proper priorities that should focus on health and safety and most fundamental rights to live,” said attorney Jon Lowy, founder of , who helped represent Mexico in an unsuccessful lawsuit against Smith & Wesson and other gunmakers that reached the Supreme Court. “The U.S. allows and enables gun industry practices that would be totally unacceptable anywhere else in the world.”

ºÚÁϳԹÏÍø News undertook an examination of gun violence during the pandemic, a period when firearm deaths reached an all-time high. Reporters reviewed academic research, congressional reports, and hospital data and interviewed dozens of gun violence and public health experts, gun owners, and victims or their relatives.

The examination found that while public officials imposed restrictions intended to prevent covid’s spread, politicians and regulators helped fuel gun sales — and another public health crisis.

As state and local governments schools, advised residents to stay home, and closed gyms, theaters, malls, and other businesses to stop covid’s spread, President Donald Trump kept gun stores open, critical to the functioning of society.

White House spokesperson Kush Desai did not respond to interview requests or answer questions about the Trump administration’s efforts to reduce regulation of the firearm industry.

During the pandemic, the federal government gave firearm businesses and groups more than $150 million in financial assistance through the Paycheck Protection Program, even as some businesses reported brisk sales, according to from Everytown for Gun Safety, an advocacy group.

Federal officials said the program would keep people employed, but millions of dollars went to firearm companies that did not say whether it would save any jobs, the report said.

About bought a gun during the first two years of the pandemic, including millions of first-time buyers, according to survey data from NORC at the University of Chicago.

Harris is keenly aware of what drives the demand.

“Guns aren’t going away unless we get to the root of people’s fears,” he said.

most Americans who own a gun feel it makes them safer. But public health data suggests that owning a gun of homicide and triples chances of suicide in a home.

“There’s no evidence that guns provide an increase in protection,” said Kelly Drane, research director for the . “We have been told a fundamental lie.”

Record Deaths

Less than a year into the pandemic, 20-year-old Jacquez Anlage was shot dead in a Jacksonville, Florida, apartment. Five years later, the killing remains unsolved.

His mother, Crystal Anlage, said she fell to her knees and wailed in grief on her lawn when police delivered the news.

She said Jacquez overcame years in the foster care system — living in 36 homes — before she and her husband, Matt, adopted him at age 16.

Jacquez Anlage had just moved into his own apartment when he was shot. He loved animals and wanted to become a veterinary technician. He was kind and loving, Crystal Anlage said, with the 6-foot-4, 215-pound physique of the football and basketball player he’d been.

“He was just getting to a point in life where he felt safe,” Crystal Anlage said.

Gun violence researchers say parents like Crystal Anlage carry trauma that destroys their sense of security.

Anlage said she endures post-traumatic stress disorder and anxiety. She is terrified of guns and fireworks.

But she has made something meaningful of her son’s killing: She co-founded the Jacksonville Survivors Foundation, which works to raise awareness about the impact of homicide and to support grieving parents.

“Jacquez’s death can’t be in vain,” she said. “I want his legacy to be love.”

His legacy and that of other young men killed by guns is muted by firearm manufacturers’ powerful message of fear.

During the pandemic, gun marketers told Americans they needed firearms to defend themselves against criminals, protesters, unreliable cops, and , filed by gun control advocacy groups with the Federal Trade Commission.

In a since-deleted June 18, 2020, from Lone Wolf Arms, an Idaho-based manufacturer, a protester is depicted being confronted by police officers in riot gear between the words “Defund Police? Defend Yourself,” the petition shows. The caption says, “10% to 25% off demo guns and complete pistols.”

Impact Arms, an online gun seller, on Instagram on Aug. 3, 2020, showing a person putting a rifle in a backpack, the document says. “The world is pretty crazy right now,” the caption reads. “Not a bad idea to pack something more efficient than a handgun.”

The National Rifle Association in 2020 posted on YouTube a of a Black woman holding a rifle and telling viewers they need a gun in the pandemic. “You might be stockpiling up on food right now to get through this current crisis,” she said, “but if you aren’t preparing to defend your property when everything goes wrong, you’re really just stockpiling for somebody else.”

The messaging worked. Background checks for firearm sales soared 60% from , the year the federal government declared a public health emergency.

The same year, more than , the highest number up till then. In 2021, was broken again.

Weapons sold at the beginning of the pandemic were more likely to wind up at crime scenes within a year than in any previous period, according to by Democrats on Congress’ Joint Economic Committee, citing ATF data.

Gun manufacturers “used disturbing sales tactics” following mass shootings in Buffalo, New York, and Uvalde, Texas, “while failing to take even basic steps to monitor the violence and destruction their products have unleashed,” according to a released by congressional Democrats in July 2022 following a House Oversight and Reform Committee investigation of industry practices and profits.

The firearm industry has marketed “to white supremacist and extremist organizations for years, playing on fears of government repression against gun owners and fomenting racial tensions,” the House investigation said. “The increase in racially motivated violence has also led to rising rates of gun ownership among Black Americans, allowing the industry to profit from both white supremacists and their targets.”

In 2024, then-President Joe Biden’s Department of the Interior provided a to the National Shooting Sports Foundation, a leading , to help companies market guns to Black Americans.

The Federal Trade Commission is responsible for protecting consumers from deceptive and unfair business practices and has the power to take enforcement action. It issued warnings to companies that made unsubstantiated claims their products could prevent or treat covid, for instance.

But when families of gun violence victims, lawmakers, and advocacy groups in 2022, during Biden’s term, how firearms were marketed to children, people of color, and groups that espouse white supremacy, officials did not announce any public action.

This summer, the National Shooting Sports Foundation pressed its and derided “a coordinated ‘lawfare’ campaign” that it said gun control groups have waged against “constitutionally-protected firearm advertising.”

FTC spokesperson Mitchell Katz declined to comment, saying in an email that the agency does not acknowledge or deny the existence of investigations.

Serena Viswanathan, who retired as an FTC associate director in June, told ºÚÁϳԹÏÍø News that the agency lost at least a quarter of the staff in its advertising practices division after Trump came into office in January.

Gun companies Smith & Wesson, Lone Wolf Arms, and Impact Arms did not respond to requests for comment. Neither did the National Shooting Sports Foundation or the NRA.

In an August 2022 , Smith & Wesson President and CEO Mark Smith said gun manufacturers were being wrongly blamed by some politicians for the pandemic surge in violence, saying cities experiencing violent crime had “promoted irresponsible, soft-on-crime policies that often treat criminals as victims and victims as criminals.”

He added, “Some now seek to prohibit firearm manufacturers and supporters of the 2nd Amendment from advertising products in a manner designed to remind law-abiding citizens that they have a Constitutional right to bear arms in defense of themselves and their families.”

Guns and Race

In 2015, the National Shooting Sports Foundation gathered supporters at a conference in Savannah, Georgia, and urged the firearm industry to diversify its customer base, according to a and reports from and the .

Competitive shooter Chris Cheng gave a presentation called “Diversity: The Next Big Opportunity.” Screenshots from the conference include slides purporting to show “demographics,” “psychographics,” and “technographics” of Black and Hispanic shooters.

The slides described Black shooters as “expressive and confident socially, in a crowd” and “less likely to be married and to be a college grad.” They said Hispanic shooters were “much more trusting of advertising and celebrities.”

Nick Suplina, senior vice president for law and policy at Everytown for Gun Safety, said industry marketing shifted in the latter half of the 20th century as the popularity of hunting declined. The new sales pitch: guns for personal safety.

“They said, ‘We need to break into new markets,’” Suplina said. “They identified women and people of color. They didn’t have a lot of success until the pandemic, the Black Lives Matter movement, and the death of George Floyd. The marketing says, ‘You deserve the Second Amendment too.’ They are selling the product as an antidote to fear and anxiety.”

Gun manufacturers were harshly criticized in the Oversight Committee’s 2022 investigation for marketing products to people of color, as gun violence remains a leading cause of death for young Black and Latino men.

At the same time, some companies also promoted assault rifles to white supremacist groups who believe a race war is imminent, the investigation found. One company sold an AK-47-style rifle called the “Big Igloo Aloha,” a reference to an anti-government movement, it said.

Still, Philip Smith wants more Black people to get guns for protection.

Smith said he was working as a human resources consultant a decade ago when he got the idea to form the , which helped the National Shooting Sports Foundation compile its report on communicating with Black consumers.

Smith encourages Black people to buy firearms for self-defense and get proper training on how to use them.

After 10 years, Smith said, his group has about 45,000 members nationwide. Single members pay $39 a year and couples $59, which gives them access to discounts from the organization’s corporate partners, including gunmakers, and raffles for gun giveaways, according to its website.

The police killing of Michael Brown in Ferguson, Missouri, and the shooting death of Florida teenager Trayvon Martin helped spark early interest from doctors, lawyers, and others in joining the group, he said. But interest took off during the pandemic, he said, even among Democrats who had resisted the idea of owning a gun.

“Hundreds of people called me and said, ‘I don’t agree with anything you’re saying, but what kind of gun should I buy,’” Smith recalled.

Smith, describing himself as “quiet, nerdy, and Afrocentric,” said criticism of guns misses the point.

“My ancestors bled for us to have this right,” he said. “Are there some racist white people? Yes. But we should buy guns because there is a need. No one is forcing us to buy guns.”

‘American Amnesia’

During the pandemic, gun violence took its greatest toll on racially segregated neighborhoods in places such as Philadelphia, where roughly residents live in poverty.

A says a one-year period in the pandemic saw more than 2,300 shootings, or about six a day. Many of the cases haven’t been solved by police.

City officials cited the boom in gun sales in the report: Fewer than 400,000 sales took place in Pennsylvania in 2000, but in 2020 it was more than 1 million.

Gun sales since the pandemic ended, but the harm they’ve caused persists.

At a conference last year inside the Eagles’ football stadium, victims of firearm violence or their relatives joined activists to share accounts of near-death experiences and the grief of losing loved ones.

Paintings flanked the stage and the meeting space to commemorate people who had been fatally shot, nearly all young people of color, under messages such as “You are loved and missed forever” and “Those we love never leave.”

Marion Wilson, a community activist, said he believes the nation has forgotten the suffering Philadelphia and other cities endured during the pandemic.

“We suffer from the disease of American amnesia,” he said.

Harris was on his way home from a job at Burlington Coat Factory nearly two decades ago when robbers followed him from a bus stop and demanded money. He said he had none and was shot.

Harris had spent his early life fixing cars with his grandfather, when he wasn’t at school or attending church. He remembers lying in a hospital bed, overcome with a sense of helplessness.

“I had to learn to feed myself again,” he said. “I was like a baby. I had to learn to sit up so I could use a wheelchair. The only way I got through it was my faith in God.”

Harris endured years of rehabilitation and counseling for PTSD. As someone in a wheelchair, he said, he sometimes fears for his safety — and a gun may be one of the few ways to protect himself and his family.

“I’m mulling it over,” Harris said. “I’m afraid of my trauma hurting someone else. That’s the only reason I haven’t gotten one yet.”

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For those in or near Columbia Memorial, the city’s only hospital, there will soon be a different plan: Shelter in place. The hospital is building a new facility next door with an on-site tsunami shelter — an elevated refuge atop columns deeply anchored in the ground, where nearly 2,000 people can safely wait out a flood.

Oregon needs more shelters like the one that Columbia Memorial is building, emergency managers say. Hospitals in the region are likely to incur serious damage, if not ruin, and could take more than three years to fully recover in the event of a major earthquake and tsunami, according to .

Columbia Memorial’s current facility is a single-story building, a half-century ago, that would likely collapse and sink into the ground or be swallowed by a landslide after a major earthquake or a tsunami, said Erik Thorsen, the hospital’s chief executive.

“It is just not built to survive either one of those natural disaster events,” Thorsen said.

At least 10 other hospitals along the Oregon coast are in danger as well. So Columbia Memorial leaders proposed building a hospital capable of withstanding an earthquake and landslide, with a tsunami shelter, instead of relocating the facility to higher ground. Residents and state officials supported the plans, and the federal government awarded a $14 million grant from the Federal Emergency Management Agency to help pay for the tsunami shelter.

The project broke ground in October 2024. Within six months, the Trump administration had , known as Building Resilient Infrastructure and Communities, or BRIC, calling it “yet another example of a wasteful and ineffective FEMA program … more concerned with political agendas than helping Americans affected by natural disasters.”

Molly Wing, director of the expansion project, said losing the BRIC grant felt like “a punch to the gut.”

“We really didn’t see that coming,” she said.

This summer, Oregon and 19 other states sued to restore the FEMA grants. On Dec. 11, a that the Trump administration had unlawfully ended the program without congressional approval.

The administration did not immediately indicate it would appeal the decision, but Department of Homeland Security spokesperson Tricia McLaughlin said by email: “DHS has not terminated BRIC. Any suggestion to the contrary is a lie. The Biden Administration abandoned true mitigation and used BRIC as a green new deal slush fund. It’s unfortunate that an activist judge either didn’t understand that or didn’t care.” FEMA is a subdivision of DHS.

Columbia Memorial was one of the few hospitals slated to receive grants from the BRIC program, which had announced more than $4.5 billion for nearly 2,000 building projects since 2022.

Hospital leaders have decided to keep building — with uncertain funding — because they say waiting is too dangerous. With the Trump administration reversing course on BRIC, fewer communities will receive help from FEMA to reduce their disaster risk, even places where catastrophes are likely.

More than three centuries have passed since a major earthquake caused the Pacific Northwest’s coastline to drop several feet and unleashed a tsunami that crashed onto the land in January 1700, according to scientists who study the evolution of the Oregon coast.

The greatest danger is an underwater fault line known as the , which lies 70 to 100 miles off the coast, from Northern California to British Columbia.

The Cascadia zone can produce a megathrust earthquake, with a magnitude of 9 or higher — the type capable of triggering a catastrophic tsunami — , according to the U.S. Geological Survey. Scientists predict a 10% to 15% chance of such an earthquake along the fault zone in the next 50 years.

“We can’t wait any longer,” Thorsen said. “The risk is high.”

Building for the Future

The BRIC program started in 2020, during the first Trump administration, to provide communities and institutions with funding and technical assistance to fortify their structures against natural disasters.

Joel Scata, a senior attorney with the environmental advocacy group Natural Resources Defense Council, said the program helped communities better prepare so they could reduce the cost of rebuilding after a flood, tornado, wildfire, or extreme weather event.

To qualify for a grant, a hospital had to show that the project’s benefits were greater than the future danger and cost. In some cases, that benefit might not be readily apparent.

“It prevents bad disasters from happening, and so you don’t necessarily see it in action,” Scata said.

Scata noted that the Trump administration has also stopped awarding grants through FEMA’s Hazard Mitigation Grant Program, which predates BRIC.

“There really is no money going out the door from the federal government to help communities reduce their disaster risk,” he said.

A recent ºÚÁϳԹÏÍø News investigation using proprietary data from Fathom, a global leader in flood modeling, found that at least 170 U.S. hospitals are at risk of significant and potentially dangerous flooding from more intense and frequent storms. That count did not include Columbia Memorial, as Fathom’s data did not account for tsunamis. It models flooding from rivers, sea level rise, and extreme rainfall.

In recent days, an atmospheric river — a narrow storm band carrying significant amounts of moisture — dumped more than 15 inches of rain on parts of Oregon and Washington, causing catastrophic flooding along rivers and the coast. In the Washington town of Sedro-Woolley, which sits along the Skagit River, the PeaceHealth evacuated nonemergency patients.

High winds battered Astoria, leaving the city with some minor landslides, according to news reports. But flooding on the road to the nearby beach town of Seaside made the drive nearly impassable.

The Trump administration is leaning on states to take greater responsibility for recovering from natural disasters, Scata said, but most states are not financially prepared to do so.

“The disasters are just going to keep on piling up,” he said, “and the federal government’s going to have to keep stepping in.”

A Hospital at Risk

Columbia Memorial is blocks from the southern shore of the Columbia River, near the Washington border, where the include earthquakes, tsunamis, landslides, and floods. A critical access hospital with 25 beds, it opened in 1977 — before state building codes addressed tsunami protections.

Thorsen said the new facility and shelter would be a “model design” for other hospitals. Design plans show a five-level hospital built atop a foundation anchored to the bedrock and surrounded by concrete columns to shield it from tsunami debris.

The shelter will be on the roof of the second floor, above the projected maximum tsunami inundation. It will be accessible via an outdoor staircase and interior staircases and elevators, with enough room for up to 1,900 people, plus food, water, tents, and other supplies to sustain them for five days.

With most patient care provided on the second and third levels, generators on the fourth level, and utility lines underground, the hospital is expected to remain operational after a natural disaster.

Thorsen said an earthquake and tsunami threaten not only vast flooding , in which the ground loosens and causes structures above it to collapse. Deep foundations, thick slabs, and other structural supports are expected to protect the new hospital and tsunami structure against such failure.

Through the years, hospital administrators and civic leaders in Astoria have sought other locations for Columbia Memorial. But relocation wasn’t economical. Columbia Memorial committed to invest in a new hospital and tsunami shelter to protect not only patients and staff but also nearby residents.

“Your community should count on your hospital to be a safe haven in a natural disaster,” Thorsen said.

Fighting To Restore Funds

The estimated construction budget for Columbia Memorial’s expansion is $300 million, mostly financed through new debt from the hospital. The tsunami shelter is budgeted at about $20 million, for which FEMA’s BRIC program , with a $6 million matching grant from the state, which has maintained its support.

The shelter and the building’s structural protections — featuring reinforced steel, deeper foundations, and thicker slabs — are integral to the design and cannot be removed without compromising the rest of the structure, said Michelle Checkis, the project architect.

“We can’t pull the TVERS [tsunami vertical evacuation refuge structure] out without pulling the hospital back apart again,” she said. “It’s kind of like, if I was going to stack it up with Legos, I would have to take all those Legos apart and stack it up completely differently.”

Columbia Memorial has sought help from Oregon’s congressional delegation. In to Department of Homeland Security Secretary Kristi Noem and former FEMA acting administrator David Richardson, the lawmakers demanded that the agencies restore the hospital’s grant.

The hospital’s leadership is seeking other grants and philanthropic donations to make up for the loss. As a last resort, Thorsen said, the board will consider removing “nonessential features” from the building, though he added that there is little fat to trim from the project.

in July alleged that FEMA lacks the authority to cancel the BRIC program or redirect its funding for other purposes.

The states argued that canceling the program and undermined projects underway., according to state estimates.

Many of Oregon’s seaside communities are near high-enough ground to seek safety from a tsunami in a relatively short time, Allan said. But he estimated that, to save lives, Oregon would need about a dozen vertical tsunami evacuation shelters along the coast, including in seaside towns that attract tourists and where the nearest high ground is a mile or more away.

Willis Van Dusen’s family has lived in Astoria since the mid-19th century. A former mayor of Astoria, Van Dusen stressed that tsunamis are not a hypothetical danger. He recalled seeing one in Seaside in 1964. The wave was only about 18 inches high, he said, but it flooded a road and destroyed a bridge and some homes. The memory has stayed with him.

“It’s not like … ‘Oh, that’ll never happen,’” he said. “We have to be prepared for it.”

ºÚÁϳԹÏÍø News correspondent Brett Kelman contributed to this report.

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At this decades-old psychiatric hospital on the edge of the Tennessee River, an intense storm could submerge the building in 11 feet of water, cutting off all roads around the facility, according to a sophisticated computer simulation of flood risk.

Aurora, a young woman who was committed to Peninsula as a teenager, said the hospital sits so close to the river that it felt like a moat keeping her and dozens of other patients inside. ºÚÁϳԹÏÍø News agreed not to publish her full name because she shared private medical history.

“My first feeling is doom,” Aurora said as she watched the simulation of the river rising around the hospital. “These are probably some of the most vulnerable people.”

Covenant Health, which runs Peninsula Hospital, said in a statement it has a “proactive and thorough approach to emergency planning” but declined to provide details or answer questions.

Peninsula is one of about 170 American hospitals, totaling nearly 30,000 patient beds from coast to coast, that face the greatest risk of significant or dangerous flooding, according to a months-long ºÚÁϳԹÏÍø News investigation based on data provided by Fathom, a company considered a leader in flood simulation. At many of these hospitals, flooding from heavy storms has the potential to jeopardize patient care, block access to emergency rooms, and force evacuations. Sometimes there is no other hospital nearby.

Much of this risk to hospitals is not captured by flood maps issued by the Federal Emergency Management Agency, which have served as the nation’s de facto tool for flood estimation for half a century, despite being incomplete and sometimes decades out of date. As FEMA’s maps have become divorced from the reality of a changing climate, private companies like Fathom have filled the gap with simulations of future floods. But many of their predictions are behind a paywall, leaving the public mostly reliant on free, significantly limited government maps.

“This is highly concerning,” said Caleb Dresser, who studies climate change and is both an emergency room doctor and a Harvard University assistant professor. “If you don’t have the information to know you’re at risk, then how can you triage that problem?”

The deadliest hospital flooding in modern American history occurred 20 years ago during Hurricane Katrina, when the bodies of 45 people were recovered from New Orleans’ Memorial Medical Center, including some patients whom investigators . More flooding deaths were narrowly avoided one year ago when helicopters rescued dozens of people as Hurricane Helene engulfed Unicoi County Hospital in Erwin, Tennessee.

Rebecca Harrison, a paramedic, called her children from the Unicoi roof to say goodbye.

“I was scared to death, thinking, ‘This is it,’” Harrison told CBS News, which interviewed Unicoi survivors as part of ºÚÁϳԹÏÍø News’ investigation. “Alarms were going off. People were screaming. It was chaos.”

The investigation — among the first to analyze nationwide hospital flood risk in an era of warming climate and worsening storms — comes as the administration of President Donald Trump has slashed and and also dismantled FEMA programs designed to protect hospitals and other important buildings from floods.

When asked to comment, FEMA said flooding is a common, costly, and “under appreciated” disaster but made no statement specific to hospitals. Spokesperson Daniel Llargués defended the administration’s changes to FEMA by reissuing an August statement that dismissed criticism as coming from “bureaucrats who presided over decades of inefficiency.”

Alice Hill, an Obama administration climate risk expert, said the Trump administration’s dismissal of climate change and worsening floods would waste billions of dollars and endanger lives.

In 2015, Hill led the creation of the Federal Flood Risk Management Standard, which required that hospitals and other essential structures be elevated or incorporate extra flood protections to qualify for federal funding.

¹ó·¡²Ñ´¡Ìý the standard in March.

“People will die as a result of some of the choices being made today,” Hill said. “We will be less prepared than we are now. And we already were, in my estimation, poorly prepared.”

‘Flood Risk Is Everywhere’

The ºÚÁϳԹÏÍø News investigation identified more than 170 hospitals facing a flood risk by comparing the locations of more than 7,000 facilities to , a United Kingdom company that simulates flooding in spaces as small as 10 meters using laser-precision elevation measurements from the .

Hospitals were determined to have a significant risk if Fathom’s 100-year flood data predicted that a foot or more of water could reach a considerable portion of their buildings, excluding parking garages, or cut off road access to the hospital. A 100-year flood is an intense weather event that has roughly a 1% chance of occurring in any given year but can happen more often.

The investigation found heightened flood risks at large trauma centers, small rural hospitals, children’s hospitals, and long-term care facilities that serve older and disabled patients. At least 21 are critical access hospitals, with the next-closest hospital 25 miles away, on average.

Flooding threatens dozens of hospitals in coastal areas, including in Florida, Louisiana, Texas, and New York. Farther inland, flooding of rivers or creeks could envelop other hospitals, particularly in Appalachia and the Midwest. Even in the sun-soaked cities and arid expanses of the American West, storms have the potential to surround some hospitals with several feet of pooling water, according to Fathom’s data.

These findings are likely an undercount of hospitals at risk because the investigation overlooked pockets of potential flooding at some hospitals. It excluded facilities like stand-alone ERs, outpatient clinics, and nursing homes.

“The reality is that flood risk is everywhere. It is the most pervasive of perils,” said Oliver Wing, the chief scientific officer at Fathom, who reviewed the findings. “Just because you’ve never experienced an extreme doesn’t mean you never will.”

Dresser, the ER doctor, said even a small amount of flooding can shut down an unprepared hospital, often by interrupting its power supply, which is needed for life-sustaining equipment like ventilators and heart monitors. He said the most vulnerable hospitals would likely be in rural areas.

“A lot of rural hospitals are now closing their pediatric units, closing their psychiatry units,” Dresser said. “In a financially stressed situation, it can be hard to prioritize long-term threats, even if they are, for some institutions, potentially existential.”

Urban hospitals can face dangerous flooding, too. Fathom’s data predicts 5 to 15 feet of water around neighboring hospitals — Kadlec Regional Medical Center and Lourdes Behavioral Health — that straddle a tiny creek in Richland, Washington.

By Fathom’s estimate, a 100-year flood could cause the nearby Columbia River to spill over a levee that protects Richland, then loosely follow the creek to the hospitals. Some of the deepest flooding is estimated around Lourdes, which was built on land the U.S. Army Corps of Engineers set aside in 1961 as a “ponding and drainage easement.”

At the time, this land was supposed to be capable of storing enough water to fill at least 40 Olympic-size swimming pools, according to obtained through the Freedom of Information Act. A mental health facility has occupied this spot since the 1970s.

Both Kadlec and Lourdes said in statements that they have disaster plans but did not answer questions about flooding. Tina Baumgardner, a Lourdes spokesperson, said government flood maps show the hospital is not in a 100-year flood plain.

This is not uncommon. Of the more than 170 hospitals with significant flood risk identified by ºÚÁϳԹÏÍø News, one-third are located in areas that FEMA has not designated as flood hazard zones.

Sometimes the difference is stark. For example, at Ochsner Choctaw General in Alabama — the only hospital for 30 miles in any direction — FEMA maps suggest a 100-year flood would overflow a nearby creek but spare the hospital. Fathom’s data predicts the same event would flood most of the hospital with 1 to 2 feet of water, including the ER and the helicopter pad.

Ochsner Health did not answer questions about flooding preparations at Choctaw General.

FEMA flood maps were launched in the ’60s as part of the National Flood Insurance Program to determine where insurance is required and building codes should include flood-proofing. According to a FEMA statement, the maps show only a “snapshot in time” and are not intended to predict where flooding will or won’t happen.

FEMA spokesperson Geoff Harbaugh said the agency intends to modernize its maps through the Future of Flood Risk Data initiative, which will enable the agency to “better project flood risk” and give Americans “the information they need to protect their lives and property.”

The program was launched by the first Trump administration in 2019 but has since received sparse public updates. Harbaugh declined to provide a detailed update or timeline for the program.

Chad Berginnis, executive director of the Association of State Floodplain Managers, said it is unknown whether FEMA is still trying to upgrade its maps under Trump, as the agency has cut off communications with outside flooding experts.

“There has been not a single bit of loosening of what I’m calling the FEMA cone of silence,” Berginnis said. “I’ve never seen anything like it.”

Floods are expected to worsen as a warming climate fuels stronger storms, drenching areas that are already flood-prone and bringing a new level of flooding to areas once considered lower risk.

The National Oceanic and Atmospheric Administration has said that 2024 was the warmest year on record — more than 2 degrees Fahrenheit higher than the 20th-century average. Scientists across the globe that each degree of global warming correlates to a 4% increase in the intensity of extreme rainfall.

“Warmer air can hold more moisture, so this leads us to experience heavier downpours,” said Kelly Van Baalen, a sea level rise expert at the nonprofit . “A 100-year flood today could be a 10-year flood tomorrow.”

Intensifying storms raise concerns about Peninsula Hospital, which has operated for decades mere feet from the Tennessee River but has no known history of flooding.

Peninsula spokesperson Josh Cox said the river is overseen by the Tennessee Valley Authority, which uses dams to manage water levels and generate electricity. Estimates provided by the TVA suggest the dams could keep Peninsula dry even in a 500-year flood.

Fathom, however, said its flood simulation accounts for the dams and stressed that a large enough storm could drop more rain than even the TVA could control. These predictions are echoed by another flood modeling firm, , which also says an intense storm could cause more than 10 feet of flooding in the area around Peninsula.

“It’s a hospital right on the banks of a major American river,” said Wing, the Fathom scientist. “It just isn’t conceivable that such a location is risk-free.”

Jack Goodwin, 75, a retired TVA employee who has lived next to Peninsula for three decades, said he was confident the dams could protect the area. But after reviewing Fathom’s predictions, Goodwin began to research flood insurance.

“Water can rise quickly and suddenly, and the destruction is tremendous,” he said. “Just because we’ve never seen it here doesn’t mean we won’t see it.”

‘All the Elements of a Real Disaster’

One year ago, as Hurricane Helene carved a deadly path across Southern Appalachia, Angel Mitchell was visiting her ailing mother at Unicoi County Hospital in the tiny town of Erwin, Tennessee.

Swollen by Helene, the nearby Nolichucky River spilled over its banks and around the hospital, which was built in a flood plain. Staff tried to bar the doors, Mitchell said, but the water got in, trapping her and others inside. The lights went out. People fled to the roof, where the roar of rushing water nearly drowned out the approach of rescue helicopters, Mitchell said.

Ultimately, 70 people from the hospital, including Mitchell and her mother, were airlifted to safety on Sept. 27, 2024. The hospital remains closed, and the company that owns it, Ballad Health, has said its .

“Why allow something — especially a hospital — to be built in an area like that?” Mitchell told CBS News. “People have to rely on these areas to get medical help, and they’re dangerous.”

Beyond Unicoi, ºÚÁϳԹÏÍø News identified 39 inland hospitals — including 16 in Appalachia — that Fathom predicts could flood when nearby rivers, creeks, or drainage canals overspill their banks, even in storms far less intense than Helene.

For example, in the Cumberland Mountains of southwestern Virginia, a 100-year flood is projected to cause Slate Creek to engulf Buchanan General Hospital in more than 5 feet of water.

Near the Great Lakes in Erie, Pennsylvania, LECOM Medical Center and Behavioral Health Pavilion could become flooded by a small drainage creek that is less than 50 feet from the front door of the ER.

Neither Buchanan nor LECOM responded to questions about flooding or preparations.

And in West Virginia’s capital of Charleston, where about 50,000 people live at the junction of two rivers in a wide and flat valley, a single storm could potentially flood five of the city’s six hospitals at once, along with schools, churches, fire departments, and other facilities.

“I hate to say it,” said Behrang Bidadian, a flood plain manager at the , “but it has all the elements of a real disaster.”

At the largest hospital in Charleston, CAMC Memorial Hospital, Fathom predicts that the Kanawha River could bring as much as 5 feet of flooding to the ER. Across town, the Elk River could surround CAMC Women and Children’s Hospital, cutting off all exits.

And in the center of the city, where the overflowing rivers are predicted to merge, Thomas Orthopedic Hospital could be besieged by more than 10 feet of water on three sides.

WVU Medicine, which owns Thomas Orthopedic Hospital, did not respond to requests for comment.

CAMC spokesperson Dale Witte said the hospital system is aware of its flood risk and has prepared by elevating electrical infrastructure and acquiring flood-proofing equipment, like a deployable floodwall. CAMC also regularly revises and drills its disaster plans, Witte said, although he added that hospitals there have never been tested by a real flood.

Shanen Wright, 48, a lifelong Charleston resident who lives near CAMC Memorial, said many in the city have little worry about flooding in the face of more immediate problems, like the opioid epidemic and the decline of manufacturing and mining.

Tugboats and coal barges sail past his neighborhood as if they were cars on his street.

“It’s not to say it’s not a possibility,” he said. “I’m sure the people in Asheville and the people in Texas, where the floods took so many lives, they probably didn’t see it coming either.”

‘The Water Is Coming’

Despite wide scientific consensus that climate change fuels more dangerous weather, the Trump administration has that concerns about global warming are overblown. In a speech to the United Nations in September, Trump called climate change “the greatest con job ever perpetrated on the world.”

The Trump administration has made deep staff and funding cuts to FEMA, NOAA, and the National Weather Service. At FEMA, the cuts prompted 191 current and former employees to in August warning that the agency is being dismantled from within.

Daniel Swain, a University of California climate scientist, said the administration’s rejection of climate change has left the nation less prepared for extreme weather, now and in the future.

“It’s akin to enforcing malpractice scientifically,” Swain said. “Imagine making a medical decision where you are not allowed to look at 20% of the patient’s vital signs or test results.”

Under Trump, FEMA has also taken actions critics say will leave the nation more vulnerable to flooding, specifically:

• FEMA disbanded the Technical Mapping Advisory Council, which had to modernize its flood maps to estimate future risk and account for the impacts of climate change.
• FEMA canceled its program, which provided grants to help communities and vital buildings, including hospitals, protect themselves from floods and other natural disasters.
• And after stopping enforcement early this year, FEMA the Federal Flood Risk Management Standard, which was designed to harden buildings against future floods and save tax dollars in the long run.

Berginnis, of the Association of State Floodplain Managers, said the administration’s unwillingness to prepare for climate change and worsening storms would result in a dangerous and costly cycle of flooding, rebuilding, and flooding again.

“The president is saying we are closed for business when it comes to hazard mitigation,” Berginnis said. “It bugs me to no end that we have to have reminders — like people dying — to show us why it’s important to make these investments.”

FEMA did not answer specific questions about these decisions. In the statement to ºÚÁϳԹÏÍø News, spokesperson Llargués touted the administration’s response to flooding in Texas and New Mexico and said FEMA had provided billions of dollars to help people and communities recover and rebuild. He did not mention any FEMA funding for protecting against future floods.

Few hospitals understand this threat more than the former Coney Island Hospital in New York City, which has suffered catastrophic flooding before and has prepared for it to come again.

Superstorm Sandy in 2012 forced the hospital to evacuate hundreds of patients. When the water receded, fish and a sea turtle were found in the building.

Eleven years later, the facility reopened as Ruth Bader Ginsburg Hospital, transformed by a FEMA-funded $923 million reconstruction project that added a 4-foot floodwall and elevated patient care areas and utility infrastructure above the first floor.

It is now likely one of the most flood-proofed hospitals in the nation.

But, so far, no storm has tested the facility.

Svetlana Lipyanskaya, CEO of NYC Health+Hospitals/South Brooklyn Health, which includes the rebuilt hospital, said the question of flooding is “not an if but a when.”

“I hope it doesn’t happen in my lifetime,” she said, “but frankly, I’d be surprised. The water is coming.”

Methodology

After Hurricane Helene made landfall a year ago, a raging river flooded a rural hospital in eastern Tennessee. Patients and employees were rescued from the rooftop. Floods have hit hospitals from New York to Nebraska to Texas in recent years. We wanted to determine how many other U.S. hospitals face similar peril. Ultimately, we found more than 170 hospitals at risk.

For this analysis, we used data from , a United Kingdom-based company that specializes in flood-risk modeling across the globe. To assess the United States’ vulnerability, Fathom uses sophisticated computer simulations and detailed terrain data covering the country. It accounts for environmental factors such as climate change, soil conditions, and many rivers and creeks not mapped by other sources. Fathom’s modeling has been and , the World Bank, the Nature Conservancy, and government agencies in Florida, Texas, and elsewhere. The Iowa Flood Center has .

Through a data use agreement, Fathom shared its U.S. mapping data that predicts areas with at least a 1% chance of flooding in any given year. Fathom’s data estimates the effects of of flooding: coastal, fluvial (from overflowing rivers, lakes, or streams), and pluvial (rainfall that the ground can’t absorb). The data also accounts for dams, reservoirs, and other structures that defend against floods.

To identify at-risk hospitals, we used a publicly available Department of Homeland Security database containing the GPS coordinates of more than 7,000 short-term acute, critical access, rehab, and psychiatric hospitals — basically any hospital with inpatient services. (DHS under the Trump administration has discontinued public access to the database, so data for hospitals and other infrastructure is no longer widely available.)

Using GPS coordinates as the centerpoint, we created a circle with a 150-yard radius around each hospital, which in most cases captured the building plus nearby grounds and access roads. We then mapped Fathom’s flood-risk data to see where it overlapped with these circles. We started by looking for hospitals where at least 20% of the circle’s area had a predicted flood depth of at least 1 foot. That gave us an initial list of more than 320 hospitals across the U.S.

From there, we visually inspected those hospitals using mapping software and Google Maps, both satellite and street view. We trimmed our list to only the hospitals where a considerable portion of the building or all access roads were predicted to have at least a foot of flooding.

If two hospitals were mapped to the same building — for instance, a small rehab facility within a large hospital — we counted only one hospital. We also excluded hospitals recently converted to nursing homes or for other uses.

We ended up with a list of 171 hospitals across the U.S. That is most likely an undercount. Some hospitals could still face significant impact from flooding that is not deep enough or widespread enough to fit our methodology. Our analysis also does not account for how flooding farther from a hospital could affect employees or patients. And it does not assess what steps hospitals may have already taken to prepare for severe weather events.

We also ran a spatial analysis comparing Fathom’s data with flood hazard maps from the Federal Emergency Management Agency, which in many cases are incomplete or haven’t been updated in years. We found that about a third of hospitals identified as flood risks by Fathom’s data did not overlap at all with FEMA’s 100- or 500-year hazard areas.

Fathom provided guidance and feedback as we developed our analysis.

CBS News correspondent David Schechter, photojournalist Chance Horner, and producer Aparna Zalani contributed to this report.

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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, , a health information nonprofit that includes ºÚÁϳԹÏÍø 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 .

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 .

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 , 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.

ºÚÁϳԹÏÍø 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, 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 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 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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Enrollment in the Affordable Care Act’s health insurance marketplace has soared over the past four years, especially in states that went for President Donald Trump in 2024. But next year, things might be very different. 

That record enrollment has been driven by a Biden-era enhancement for subsidies that lower the out-of-pocket cost of premiums for eligible people. Those enhanced subsidies are due to expire at the end of the year unless Congress extends them. 

If they don’t, ACA enrollees’ health insurance premiums would rise by more than 75% on average, with bills for people in some states more than doubling, according to , a health information nonprofit that includes ºÚÁϳԹÏÍø News. 

Of the more than 24 million Americans who signed up for insurance through the marketplace this year, 9 in 10 receive a subsidy. Many are unaware that the enhanced subsidies are in place only through Dec. 31. 

Fabiola Auguste, a Florida insurance agent who lives in Miami-Dade County, said the enhanced subsidy reduced the premiums she pays by more than half, to $20 a month. If she can’t afford her premiums next year, Auguste said, she would most likely end up uninsured. 

“That would be, like, scary,” she said. “Just like before, everybody would stay without insurance until something happens, then you go to the hospital and ask for emergency Medicaid.” 

Low-income enrollees such as Auguste would experience the biggest bump in premiums if enhanced subsidies expire. Middle-income enrollees who earn more than four times federal poverty ($62,600 for a single person or $84,600 for a couple in 2025) would be ineligible for subsidies. 

Those middle-income enrollees are disproportionately older (ages 50 to 64), self-employed, and living in rural areas, according to . A study by the Urban Institute, a nonprofit think tank, found that Hispanic and Black people would see than other groups if the extra subsidies lapse. 

The Congressional Budget Office estimates from 22.8 million in 2025 to 18.9 million in 2026 and 15.4 million by 2030. While some people might be able to find other sources of coverage, others would become uninsured. 

Brian Blase, president of , a conservative health policy think tank, said the enhanced subsidies were supposed to be a temporary measure during the covid pandemic to help people at risk of losing coverage. 

Allowing the subsidies to expire, he said, “is really going back to what the Obamacare structure was like,” he said.

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She helps her mother feed, bathe, and give medicine to her adult brother, Rodrigo Muralles, who has epilepsy and became disabled after contracting covid-19 in 2020.

“He lives because we feed him and take care of his personal needs,” said Josefina Muralles, 41. “He doesn’t say, ‘I need this or that.’ He has forgotten everything.”

Though her husband works full time, the arrangement means their household income is just above the federal poverty line — too high to qualify for Florida’s Medicaid program but low enough to make Muralles and her husband eligible for subsidized health insurance through the Affordable Care Act marketplace, also known as Obamacare.

Next year, Muralles said, she and her husband may not be able to afford that health insurance coverage, which has paid for her prescription blood thinners, cholesterol medication, and two surgeries, including one to treat a genetic disorder.

Extra subsidies put in place during the pandemic — which reduced the premiums Muralles and her husband paid by more than half, to $30 a month — are in place only through Dec. 31. Without enhanced subsidies, Affordable Care Act insurance premiums would rise by more than 75% on average, with bills for people in some states more than doubling, according to , a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Florida and Texas would be hit especially hard, as they have more people enrolled in the marketplace than other states. Some of their alone, especially in South Florida, have more people signed up for Obamacare than entire states.

Like many of the more than 24 million Americans enrolled in the insurance marketplace this year, Muralles was unaware that the enhanced subsidies are slated to expire. She said she cannot afford a premium hike because inflation has already eaten into her household’s budget.

“The rent is going up,” she said. “The water bill is going up.”

Low-income enrollees like the Muralles couple would see the biggest percentage increases in premiums if enhanced subsidies expire.

Middle-income enrollees who earn more than four times the federal poverty line would no longer be eligible for subsidies at all. Those middle-income enrollees (who earn at least $62,600 for a single person in 2025) older, self-employed, and living in rural areas.

Julio Fuentes, president of the , said many of his organization’s members are small business owners for health coverage.

“It’s either this or nothing,” he said.

The that letting the enhanced subsidies expire would, by 2034, increase the number of people without health insurance by 4.2 million. In tandem with changes to Medicaid in the House of Representatives’ and the Trump administration’s for the marketplace, including toughening income verification and shortening enrollment periods, it would increase the number of uninsured people by 16 million over that time period.

A , a nonprofit think tank, found that Hispanic and Black people would see greater coverage losses than other groups if the extra subsidies lapse.

Fuentes noted that about 5 million Hispanics are enrolled in the ACA marketplace, and that Donald Trump won the Hispanic vote in Florida in 2024. He hopes the president and congressional Republicans see extending the enhanced subsidies as a way to hold on to those voters.

“This is probably a good way, or a good start, to possibly grow that base even more,” he said.

Enrollment in the marketplace has grown faster since 2020 in the states won by Trump in 2024. A found that 45% of Americans who buy their own health insurance identify as or lean Republican, including 3 in 10 who identify as Make America Great Again supporters. Smaller shares identify as Democrats or Democratic-leaning independents (35%) or do not lean toward either party (20%).

Kush Desai, a White House spokesperson, said the rules proposed by the Trump administration, combined with the provisions in the House-passed budget bill, would “strengthen the ACA marketplace.” He noted that the CBO projects the legislation would reduce premiums for some plans about 12% on average by 2034 — but out-of-pocket costs would for most subsidized ACA consumers.

“Democrats know Americans broadly support ending waste, fraud, and abuse, as The One, Big, Beautiful Bill does, which is why they are desperately trying to change the conversation,” Desai said.

But Lauren Aronson, executive director of , a group in Washington, D.C., representing health insurers, hospitals, physicians, and patient advocates, said it is critical to raise awareness about the likely impact of losing the enhanced subsidies, which are also known as advanced premium tax credits. She is encouraged that Democrats have to extend the enhanced tax credits, and that some Republican senators have voiced support.

What worries Aronson most is that the Republican-controlled Congress is more focused on extending tax cuts than enhanced subsidies, she said. The current bill extending the 2017 tax cuts would by about $2.4 trillion over the next decade, according to the CBO, while making the enhanced subsidies permanent would increase the deficit by over roughly the same period.

“Congress is moving forward on a tax reconciliation package that purports to benefit working families,” Aronson said. “But if you don’t take care of the tax credits, working families will be left holding the bag.”

Brian Blase, president of , a conservative health policy think tank, said the enhanced subsidies were supposed to be a temporary measure during the covid-19 pandemic to help people at risk of losing coverage.

Instead, he said, the because enrollees did not need to verify their income eligibility to receive zero-premium plans if they reported incomes at or near the federal poverty level.

The enhanced subsidies also worsen health inflation, discourage employers from offering health insurance benefits, and crowd out alternative models, such as short-term insurance and Farm Bureau plans, Blase said.

“Permitting these subsidies to expire would just be going back to Obamacare as it was written,” Blase said. “That is a more efficient program than the program that we have now.”

for the marketplace proposed by the Trump administration in March are already designed to address fraud, said Anna Howard, a policy expert with the , which advocates for increased health insurance coverage. Howard said extending the enhanced tax credits would help ensure that people who are legitimately eligible for coverage can get it.

“We don’t want to see over 5 million people be kicked off their health insurance coverage out of fears of fraud when the policies being proposed don’t necessarily address fraud,” she said.

Without affordable premiums, many consumers will turn to short-term health plans, health care cost-sharing ministries, and other forms of coverage that do not have the benefits or protections of the health law, she said.

“These are plans that don’t provide coverage for prescription drugs, or they have lifetime and annual limits,” she said. “For a cancer patient, those plans don’t work.”

Though the enhanced subsidies do not expire until the end of the year, the would prefer Congress to act by fall to avoid confusion during open enrollment, said David Merritt, a senior vice president. Insurers are preparing rates to meet state deadlines. By October, consumers will receive 60-day plan renewal notices with their 2026 premiums.

Without enhanced subsidies, Merritt said, competition in the marketplace will wither, leading to fewer coverage options and higher prices, especially in states that have not expanded Medicaid eligibility and where Obamacare enrollment spiked during the past four years, like Florida and Texas. “Voters and patients are really going to see the impact,” he said.

Republican and Democratic representatives for some of the Florida congressional districts with the highest numbers of people in the marketplace did not respond to repeated interview requests.

Muralles, of North Miami, Florida, said she wants her representatives to work in the interest of constituents like herself, who need health insurance coverage to care for their families.

“Now is the time to prove to us that they are with us,” Muralles said. “When everybody’s healthy, everybody goes to work, everybody can pay taxes, everybody can have a better life.”

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También ayuda a su madre a alimentar, bañar y dar la medicación a Rodrigo Muralles, el hermano que padece epilepsia y quedó discapacitado luego de desarrollar covid-19 en 2020.

“Vive porque le damos de comer y atendemos sus necesidades personales”, explica Josefina Muralles, de 41 años. “No dice: ‘Necesito esto o aquello’. Lo ha olvidado todo”.

Aunque su marido trabaja a tiempo completo, este arreglo hace que los ingresos familiares estén justo por encima del umbral federal de pobreza: son demasiado altos para aplicar al Medicaid de Florida, pero lo suficientemente bajos como para que Muralles y su marido puedan optar por un seguro médico subvencionado a través del mercado de seguros establecido por la Ley de Cuidado de Salud a Bajo Precio (ACA, también conocida como Obamacare).

Muralles dijo que el año que viene es posible que ella y su marido no puedan permitirse ese seguro médico, que ha pagado por los anticoagulantes que le han recetado, la medicación para el colesterol y dos operaciones, incluida una para tratar un trastorno genético.

A esto se suma que los subsidios adicionales establecidos durante la pandemia, que redujeron las primas que pagaban Muralles y su marido a menos de la mitad, es decir a $30 al mes, solo estarán vigentes hasta el 31 de diciembre.

Sin estos subsidios, las primas de los planes médicos de ACA aumentarían en promedio más del 75%, y en algunos estados las facturas que pagan las personas se duplicarían con creces, .

Florida y Texas se verían especialmente afectados, ya que tienen más gente inscrita en este mercado que otros estados. Solo algunos de sus , especialmente en el sur de Florida, tienen más personas anotadas en Obamacare que otros estados enteros.

Al igual que muchos de los más de 24 millones de estadounidenses registrados en el mercado de seguros este año, Muralles no sabía que los subsidios mejorados estaban a punto de expirar. Dijo que no puede permitirse un aumento de la prima porque la inflación ya lesionado el presupuesto de su hogar.

“El alquiler está subiendo y la cuenta del agua también”, señaló.

Si se terminan los subsidios ampliados, los inscriptos con bajos ingresos, como el matrimonio Muralles serán los que reciban los mayores aumentos porcentuales en las primas.

En la práctica, los inscriptos de ingresos medios que ganan más de cuatro veces el umbral federal de pobreza ya no serían elegibles para recibir ningún subsidio. Esos afiliados —que en 2025, ganan unos  $62.600 por individuo — son, , adultos mayores, trabajadores autónomos y residentes en zonas rurales.

Julio Fuentes, presidente de la dijo que muchos de los miembros de su organización son propietarios de pequeñas empresas que para ofrecer cobertura de salud.

“Es esto o nada”, afirmó.

La (CBO) calculó que si se dejan de aplicar los subsidios mejorados aumentará en 4,2 millones el número de personas sin seguro médico.

Si se suman los cambios en Medicaid que propone el de la Cámara de Representantes y las por la administración Trump para el mercado de seguros, que incluyen una verificación de ingresos más estricta y la reducción de los períodos de inscripción, el número total de personas sin cobertura crecerá en 16 millones durante ese período.

Un reveló que, sin los subsidios adicionales, los hispanos y los afroamericanos sufrirán mayores pérdidas de cobertura que otros grupos.

Fuentes señaló que alrededor de 5 millones de hispanos están inscritos en el mercado de ACA y que Donald Trump ganó el voto hispano en Florida en 2024. Espera que el presidente y los republicanos del Congreso vean la ampliación de los subsidios mejorados como una forma de conservar a esos votantes.

“Probablemente esta sea una buena forma de aumentar aún más esa base”, afirmó. “O un buen comienzo”.

La inscripción en el mercado de seguros ha crecido más rápidamente desde 2020 en los estados donde Trump ganó en 2024.

Una reveló que el 45% de los estadounidenses que compran su propio seguro médico se identifican como republicanos o se inclinan por este partido, incluidos 3 de cada 10 que se identifican como partidarios de Make America Great Again (MAGA).

Un porcentaje menor se identifica como demócrata o independiente con tendencia demócrata (35%) o no se inclina por ninguno de los dos partidos (20%).

Kush Desai, vocero de la Casa Blanca, afirmó que las normas propuestas por la administración Trump, junto con las disposiciones del proyecto de ley presupuestaria aprobado por la Cámara de Representantes, “fortalecerán el mercado de ACA”.

El funcionario señaló que la CBO prevé que la legislación reduzca las primas de algunos planes en un promedio del 12% para 2034, pero que los gastos de bolsillo para la mayoría de los consumidores que reciben subsidios.

“Los demócratas saben que los estadounidenses apoyan ampliamente el fin del despilfarro, el fraude y el abuso, tal y como lo hace The One, Big, Beautiful Bill, y por eso están tratando desesperadamente de cambiar el discurso”, afirmó Desai.

Sin embargo, Lauren Aronson, directora ejecutiva de , un grupo con sede en Washington, D.C. que representa a aseguradoras de salud, hospitales, médicos y defensores de los pacientes, afirmó que es fundamental generar conciencia sobre el posible impacto de la pérdida de los subsidios mejorados, también conocidos como créditos fiscales anticipados para el pago de primas.

Aronson se mostró entusiasmada por el hecho de que los demócratas para extender la vigencia de estos subsidios, y que algunos senadores republicanos hayan expresado su apoyo.

Lo que más preocupa a Aronson es que el Congreso, controlado por los republicanos, esté más centrado en prorrogar los recortes fiscales que en mejorar los subsidios, afirmó. Según la CBO, el proyecto de ley actual que prorroga los recortes fiscales de 2017 en unos $2,4 mil millones durante la próxima década, mientras que hacer que los subsidios mejorados sean permanentes aumentaría el déficit en millones durante aproximadamente el mismo período.

“El Congreso está avanzando en un paquete de reconciliación fiscal que pretende beneficiar a las familias trabajadoras”, explicó Aronson. “Pero si los legisladores no se ocupan de los créditos fiscales, las familias trabajadoras terminarán cargando con el problema”.

Brian Blase, presidente del , un centro de estudios conservador en políticas de salud, dijo que se suponía que los subsidios mejorados eran una medida temporal establecida durante la pandemia de covid-19 para ayudar a las personas que corrieran el riesgo de perder la cobertura.

Pero en realidad, afirmó, los subsidios mejorados porque los afiliados no necesitaban verificar su elegibilidad por ingresos para recibir planes sin costo mensual. Alcanzaba con declarar ingresos iguales o cercanos al nivel federal de pobreza.

Los subsidios mejorados también empeoran la inflación en el sector de salud, desalientan a los empleadores a ofrecer cobertura médica y desplazan a modelos alternativos, como los seguros a corto plazo y los planes de la Farm Bureau, dijo Blase.

“Permitir que se acaben estos subsidios sería simplemente volver al Obamacare tal y como estaba redactado”, opinó Blase. “Es un programa más eficiente que el que tenemos ahora”.

Las para el mercado propuestas por la administración Trump en marzo ya están diseñadas para combatir el fraude, dijo Anna Howard, experta en políticas de la , que aboga por una mayor cobertura de seguro médico. Howard señaló que la ampliación de los créditos fiscales mejorados ayudaría a garantizar que las personas que tienen derecho legítimo a la cobertura puedan obtenerla.

“No queremos que más de 5 millones de personas se vean privadas de su cobertura de salud por temor al fraude, cuando las políticas que se proponen no abordan necesariamente este problema”, manifestó.

Sin primas accesibles, muchos consumidores recurrirán a planes de salud de corto plazo, a organizaciones religiosas que ayudan con los costos médicos, y a otras formas de cobertura que no ofrecen las prestaciones ni las protecciones de la ley de salud, afirmó.

“Se trata de planes que no cubren los medicamentos prescriptos o que tienen límites anuales o de por vida”, explicó. “Para un paciente con cáncer, esos planes no sirven”, añadió.

Aunque los subsidios mejorados no expiran hasta finales de año, la preferiría que el Congreso actuara antes del otoño para evitar confusiones durante el período de inscripción abierta, señaló David Merritt, vicepresidente senior.

Las aseguradoras están preparando las tarifas para cumplir con los plazos estatales. Hacia octubre, los consumidores recibirán avisos de renovación de sus planes, con 60 días de anticipación. Estos avisos incluirán las primas correspondientes a 2026.

Sin los subsidios mejorados, explicó Merritt, la competencia en el mercado de seguros se reducirá, lo que dará lugar a menos opciones de cobertura y precios más altos, especialmente en los estados que no han ampliado la elegibilidad para Medicaid y donde la inscripción en Obamacare se disparó durante los últimos cuatro años, como Florida y Texas. “Los votantes y los pacientes realmente van a sentir el impacto”, afirmó.

Los representantes republicanos y demócratas de algunos de los distritos electorales de Florida que tienen el mayor número de personas en el mercado no respondieron a las repetidas solicitudes de entrevista.

Muralles, de North Miami, Florida, explicó que quiere que sus representantes se ocupen de defender a las personas que los votan y que, como ella, necesitan cobertura sanitaria para cuidar de sus familias.

“Ahora es el momento de demostrar que están con nosotros”, expresó Muralles. “Cuando todo el mundo está sano, todo el mundo va a trabajar, todo el mundo puede pagar impuestos, todo el mundo puede tener una vida mejor”.

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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This story can be republished for free (details).