Cuando cae la noche y bajan las temperaturas, arma una tienda de campaña y enciende una fogata bajo un grupo de pinos, abetos y cedros.

Evita a las autoridades rotando el uso de tres tiendas de distintos colores en tres campamentos diferentes. Al amanecer, desmonta su refugio, enrolla sus pertenencias y las esconde para la noche siguiente. “No te ven si estás en el bosque”, dijo este hombre de 32 años. “Pero asegúrate de tener todo desmontado por la mañana o te van a encontrar”.

Durante el día, deambula, haciendo paradas en una biblioteca pública para calentarse o en un comedor comunitario para comer. Lo importante es no llamar la atención por no tener hogar.

“La policía quiere que no estorbemos”, dijo, vestido con una chaqueta gris y sin cargar ninguna de sus pertenencias. “Fuera de la vista, fuera de sus mentes”.

Ibrahim ha buscado intencionalmente pasar desapercibido desde agosto, cuando el presidente Donald Trump puso a la policía del distrito y ordenó que soldados de la Guardia Nacional patrullaran las calles. También ordenó el de las personas sin hogar. “No habrá ningún señor amable”, .

La administración Trump argumenta que los operativos para desmantelar campamentos han reducido la visibilidad del problema de personas sin hogar, mejorando así la ciudad. “Es innegable que Washington, D.C., es una ciudad más segura, limpia y hermosa gracias a las acciones históricas del presidente Trump para restaurar la capital del país”, dijo la vocera de la Casa Blanca, Taylor Rogers.

Aunque puede parecer que hay menos personas sin hogar en la capital del país, no han desaparecido.

En entrevistas, personas sin hogar dijeron que cambian de lugar constantemente, escondiéndose a plena vista.

Durante el día, se mantienen en movimiento, comen en comedores comunitarios y descansan de vez en cuando en bibliotecas públicas, bancos de parques o paradas de autobús. Por la noche, muchos duermen en entradas de negocios, aceras de parques y escalinatas de iglesias. Algunos pasan la noche en el autobús, otras se refugian en salas de emergencia, y algunas buscan cobijo en áreas boscosas o se van a suburbios en Virginia o Maryland.

Hay aproximadamente 5.100 personas sin hogar en Washington, D.C., incluyendo aquellas en albergues temporales, según realizado a inicios de 2025. Después de que Trump ordenara la ofensiva contra la falta de vivienda en espacios públicos, las personas que vivían en comunidades improvisadas se dispersaron y ahora viven en las sombras. En agosto, funcionarios de la ciudad estimaron que cerca de 700 personas vivían al aire libre sin tiendas ni ningún tipo de refugio.

Con la llegada del invierno, estas personas están expuestas al clima extremo y se enferman más, ya que afecciones crónicas como la diabetes o enfermedades cardíacas no se tratan. Proveedores de atención médica en la calle afirman que, desde el despliegue de la Guardia Nacional, ha sido sumamente difícil localizar a sus pacientes.

Muchos afectados por los operativos han perdido medicamentos esenciales y son más propensos a faltar a citas médicas porque viven en constante desplazamiento.

Los equipos médicos no logran entregar medicamentos ni transportar a pacientes a sus consultas. Este caos permanente también puede hundir aún más a quienes padecen enfermedades mentales o adicciones, aumentando el riesgo de sobredosis.

Trabajadores sociales reportan las mismas dificultades: cuando pierden el rastro de sus clientes, se rompe la conexión esencial para conseguir documentos clave como identificaciones oficiales o tarjetas del Seguro Social.

Funcionarios del distrito y proveedores de salud advierten que esta cadena de efectos puede empeorar la situación de las personas sin hogar, poner en riesgo la salud pública y la seguridad, y generar costos enormes para el sistema de salud.

“Ya era difícil encontrar a las personas, pero la presencia federal lo empeoró”, dijo la doctora Tobie Smith, médica de atención en la calle y directora ejecutiva de Street Health D.C.

El ir y venir de los sin techo

Chris Jones nació y creció en Washington, D.C., pero ahora vive en la calle, luego de ser desplazado de su tienda de campaña cerca de la Casa Blanca en los primeros días de la ofensiva federal.

Dijo que durante los operativos le confiscaron dos tiendas. Ahora duerme en una acera frente a una iglesia y ya no intenta conseguir otra. “¿Para qué? ¿Cuál es el punto? Igual la van a tirar a la basura”.

Jones, de 57 años, tiene una lesión grave en la rodilla que a veces le impide caminar y tiene programada una cirugía de reemplazo de rodilla en diciembre. Dice que necesita quedarse en esa zona porque depende de una farmacia cercana para surtir sus medicamentos para el trastorno bipolar, la diabetes y la presión alta. Cuando tiene hambre, va al comedor comunitario o trata de conseguir una hamburguesa con refresco en un local de comida rápida enfrente de donde está.

También se mantiene en ese lugar para que su trabajadora social lo pueda encontrar si se libera una plaza de vivienda permanente. Si hace demasiado frío, cruza la calle y duerme en la entrada de un negocio, que le da un poco más de protección. Quiere estar bajo techo, pero por ahora espera.

Desde que tomó el control de la policía del distrito, la administración Trump sobre ciudades y condados en todo el país para desmantelar campamentos de personas sin hogar, bajo amenaza de arresto, citaciones o detenciones. Ha ordenado o amenazado con desplegar la Guardia Nacional en ciudades con grandes poblaciones sin hogar como Los Ángeles y .

Rogers, la vocera de la Casa Blanca, dijo que el presidente mantiene la presencia de la Guardia Nacional y fuerzas federales del orden en la capital para “garantizar el éxito a largo plazo de la operación federal”.

Desde marzo, funcionarios federales y del distrito han eliminado más de 130 campamentos, según dijo. Sin embargo, algunos expertos en temas de personas sin hogar creen que esa cifra está inflada.

La Corte Suprema facilitó el año pasado que funcionarios y agentes del orden impusieran multas o arrestaran a personas sin hogar por vivir en la calle. Luego, en julio de este año, el presidente emitió una orden ejecutiva que exige una ofensiva nacional contra los campamentos urbanos, incluyendo el desalojo masivo de personas que viven al aire libre y tratamientos forzados para la salud mental o adicciones.

Trump también lidera una reforma de la política federal de vivienda, con planes de para vivienda permanente y servicios para personas sin hogar.

Esta medida limitaría el uso de una política federal conocida como “Primero la Vivienda” (Housing First), que ofrece vivienda sin exigir tratamiento para salud mental o adicciones.

La Alianza Nacional para Terminar con la Falta de Vivienda (National Alliance to End Homelessness) advierte que este cambio podría dejar sin hogar a por lo menos actualmente en viviendas de apoyo permanente. El Departamento de Vivienda y Desarrollo Urbano (HUD, por sus siglas en inglés) suspendió el plan el 8 de diciembre para hacer revisiones, que “piensan” implementar.

Funcionarios del distrito dicen que están cumpliendo con la exigente campaña federal contra las personas sin hogar en espacios públicos. Bajo presión de la Casa Blanca, reconocen haber intensificado la disolución de campamentos. Defensores de personas sin hogar señalan que algunos operativos se han realizado de noche o sin previo aviso.

Líderes locales creen que se podrían hacer de manera más compasiva, ofreciendo servicios y refugio.

“Hemos pasado de permitir campamentos si no afectaban la salud o la seguridad pública, a decir: ‘No los queremos en la calle’”, dijo Wayne Turnage, vicealcalde para Salud y Servicios Humanos del distrito, quien supervisa el desmantelamiento de campamentos. “Es inseguro, insalubre y peligroso”. Sin embargo, reconoce que los operativos pueden desperdiciar recursos públicos, ya que los trabajadores sociales y equipos médicos deben volver a buscar a sus pacientes y clientes.

Defensores afirman que la administración Trump está generando miedo y desconfianza entre personas sin hogar y quienes tratan de ayudarlas, a la vez que malgasta fondos públicos que podrían utilizarse para brindar atención o ubicar a estas personas en viviendas. Eso sí, ahora hay muchas menos tiendas de campaña y campamentos visibles para turistas y residentes.

“Las personas encontraban seguridad en esas comunidades, y los proveedores de servicios podían localizarlas. Ahora hay gente armada y luces que destellan sacando a la fuerza a personas sin hogar sin previo aviso y tirando sus cosas”, dijo Jesse Rabinowitz, director de campaña y comunicaciones del Centro Nacional de Leyes sobre Personas sin Hogar (National Homelessness Law Center).

Funcionarios del distrito dicen que algunas personas han aceptado ir a refugios de emergencia. Pero incluso mientras la ciudad trata de ampliar la capacidad de albergues y conectar a la gente con servicios, reconoce que no hay suficientes camas ni viviendas permanentes para todos.

Y habrá menos lugares disponibles para quienes viven en la calle.

El presupuesto del distrito para el año fiscal 2026 concentró los fondos para personas sin hogar en las familias, con 336 nuevos vales para viviendas de apoyo permanente.

Sin embargo, se recortó el financiamiento para albergues temporales tanto para familias como para personas solas, y no se asignaron nuevos vales de vivienda permanente para individuos.

Eso significa menos espacios disponibles para adultos solos, que representan la mayoría de quienes deambulan por las calles. No obstante, las autoridades locales señalaron que han incluido 260 nuevas unidades de vivienda permanente para personas sin hogar, ya sean familias o individuos, en sus planes de construcción.

Empeorando la atención médica

La situación ha saturado los comedores comunitarios, como Miriam’s Kitchen en Foggy Bottom. Esta institución local ofrece comidas calientes, asistencia para vivienda y cobijas a personas en situación de necesidad.

Trabajadores sociales dicen que cada vez es más difícil ayudar a los clientes a obtener identificaciones y otros documentos necesarios para servicios sociales y de vivienda.

“Estoy buscando por todos lados, pero no puedo encontrarlos”, dijo Cyria Knight, trabajadora social de Miriam’s Kitchen. “La mayoría de mis clientes se fue a Virginia”.

No está claro cuántas personas se han trasladado a comunidades vecinas en Virginia o Maryland. En enero, antes de la ofensiva de Trump, se estimaba que había unas en la región. Cuatro de los seis condados que rodean Washington vieron un aumento en la falta de vivienda desde 2024, mientras que en el distrito .

“No veo a mis pacientes por un mes o más, y cuando los encuentro, sus enfermedades crónicas están fuera de control. Han entrado y salido de la sala de emergencia, y tienen más probabilidades de ser hospitalizados”, dijo Anna Graham, enfermera especializada en medicina callejera de , una red de clínicas en Washington. “Esto nos hace retroceder”.

El equipo de Graham estaciona su unidad médica móvil afuera de Miriam’s Kitchen durante la hora de la cena para tener más probabilidades de encontrar pacientes.

Willie Taylor, de 63 años, buscaba dónde dormir esa noche tras recibir la cena. Vio a Graham para recibir medicamentos para una enfermedad pulmonar avanzada, convulsiones, dolor crónico y otros padecimientos.

Le cuesta caminar y necesita una silla de ruedas, lo cual es complicado porque no tiene una dirección fija. Sus proveedores médicos dicen que le han robado sillas de ruedas antes mientras dormía en la calle.

Taylor usa un carrito de compras para mantenerse en pie durante el día, caminando sin rumbo hasta que cae la noche.

En una fría noche de noviembre, Graham lo ayudó a organizar sus medicamentos y revisó sus signos vitales. El equipo le dio un abrigo y calentadores de manos antes de que volviera a irse.

Después de caminar unos 45 minutos, encontró un rincón de pavimento en un parque donde pudo armar su cama con lonas y sacos de dormir.

“Mi cuerpo ya no aguanta esto”, dijo Taylor mientras se preparaba para dormir. “Hay hielo en el concreto. Me duele muchísimo más cuando hace frío”.

Las personas sin hogar  y les cuesta más al sistema de salud que quienes tienen vivienda, en gran parte porque no reciben tratamiento en la calle y, cuando buscan atención, suelen ir a la sala de emergencia.

Se estima que, entre las personas inscritas en Medicaid, quienes no tienen hogar generan un gasto anual de $18.764, frente a $7.561 de otros beneficiarios.

Más temprano ese día, en el comedor comunitario So Others Might Eat, Tyree Kelley terminaba su desayuno: un sándwich de salchicha y huevos duros. Estaba considerando ir a un refugio. Dijo que las calles se estaban volviendo demasiado peligrosas, en referencia a la presencia policial y de la Guardia Nacional. Extrañaba la comunidad de su antiguo campamento, que lo ayudaba a mantenerse seguro.

Este año ha ido al hospital al menos siete veces por una fractura en el tobillo tras caer de un scooter eléctrico. El accidente le hizo perder su trabajo y su seguro médico como recolector de basura, contó. Dijo que su situación lo ha hundido en una depresión que comenzó hace tres años, cuando murió su madre.

Después, este año murieron su padre y su hermana. Para adormecer el dolor, comenzó a beber.

“Uno se deprime mucho estando aquí”, dijo Kelley, de 42 años. “Se vuelve adictivo. Empiezas a no preocuparte ni por cambiarte de ropa”.

Esa depresión lo llevó a buscar marihuana. Luego fumó un cigarro mezclado con fentanilo. La sobredosis lo mantuvo en el hospital durante varios días.

“En realidad morí y volví”, dijo, agradeciendo a otras personas sin hogar que le administraron naloxona y le salvaron la vida. “Necesito salir de esto, pero me siento atrapado”.

A unas cuadras al oeste de la Casa Blanca hay un terreno baldío en donde hasta hace poco había más de una docena de tiendas de campaña. Quienes trabajan en la zona perciben lo que ya no se ve.

“Estuve aquí cuando limpiaron todo. Llegó una topadora y tiraron todo a un camión de basura”, dijo Ray Szemborski, quien trabaja frente a ese lote. “Las personas siguen sin hogar. Las sigo viendo debajo del puente. A veces están en las paradas de bus, otras solo caminando. Las tiendas ya no están, pero ellos siguen aquí”.

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As night falls and temperatures drop, he erects a tent and builds a fire beneath a canopy of pine, hemlock, and cedar trees.

He evades authorities by rotating use of three tents of different colors at three campsites. As day breaks, he dismantles his shelter, rolls up his belongings, and hides them for the next night. “They don’t see you if you’re in the woods,” the 32-year-old said. “But make sure it’s broken down by morning or they’ll find you.”

During the day, he wanders, stopping at a public library to warm up or a soup kitchen to eat. What’s important is to not draw attention to himself for being homeless.

Ibrahim has been deliberate about blending in since August, when President Donald Trump placed the district’s police under and ordered National Guard soldiers to patrol its streets. The president homeless people to leave immediately. “There will be no ‘MR. NICE GUY,’” .

The Trump administration says encampment sweeps have reduced the visibility of homelessness, thereby enhancing the city. “There is no disputing that Washington, DC is a safer, cleaner, and more beautiful city thanks to President Trump’s historic actions to restore the nation’s capital,” White House spokesperson Taylor Rogers said.

While there may appear to be fewer homeless people in the nation’s capital now, they have not disappeared.

In interviews, homeless people said they are in a constant shuffle, hiding in plain sight. During the day, they stay on the move, grabbing meals at soup kitchens and resting on occasion in public libraries, on park benches, or at bus stops. At night, many unsheltered people bed down in business doorways, on park sidewalks, and on church stoops. Some ride the bus all night, while a few shelter in emergency rooms. Others find respite in the woods or flee to suburbs in Virginia or Maryland.

There are about 5,100 homeless people in Washington, D.C., including in temporary shelters, according to an . After Trump ordered the crackdown on public homelessness, people living in makeshift communities scattered and are now living in the shadows. City officials estimated in August that nearly 700 homeless people were living outdoors without tents or other shelter.

As winter draws near, they are exposed to the elements and grow sicker as chronic ailments such as diabetes and heart disease go untreated. Street medicine providers say that, since the National Guard was deployed, they have faced enormous difficulty finding patients. Many caught up in sweeps have had their lifesaving medications thrown away, and they are more likely to miss medical appointments because they are constantly on the move. Street medicine providers say they can’t find their patients to deliver medication or transport them to medical appointments. The constant chaos can suck patients with mental illness and substance use deeper into drug and alcohol addiction, raising the risk of overdose.

Caseworkers report similar disruptions, saying as clients get lost, they break connections essential for obtaining housing documents, particularly IDs and Social Security cards.

District officials and health providers say this cascade will make homelessness worse, threatening public health and public safety and racking up enormous costs for the health care system.

“It was already hard locating people, but the federal presence just made it worse,” said Tobie Smith, a street medicine doctor and the executive director of Street Health D.C.

The Homeless Shuffle

Chris Jones was born and raised in Washington, D.C., but now is homeless, having been pushed out of his tent near the White House in the initial days of the federal homelessness crackdown. He said two of his tents were taken during sweeps. Now, sleeping on a sidewalk outside a church, he doesn’t bother trying to get another one. “Why? What’s the point? It’ll just get thrown away again.”

Jones, 57, has a severe knee injury that prevents him from walking some days and said he was scheduled for a knee replacement in December. He said it’s important to stay where he is — he relies on a nearby drugstore to refill his medications for bipolar disorder, diabetes, and high blood pressure. When he’s hungry, he goes to a soup kitchen for a meal or tries to get a cheeseburger and a soda from a fast-food joint across the street.

It’s important for him to stay outside the church, he said, so his case manager can find him when a permanent housing slot opens up. If it gets too cold, he said, he will cross the street and sleep in the doorway of a business, which can provide a bit more shelter. He wants to get indoors, but for now, he waits.

Since taking control of Washington’s police force, the Trump administration has on cities and counties across the nation to clear homeless encampments under threat of arrest, citation, or detention. It has ordered or threatened similar National Guard deployments in Los Angeles; ; and other cities with large homeless populations.

Rogers, the White House spokesperson, said the president is maintaining National Guard and federal law enforcement presence in the nation’s capital “to ensure the long-term success of the federal operation.” Since March, city and federal officials have removed more than 130 homeless encampments, she said, though some local homelessness experts say that number could be inflated.

The Supreme Court last year made it easier for elected officials and law enforcement to fine or arrest homeless people for living outside. Then, in July of this year, the president issued an executive order calling for a nationwide crackdown on urban camping, including a massive removal of people living outdoors and forced mental health or substance use treatment.

Trump is also spearheading an overhaul of homelessness policy, moving to and services for homeless people. The move would limit the use of a long-standing federal policy known as “Housing First” that offers housing without mandating mental health or addiction treatment. The National Alliance to End Homelessness warns the move risks displacing in permanent supportive housing. The Department of Housing and Urban Development paused the plan on Dec. 8 to make revisions, which it “intends” to do, .

City officials say they are complying with the Trump administration’s forceful campaign against homeless people sheltering outside. Pressured by the White House, local officials said they’ve gotten more aggressive in breaking up camps. Advocates for homeless people say some of the sweeps have been conducted at night and others with little or no notice to move. City leaders believe they could be done more compassionately by offering services and shelter.

“We’ve pivoted from the notion of allowing encampments if they didn’t violate public health or safety to a position of, ‘We don’t want you in the streets,’” said Wayne Turnage, deputy mayor for District of Columbia Health and Human Services, who oversees encampment cleanups. “It’s unsafe, it’s unhealthy, and it’s dangerous.” Yet he acknowledges the encampment sweeps can waste city resources as caseworkers and street medicine providers scramble to find their clients and patients.

Advocates say the Trump administration is inciting fear and mistrust between homeless people and those working to help them while wasting taxpayer dollars used to provide care and place people into housing. There are, however, far fewer tents and large-scale encampments visible to tourists and residents.

“People found safety in those communities and service providers could find them. Now there are people with guns and flashing lights dislocating folks experiencing homelessness without notice and just throwing stuff away,” said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

District officials say some people have accepted emergency shelter. But even as the city works to connect people with services and expand shelter capacity, officials acknowledge there isn’t enough permanent housing or temporary beds for everyone.

And there will be fewer places for people living outside to go.

The city, in its fiscal year 2026 budget, concentrated its homelessness funding on families, funding 336 new permanent supportive housing vouchers. Yet it cut funding for temporary housing for both families and individuals and provided no new permanent supportive housing vouchers for individuals. That means fewer housing slots for single adults, who make up most of those wandering the streets. City officials said, however, that they have slotted 260 more permanent housing units for homeless individuals or families into their construction pipeline.

Worsening Health Care

The fallout is inundating local soup kitchens with demand, including Miriam’s Kitchen in Foggy Bottom. The local institution provides hot meals, housing assistance, and warm blankets to people in need.

Caseworkers say it’s becoming increasingly difficult to help clients secure IDs and other documents needed for housing and other social services.

“I’m looking everywhere, but I can’t find people,” said Cyria Knight, a caseworker at Miriam’s Kitchen. “Most of my clients went to Virginia.”

It’s unclear how much of the district’s homeless population has fanned out to neighboring Virginia and Maryland communities. There were an estimated in the region in January, months before Trump’s crackdown. Four of six counties around Washington saw homelessness rise from 2024, while it .

“I’m not seeing my patients for a month or more, and then when I do, their chronic conditions are uncontrolled. They’ve been in and out of the ER, and they’re more likely to be hospitalized,” said Anna Graham, a street medicine nurse practitioner for , a network of clinics in Washington. “It’s just setting us back.”

Graham’s team stations its mobile medical van outside Miriam’s Kitchen at dinnertime to better find patients.

Willie Taylor, 63, was figuring out where to sleep for the night after grabbing dinner from Miriam’s. He saw Graham to receive his medications for advanced lung disease, seizures, chronic pain, and other health disorders.

He has difficulty walking and needs a wheelchair, which is complicated because he doesn’t have a permanent address. Taylor and his medical providers say his previous wheelchairs have been stolen while he slept outdoors at night. He uses a shopping cart to keep him steady, walking around all day, until nightfall.

On a cold November night, Graham helped Taylor figure out his daily medications and checked his vitals. The team handed him a warm coat and hand warmers before sending him back outside.

After walking for about 45 minutes, he found a piece of park pavement where he could build a bed out of tarps and sleeping bags.

“My body can’t take this,” Taylor said, preparing to sleep. “There’s ice on the concrete. I’m in so much pain; it hurts so much worse when it’s cold.”

Homeless people and cost the health care system more than housed people, largely because conditions go untreated on the streets, and when they do seek care, many go to the ER. Among Medicaid enrollees, homeless people have been estimated to incur $18,764 a year in spending, compared with $7,561 for other enrollees.

Over at the So Others Might Eat soup kitchen earlier that day, Tyree Kelley was finishing his breakfast of a sausage sandwich and hard-boiled eggs. He was considering going into a shelter. The streets were becoming too dangerous for someone like him, he said, referring to the police and National Guard presence. He was feeling the loss of an encampment community that would watch his back.

He’s been to the ER at least seven times this year to get care for a broken ankle he sustained falling off an electric scooter. The accident caused him to lose his job and health insurance as a garbageman, he said. His situation has caused him to sink deeper into a depression that began three years ago after his mother died, he said.

Then his father and sister died this year. He began to numb his pain with beer.

“You get so depressed, being out here,” said Kelley, 42. “It gets addictive. You start to not care about even changing your clothes.”

His depression also led him to seek out marijuana. Then he smoked a joint laced with fentanyl. The overdose sent him to the hospital for days.

“I actually died and came back,” he said, crediting other homeless people with administering naloxone and saving his life. “I need to get out of this, but I feel so stuck.”

A few blocks west of the White House sits a vacant plot of land that earlier this year held more than a dozen tents. Workers in the area sense what they don’t always see.

“I was here when this was all cleared. A bulldozer came in, and all their stuff was thrown in a garbage truck,” said Ray Szemborski, who works across the street from the now-empty lot. “People are still homeless. I still see them around underneath the bridge. Sometimes they’re at bus stops, sometimes just walking around. Their tents are gone but they’re still here.”

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His monthly premium payment of $435 for family coverage is roughly the same as the insurance at his previous job. But the policy at his current job carries an annual deductible of $4,000, which he must pay out-of-pocket for his family’s care until he reaches that amount each year.

“Now everything is full price,” said the 53-year-old, who works at a warehouse just south of Dallas-Fort Worth. “That’s been a little bit of a struggle.”

To reduce his costs, Garza switched to a lower-cost diabetes medication, and he no longer wears a continuous glucose monitor to check his blood sugar. Since he started his job nearly two years ago, he said, his blood sugar levels have inched upward from an A1c of 7% or less, the target goal, to as high as 14% at his most recent doctor visit in November.

“My A1c is through the roof because I’m not on, technically, the right medication like before,” Garza said. “I’m having to take something that I can afford.”

Plans with high deductibles — the amount that patients must pay for most medical care before insurance starts pitching in — have become increasingly common. In 2024, participating in medical care plans were offered this type of insurance, up from 38% in 2015, according to federal data. Such plans are also offered through the Affordable Care Act marketplace.

With and many of the subsidies to help people pay for them poised to expire at year’s end, more people face tough choices as they weigh monthly premium costs against deductibles. To afford insurance at all, people may opt for a plan with low premium payments but with a high deductible, gambling that they won’t have any medical crises.

But high-deductible plans pose a particular challenge for those with chronic conditions, such as the who live with Type 1 or Type 2 diabetes. Adults with diabetes who are involuntarily switched to a high-deductible plan, compared with adults on other types of insurance, face an 11% higher risk of being hospitalized with a heart attack, a 15% higher risk of hospitalization for a stroke, and that they’ll go blind or develop end-stage kidney disease, according to a study published in 2024.

“All of these complications are preventable,” said , the study’s lead author.

Care vs. Cost

The initial rationale behind such high-deductible plans was to encourage people to become wiser health care shoppers, said McCoy, an associate professor of medicine at the University of Maryland School of Medicine in Baltimore. And they can be a good fit, proponents say, for people who don’t use a lot of medical care or who have cash on hand for a health crisis.

But while people with an excruciating earache will seek care, McCoy said, those with unhealthy blood sugar levels might not feel as urgent a need to seek treatment — despite the potential long-term damage — given the acute financial pain.

“You have no symptoms until it’s too late,” she said. “At that point, the damage is irreversible.”

Overall, medical care for people with diabetes costs insurers and patients an average of the disease, according to an analysis. Type 2 diabetes, the more common form, is diagnosed when the body can no longer process or produce enough insulin to adequately regulate blood sugars. With Type 1, the body can’t produce insulin. Those with the disease may end up on the financial hook not just for insulin and other types of medication but for related equipment.

Mallory Rogers, whose 6-year-old daughter, Adeline, has Type 1, calculates that it costs roughly $1,200 a month for insulin, a pump, and a continuous glucose monitor. That figure doesn’t include the cost of emergency supplies needed in case Adeline’s technology malfunctions. Those include another type of insulin, blood-testing strips, and a nasal spray that’s nearly $600 for a two-pack of vials — supplies that must be replaced once a year or more frequently.

“If she doesn’t have insulin, it would become an emergency situation within two hours,” said Rogers, a technology consultant who lives in Sanford, Florida. Rogers has been saving for the coming year when her daughter moves to the high-deductible health plan offered by Rogers’ employer, which has a $3,300 deductible for family coverage.

Taxing Decisions

Many insurance plans carry increasingly high deductibles. But to be defined as a high-deductible health plan — and thus be eligible to offer a health savings account — a plan’s deductible for 2026 must be , according to IRS rules.

Health savings accounts enable people to squirrel away money that can be rolled over from year to year to be used for eligible medical expenses, including prior to meeting a deductible. Such accounts, available through a plan or employer, can provide tax benefits. The contributions are limited to $4,400 individually and $8,750 for a family in 2026, and employers may contribute toward that total. Rogers’ employer pays $2,000 spread out over the year, and Garza’s contributes $1,200.

Rogers recognizes that she’s fortunate to have accumulated $7,000 so far in her health savings account to prepare for her daughter’s insurance shifting to Rogers’ plan.

“Adding a financial burden to an already very stressful medical condition, it hurts my heart,” she said, reflecting on those who can’t similarly stockpile. “Nobody asks to have diabetes, Type 1 or Type 2.”

The median deductible for employer health insurance plans was $2,750 in 2024, but deductibles can run $5,000 or higher, said George Huntley, CEO of both the and .

When deductibles are too high, Huntley said, routine maintenance is what patients skimp on: “You don’t take the drug that you’re supposed to take to maintain your blood glucose. You ration your insulin, if that’s your scenario. You take pills every other day.”

Garza knows he should do more to control his blood sugar, but financial realities complicate the equation. His previous health plan covered a newer class of diabetes medication, called a GLP-1 agonist, for $25 a month. He wasn’t charged for his remaining medications, which included blood pressure and cholesterol drugs, or his continuous glucose monitor.

With his new insurance, he pays $125 monthly for insulin and several other medications. He doesn’t see his endocrinologist for checkups more than twice a year.

“He wants to see me every three months,” Garza said. “But I told him it’s not possible at $150 a pop.”

Plus, he typically needs lab testing before each visit, an additional $111.

In 2026, the deductible for a “silver”-level plan on the marketplace will average $5,304 without cost-sharing reductions, according to an analysis from KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. For a . An annual visit and some preventive screenings, such as a mammogram, would be covered free of cost to the patient.

Moreover, people , whether through their employer or the marketplace, should figure out their annual out-of-pocket maximum, which still applies after the deductible is met, Huntley said.

Garza’s family policy requires him to pay 20% until he reaches $10,000, for example.

Given Garza’s high blood sugar levels, his doctor prescribed a fast-acting form of insulin to take as needed with meals, which costs an additional $79 monthly. He planned to fill it in December, when he’s responsible for only 20% of the cost after he has hit his deductible but not yet reached his out-of-pocket maximum.

Garza likes his job despite its health plan, saying he’s never missed a day of work, even recently when he had a stomach bug. As of late 2025, he remained conflicted about whether to sign up for health insurance when his company’s enrollment period rolls around in mid-2026.

He worries that dropping insurance would place his family too much at risk if a major medical crisis struck. Still, he pointed out, he could then use the money he now spends on monthly premiums to directly pay for care to better manage his diabetes.

“I’m just stuck, to be honest with you,” he said.

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Permanent changes to the Supplemental Nutrition Assistance Program are coming regardless of the outcome of at least two federal lawsuits that seek to prevent the government from cutting off November SNAP benefits. The lawsuits challenge the Trump administration’s refusal to release emergency funds to keep the program operating during the government shutdown.

A federal judge in Rhode Island ordered the government to use those funds to keep SNAP going. A Massachusetts judge in a separate lawsuit also said the government must use its food aid contingency funds to pay for SNAP, but gave the Trump administration until Nov. 3 to come up with a plan.

Amid that uncertainty, food banks across the U.S. braced for a surge in demand, with the possibility that millions of people will be cut off from the food program that helps them buy groceries.

On Oct. 28, a vanload of SpaghettiOs, tuna, and other groceries arrived at Gateway Food Pantry in Arnold, Missouri. It may be Gateway’s last shipment for a while. The food pantry south of St. Louis largely serves families with school-age children, but it has already exhausted its yearly food budget because of the surge in demand, said Executive Director Patrick McKelvey.

New Disabled South, a Georgia-based nonprofit that advocates for people with disabilities, announced that it was offering one-time payments of $100 to $250 to individuals and families who were expected to lose SNAP benefits in the 14 states it serves.

Less than 48 hours later, the nonprofit had received more than 16,000 requests totaling $3.6 million, largely from families, far more than the organization had funding for.

“It’s unreal,” co-founder Dom Kelly said.

The threat of a SNAP funding lapse is a preview of what’s to come when changes to the program that were included in the One Big Beautiful Bill Act that President Donald Trump signed in July take effect.

The domestic tax-and-spending law cuts $187 billion within the next decade from SNAP. That’s a nearly 20% decrease from current funding levels, according to the Congressional Budget Office.

The new rules shift many food and administrative costs to states, which may lead some to consider withdrawing from the program, which helped about 42 million people buy groceries last year. Separate from the new law, the administration is also pushing states to limit SNAP purchases by barring such things as candy and soda.

All that “puts us in uncharted territory for SNAP,” said Cindy Long, a former deputy undersecretary at the Department of Agriculture who is now a national adviser at the law firm Manatt, Phelps & Phillips.

The country’s first food stamps were issued at the end of the Great Depression, when the poverty-stricken population couldn’t afford farmers’ products. Today, instead of stamps, recipients use debit cards. But the program still buoys farmers and food retailers and prevents hunger during economic downturns.

The CBO estimates that will lose food assistance as a result of in the budget law, including applying work requirements to more people and shifting more costs to states. Trump administration leaders have backed the changes as a way to limit waste, to , and to .

This is the biggest cut to SNAP in its history, and it is coming against the backdrop of rising food prices and a fragile labor market.

The exact toll of the cuts will be difficult to measure, because the Trump administration that measures food insecurity.

Here are five big changes that are coming to SNAP and what they mean for Americans’ health:

1. Want food benefits? They will be harder to get.

Under the new law, people will have to file more paperwork to access SNAP benefits.

Many recipients are already required to work, volunteer, or participate in other eligible activities for 80 hours a month to get money on their benefit cards. The new law to previously exempted groups, including homeless people, veterans, and young people who were in foster care when they turned 18. The expanded work requirements also apply to parents with children 14 or older and adults ages 55 to 64.

, if recipients fail to document each month that they meet the requirements, they will be limited to three months of SNAP benefits in a .

“That is draconian,” said Elaine Waxman, a senior fellow at the Urban Institute, a nonprofit research group. About 1 in 8 adults reported having lost SNAP benefits because they had problems filing their paperwork, according to .

Certain refugees, asylum-seekers, and other lawful immigrants are cut out of SNAP entirely under the new law.

2. States will have to chip in more money and resources.

The federal law drastically increases what each state will have to pay to keep the program.

Until now, states have needed to pay for only half the administrative costs and none of the food costs, with the rest covered by the federal government.

Under the new law, states are on the hook for 75% of the administrative costs and must cover a portion of the food costs. That amounts to an estimated median cost increase for states of more than 200%, according to by the Georgetown Center on Poverty and Inequality.

A ºÚÁϳԹÏÍø News analysis shows that a single funding shift related to the cost of food could put states on the hook for an additional $11 billion.

All states participate in the SNAP program, but they could opt out. In June, nearly wrote to congressional leaders warning that some states wouldn’t be able to come up with the money to continue the program.

“If states are forced to end their SNAP programs, hunger and poverty will increase, children and adults will get sicker, grocery stores in rural areas will struggle to stay open, people in agriculture and the food industry will lose jobs, and state and local economies will suffer,” the governors wrote.

3. Will the changes lead to more healthy eating?

The Trump administration, through its “Make America Healthy Again” platform, has made healthy eating a priority.

Health and Human Services Secretary Robert F. Kennedy Jr. has championed the restrictions on soda and candy purchases within the food aid program. To date, to limit what people can buy with SNAP dollars.

Federal officials previously blocked such restrictions, because they were difficult for states and stores to implement and they boost stigma around SNAP, according to . In 2018, the first Trump administration to ban sugar-sweetened drinks and candy.

A store may decide that hassle isn’t worth participating in the program and drop out of it, leaving SNAP recipients fewer places to shop.

People who receive SNAP are no more likely to buy sweets or salty snacks than people who shop without the benefits, . Research shows that encouraging healthy food choices is than regulating purchases.

When people have less money to spend on food, they often resort to cheaper, unhealthier alternatives that keep them sated longer rather than paying for more expensive food that is healthy and fresh but quick to perish.

4. How will SNAP cuts affect health?

Advocacy organizations working to end hunger in the nation say the cuts will have long-term health effects.

Research has found that kids in households with limited access to food to have a mental disorder. Similarly, food insecurity is linked to .

Working-age people with food insecurity to experience chronic disease. That high blood pressure, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

Those health issues come with costs for individuals. Low-income adults who aren’t on SNAP more a year on health care than those who are.

lived in households with limited or uncertain access to food in 2023.

5. What does this mean for the nation’s food supply chain?

SNAP spending directly boosts grocery stores, their suppliers, and the transportation and farming industries. Additionally, when low-income households have help accessing food, they’re more likely to spend money on other needs, such as prescriptions or car repairs. All that means that every dollar spent through SNAP generates at least $1.50 in economic activity, .

A report by associations representing convenience stores, grocers, and the food industry estimated it to comply with the new SNAP restrictions.

Advocates warn stores may pass the costs on to shoppers, or they may close.

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If you regularly experience connection issues, .

Next to the router sat medications, vitamin D pills, and Williams’ blood glucose monitor kit.

“I haven’t used that thing in a month or so,” said Williams, 72, waving toward the kit. Diagnosed with diabetes more than six years ago, she has developed nerve pain from neuropathy in both legs.

Williams is one of nearly 3 million Americans who live in mostly rural counties that lack both health care and reliable high-speed internet, according to an analysis by ºÚÁϳԹÏÍø News, which showed that these people tend to live sicker and die younger than others in America.

Compared with those in other regions, patients across the rural South, Appalachia, and remote West are most often unable to make a video call to their doctor or log into their patient portals. Both are essential ways to participate in the U.S. medical system. And Williams is among those who can do neither.

This year, more than $42 billion allocated in the 2021 Infrastructure Investment and Jobs Act is expected to begin flowing to states as part of a national “” initiative launched by the Biden administration. But the program faces uncertainty after Commerce Department Secretary Howard Lutnick a “rigorous review” asserting that the previous administration’s approach was full of “woke mandates.”

High rates of chronic illness and historical inequities are hallmarks of many of the more than 200 U.S. counties with poor services that ºÚÁϳԹÏÍø News identified. Dozens of doctors, academics, and advocates interviewed for this article unanimously agreed that limited internet service hinders medical care and access.

Without fast, reliable broadband, “all we’re going to do is widen health care disparities within telemedicine,” said Rashmi Mullur, an endocrinologist and chief of telehealth at VA Greater Los Angeles. Patients with diabetes who also use telemedicine are more likely to get care and control their blood sugar, .

Diabetes requires constant management. Left untreated, uncontrolled blood sugar can cause blindness, kidney failure, nerve damage, and eventually death.

Williams, who sees a nurse practitioner at the county hospital in the next town, said she is not interested in using remote patient monitoring or video calls.

“I know how my sugar affects me,” Williams said. “I get a headache if it’s too high.” She gets weaker when it’s down, she said, and always carries snacks like crackers or peppermints.

Williams said she could even drink a soda pop — orange, grape — when her sugar is low but would not drink one when she felt it was high because she would get “kind of goozie-woozy.”

‘This Is America’

Connectivity dead zones persist in American life despite at least $115 billion lawmakers have thrown toward fixing the inequities. Federal broadband efforts are fragmented and overlapping, with more than 133 funding programs administered by 15 agencies, according to a .

“This is America. It’s not supposed to be this way,” said Karthik Ganesh, chief executive of Tampa, Florida-based OnMed, a telehealth company that in September installed a walk-in booth at the Boligee Community Center about 10 minutes from Williams’ home. Residents can call up free life-size video consultations with an OnMed health care provider and use equipment to check their weight and blood pressure.

OnMed, which partnered with local universities and the Alabama Cooperative Extension System, relies on SpaceX’s Starlink to provide a high-speed connection in lieu of other options.

A short drive from the community center, beyond Boligee’s Main Street with its deserted buildings and an empty railroad depot and down a long gravel drive, is the 22-acre property where Williams lives.

Last fall, Williams washed a dish in her kitchen, with its unforgiving linoleum-topped concrete floors. A few months earlier, she said, a man at the community center signed her up for “diabetic shoes” to help with her sore feet. They never arrived.

As Williams spoke, steam rose from a pot of boiling potatoes on the stove. Another pan sizzled with hamburger steak. And on a back burner simmered a mix of Velveeta cheese, diced tomatoes, and peppers.

She spent years on her feet as head cook at a diner in Cleveland, Ohio. The oldest of nine, Williams returned to her family home in Greene County more than 20 years ago to care for her mother and a sister, who both died from cancer in the back bedroom where she now sleeps.

Williams looked out a window and recalled when the landscape was covered in cotton that she once helped pick. Now three houses stand in a carefully tended clearing surrounded by tall trees. One belongs to a brother and the other to a sister who drives with her daily to the community center for exercise, prayers, and friendship with other seniors.

All the surviving siblings, Williams said, have diabetes. “I don’t know how we became diabetic,” she said. Neither of their parents had been diagnosed with the illness.

In Greene County, an estimated quarter of adults have diabetes — twice the national average. The county, which has about 7,600 residents, also has among the nation’s highest rates for several chronic diseases such as high blood pressure, stroke, and obesity, Centers for Disease Control and Prevention data shows.

The county’s population is predominately Black. The federal CDC reports that Black Americans are to be diagnosed with diabetes and are 40% more likely than their white counterparts to die from the condition. And in the South, rural Black residents are more likely , according to the Joint Center for Political and Economic Studies, a Washington-based think tank.

To identify counties most lacking in reliable broadband and health care providers, ºÚÁϳԹÏÍø News used data from the Federal Communications Commission and George Washington University’s Mullan Institute for Health Workforce Equity. Reporters also analyzed U.S. Census Bureau, CDC, and other data to understand the health status and demographics of those counties.

The analysis confirms that internet and care gaps are “hitting areas of extreme poverty and high social vulnerability,” said Clese Erikson, deputy director of the health workforce research center at the Mullan Institute.

Digital Haves vs. Have-Nots

Just over half of homes in Greene County have access to reliable high-speed internet — among the lowest rates in the nation. Greene County also has some of the country’s poorest residents, with a median household income of about $31,500. Average life expectancy is less than 72 years, below the national average.

By contrast, the ºÚÁϳԹÏÍø News analysis found that counties with the highest rates of internet access and health care providers correlated with higher life expectancy, less chronic disease, and key lifestyle factors such as higher incomes and education levels.

One of those is Howard County, Maryland, between Baltimore and Washington, D.C., where nearly all homes can connect to fast, reliable internet. The median household income is about $147,000 and average life expectancy is more than 82 years — a decade longer than in Greene County. A much smaller share of residents live with chronic conditions such as diabetes.

One is 78-year-old Sam Wilderson, a retired electrical engineer who has managed his Type 2 diabetes for more than a decade. He has fiber-optic internet at his home, which is a few miles from a cafe he dines at every week after Bible study. On a recent day, the cafe had a guest Wi-Fi download speed of 104 megabits per second and a 148 Mbps upload speed. The speeds are fast enough for remote workers to reliably take video calls.

Americans are demanding more speed than ever before. Most households have multiple devices — televisions, computers, gaming systems, doorbells — in addition to phones that can take up bandwidth. The more devices connected, the higher minimum speeds are needed to keep everything running smoothly.

To meet increasing needs, federal regulators updated the , establishing standard speeds of 100/20 Mbps. Those speeds are typically enough for several users to stream, browse, download, and play games at the same time.

Christopher Ali, professor of telecommunications at Penn State, recommends minimum standard speeds of 100/100 Mbps. While download speeds enable consumption, such as streaming or shopping, fast upload speeds are necessary to participate in video calls, say, for work or telehealth.

At the cafe in Howard County, on a chilly morning last fall, Wilderson ordered a glass of white wine and his usual: three-seeded bread with spinach, goat cheese, smoked salmon, and over-easy eggs. After eating, Wilderson held up his wrist: “This watch allows me to track my diabetes without pricking my finger.”

Wilderson said he works with his doctors, feels young, and expects to live well into his 90s, just as his father and grandfather did.

Telehealth is crucial for people in areas with few or no medical providers, said Ry Marcattilio, an associate director of research at the Institute for Local Self-Reliance. The national research and advocacy group works with communities on broadband access and reviewed ºÚÁϳԹÏÍø News’ findings.

High-speed internet makes it easier to use video visits for medical checkups, which most patients with diabetes need every three months.

Being connected “can make a huge difference in diabetes outcomes,” said Nestoras Mathioudakis, an endocrinologist and the co-medical director of Johns Hopkins Medicine Diabetes & Education Program, who treats patients in Howard County.

Paying More for Less

At Williams’ home in Alabama, pictures of her siblings and their kids cover the walls of the hallway and living room. A large, wood-framed image of Jesus at the Last Supper with his disciples hangs over her kitchen table.

Williams sat down as her pots simmered and sizzled. She wasn’t feeling quite right. “I had a glass of orange juice and a bag of potato chips, and I knew that wasn’t enough for breakfast, but I was cooking,” Williams said.

Every night Williams takes a pill to control her diabetes. In the morning, if she feels as if her sugar is dropping, she knows she needs to eat. So, that morning, she left the room to grab a peppermint, walking by the flickering wireless router.

The router’s download and upload speeds were 0.03/0.05 Mbps, nearly unusable by modern standards. Williams’ connection on her house phone can sound scratchy, and when she connects her cellphone to the router, it does not always work. Most days it’s just good enough for her to read a daily devotional website and check Facebook, though the stories don’t always load.

Rural residents like Williams on average in late 2020 for slow internet connections than those in urban areas, according to Brian Whitacre, an agricultural economics professor at Oklahoma State University.

“You’re more likely to have competition in an urban area,” Whitacre said.

In rural Alabama, cellphone and internet options are limited. Williams pays $51.28 a month to her wireless provider, Ring Planet, which did not respond to calls and emails.

In Howard County, Maryland, national fiber-optic broadband provider Verizon Communications faces competition from Comcast, a hybrid fiber-optic and cable provider. Verizon advertises a home internet plan promising speeds of 300/300 Mbps starting at $35 a month for its existing mobile customers. The company also offers a discounted price as low as $20 a month for customers who participate in certain federal assistance programs.

“Internet service providers look at the economics of going into some of these communities and there just isn’t enough purchasing power in their minds to warrant the investment,” said Ross DeVol, chief executive of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

Conexon, a fiber-optic cable construction company, estimates it costs $25,000 per mile to build above-ground fiber lines on poles and $60,000 to $70,000 per mile to build underground.

Former President Joe Biden’s 2021 infrastructure law earmarked $65 billion with a goal of Money was designated to establish digital equity programs and to help low-income customers pay their internet bills. The law also set aside tens of billions through the Broadband Equity, Access, and Deployment Program, known as BEAD, to connect homes and businesses.

That effort prioritizes fiber-optic connections, but federal regulators recently outlined , including low Earth orbit satellites like SpaceX’s Starlink service.

Funding the use of satellites in federal broadband programs has been controversial inside federal agencies. It has also been a sore point for Elon Musk, who is chief executive of SpaceX, which runs Starlink, and is a lead adviser to President Donald Trump.

After preliminary approval, a federal commission ruled that Starlink’s satellite system was “” of offering reliable high speeds. Musk tweeted last year that the commission had “” money awarded under the agency’s Trump-era Rural Digital Opportunity Fund.

In February, Trump nominated Arielle Roth to lead the federal agency overseeing the infrastructure act’s BEAD program. Roth is telecommunications policy director for the Senate Committee on Commerce, Science, and Transportation. Last year, ’s emphasis on fiber and said it was beleaguered by a “woke social agenda” with too many regulations.

Commerce Secretary Lutnick he will get rid of “burdensome regulations” and revamp the program to “take a tech-neutral approach.” Republicans echoed his positions during a U.S. House subcommittee hearing the same day.

When asked about potentially weakening the program’s required low-cost internet option, former National Telecommunications and Information Administration official Sarah Morris said such a change would build internet connections that people can’t afford. Essentially, she said, they would be “building bridges to nowhere, building networks to no one.”

'That Hurt’

Over a lunch of tortilla chips with the savory sauce that had been simmering on the stove, Williams said she hadn’t been getting regular checkups before her diabetes diagnosis.

“To tell you the truth, if I can get up and move and nothing is bothering me, I don’t go to the doctor,” Williams said. “I’m just being honest.”

Years ago, Williams recalled, “my head was hurting me so bad I had to just lay down. I couldn’t stand up, walk, or nothing. I’d get so dizzy.”

Williams thought it was her blood pressure, but the doctor checked for diabetes. “How did they know? I don’t know,” Williams said.

As lunch ended, she pulled out her glucose monitor. Williams connected the needle and wiped her finger with an alcohol pad. Then she pricked her finger.

“Oh,” Williams said, sucking air through her teeth. “That hurt.”

She placed the sample in the machine, and it quickly displayed a reading of 145 — a number, Williams said, that meant she needed to stop eating.

Here’s how ºÚÁϳԹÏÍø News did its analysis for the “Dead Zone” series, which pinpointed counties that lag behind the rest of the United States in access to broadband service and health care providers.

To identify “dead zones,” ºÚÁϳԹÏÍø News consulted two main data sources.

• The Federal Communications Commission was used to identify broadband deserts as of June 2024. We used the FCC’s minimum speed standard of 100 Mbps download and 20 Mbps upload, and followed its definition of reliable broadband: service accessible via wired (fiber optics, cable, DSL) or licensed fixed wireless technology. It’s the standard for grants awarded through the federal Broadband Equity, Access, and Deployment Program, . The FCC data shows whether such service is available, and not necessarily whether households subscribe to it.
• Data from George Washington University’s Fitzhugh Mullan Institute for Health Workforce Equity was used to determine counties with health provider shortages. GWU’s (family and internal medicine doctors, pediatricians, obstetricians and gynecologists, physician assistants, and nurse practitioners) reflects providers who serve at least one person enrolled in Medicaid. We used the most recent years available: 2020 for 44 states, and 2019 data for Texas. Five states — Delaware, Florida, Maine, Minnesota, and New Hampshire — were excluded from analysis because they lacked reliable data for either year.

GWU’s reflects psychiatrists, psychologists, counselors, therapists, and addiction medicine specialists, regardless of whether their patients receive Medicaid. We used data from 2021, the most recent year available.

We classified counties as “dead zones” if they met these criteria:

• Fewer than 70% of homes had access to fast, reliable broadband.
• They ranked in the bottom third of Medicaid primary care providers, defined as the number of Medicaid enrollees per provider.
• They ranked in the bottom third of behavioral health providers, defined as the number of residents per provider.

A total of 210 counties met those criteria. At the other extreme, we defined 203 counties as “most served” if they had the most residences with broadband access (at least 96.7%) and ranked in the top third of Medicaid primary care and behavioral health provider ratios.

We also compared the health outcomes and demographics of dead zone counties relative to others using several data sources:

• , for data on household income, education levels, and other demographics.
• , part of the University of Wisconsin Population Health Institute, for data on life expectancy and the percentage of residents living in rural areas.
• , for data on diabetes, high blood pressure, and other chronic health conditions.

This project was produced in partnership with . InvestigateTV is Gray Television’s national investigative team and provides innovative, original journalism from a dedicated investigative team and partners, as well as weekday and weekend shows. Gray is the nation’s second-largest television broadcaster, with television stations serving 113 markets. 

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Para Taylor Farms, que es uno de los principales proveedores mundiales de ensaladas envasadas y verduras cortadas, esto lo ha convertido en un lugar ideal para implementar un innovador modelo de atención médica para sus empleados.

Este método, que podría llegar a tener gran utilidad en la era de los teléfonos inteligentes, es una aplicación que permite efectuar consultas médicas transfronterizas.

Taylor Farms es uno de los principales clientes de una startup llamada MiSalud, que pone en contacto a los empleados hispanohablantes de la empresa con médicos y terapeutas de salud mental en México.

Estos profesionales no tienen licencia en Estados Unidos y no pueden recetar medicamentos, pero actúan como consejeros de salud, colaborando, si es necesario, con un médico estadounidense.

Amy Taylor, que dirige esta iniciativa de promoción de la salud de la empresa desde 2014 y es la nuera de , dijo que unos 5.600 de los 6.400 empleados de Taylor Farms se han registrado en MiSalud y 2.300 han utilizado la aplicación por lo menos una vez.

El servicio es gratuito para los empleados y hasta tres miembros de su familia.

Amy Taylor explicó que la empresa espera que la aplicación, que forma parte de un programa de bienestar más amplio, pueda ayudar a los empleados a mantenerse saludables y, al mismo tiempo, controlar tanto los gastos de la atención médica como otros costos laborales.

Está previsto realizar una evaluación completa de este programa una vez que haya estado en funcionamiento dos años.

La salud de estos trabajadores es una de las principales preocupaciones de la economía agrícola del estado.

Un , dirigido por investigadores de la Universidad de California-Merced, evaluó la salud de más de 1.200 trabajadores agrícolas y descubrió que el 37% de los hombres y el 47% de las mujeres informaron que padecían al menos una enfermedad crónica, incluidas afecciones comunes como diabetes, hipertensión y ansiedad.

Taylor explicó que los empleados de la empresa, que abarcan desde trabajadores del campo y choferes hasta personal de empaque y empleados de oficina, tienen los mismos problemas que los participantes del estudio. Destacó que las principales preocupaciones de salud entre los trabajadores incluyen la obesidad, la hipertensión, la diabetes y la salud mental.

“Estas son las personas que alimentan a Estados Unidos con comida saludable”, dijo Taylor refiriéndose a los trabajadores de la compañía: “También deberían estar sanos”.

MiSalud fue resultado de la inspiración de Bismarck Lepe, un emprendedor de múltiples proyectos, graduado de la Universidad de Stanford, que proviene de una familia de trabajadores agrícolas migrantes.

Hasta los 6 años, cuando finalmente se estableció en Oxnard, California, toda la familia Lepe viajaba entre México, California y el estado de Washington para cosechar fruta.

Lepe observó que tanto su familia como los amigos a menudo retrasaban la atención médica hasta que podían regresar a México. El sistema de salud estadounidense les resultaba demasiado complicado y el seguro demasiado costoso o de difícil acceso.

“Mi madre sigue prefiriendo recibir atención médica en México”, dijo Lepe. “Para ella es más sencillo”.

Lepe y las cofundadoras Wendy Johansson y Cindy Blanco Ochoa lanzaron MiSalud Health en 2021 con $5 millones de un fondo de capital de riesgo respaldado por Pivotal Ventures, la firma de Melinda French Gates que se enfoca en inversiones de impacto social. Desde entonces, han sumado dos nuevos inversores, Samsung Next y Ulu Ventures.

MiSalud comenzó ofreciendo consultas con médicos mexicanos para las personas que descargaban la aplicación, contó Johansson.

Pero los que podían bajar la aplicación y registrarse por sí mismos no eran, en última instancia, los que más la necesitaban. Por eso, en 2023, la compañía dio un giro para ofrecer su servicio a las empresas como beneficio para los empleados. (Aunque los individuos también pueden seguir utilizándolo).

Además de Taylor Farms, MiSalud tiene entre sus clientes a la ciudad de Lynwood, en California, y a otra docena de empresas. La compañía asegura que casi el 40% de los empleados atendidos por su plataforma admiten que, sin la aplicación, hubieran ignorado sus problemas de salud o hubieran esperado hasta viajar a México para buscar atención médica.

Paul Brown, profesor de economía de la salud de la UC-Merced, colaboró en la investigación sobre el estado físico y  mental de los trabajadores agrícolas que efectuó la universidad. Advirtió que las consultas de telemedicina no sustituyen adecuadamente la atención presencial de un médico de atención primaria o un especialista.

Sin embargo, agregó: “En la medida en que este tipo de programas puedan conectar a las personas con una atención más estándar, son beneficiosos”.

Brown comentó que el enfoque de MiSalud podría ser más eficaz si se modificaran las políticas para permitir que los médicos mexicanos puedan atender a pacientes en Estados Unidos con más facilidad.

Un programa de California iniciado en 2002 permite que los médicos mexicanos viajen al Valle de Salinas y a otras comunidades con gran presencia de población latina para atender pacientes, pero la telemedicina transfronteriza, incluso , sigue siendo limitada.

Aun así, los empleados de Taylor Farms afirman que la aplicación ha sido útil. Rosa “Rosita” Flores, supervisora de línea de las operaciones minoristas de la empresa, dijo que decidió probar MiSalud después que sus compañeros de trabajo le hablaran bien de la aplicación.

En una reciente feria de bienestar de la empresa, patrocinada en parte por MiSalud, le hicieron notar la importancia de monitorear sus niveles de azúcar en sangre y la presión arterial, por lo que reservó una cita en la aplicación para hablar del tema.

“La aplicación es muy fácil de usar”, dijo. Cuando tuvo que cancelar una videollamada porque su hija se enfermó, los asesores de salud hicieron el seguimiento por mensaje de texto.

Los defensores de la medicina transfronteriza afirman que este enfoque ayuda a salvar las barreras lingüísticas y culturales en la atención médica.

En el país, casi la mitad de los inmigrantes —de los cuales aproximadamente dos tercios son hispanohablantes nativos— tienen , y las investigaciones han demostrado muchas veces que las barreras lingüísticas a menudo disuaden a las personas de buscar atención médica.

Por ejemplo, Alfredo Álvarez, asesor de salud de MiSalud que es médico certificado en México, mencionó la creencia en el “mal de ojo”, la idea de que una mirada envidiosa o celosa de una persona puede causar daño, especialmente a los niños.

Un médico estadounidense podría descartar esa idea, pero Álvarez la comprende.

“Esto no es raro aquí”, dijo refiriéndose a  México. “Es una creencia de la medicina tradicional”.

No es que Álvarez anime a sus los usuarios de la aplicación a pasar un huevo por encima del niño o a hacer que el niño lleve una pulsera especial, formas tradicionales de “diagnosticar” y tratar el mal de ojo. Más bien, reconoce sus tradiciones y los orienta hacia la medicina basada en la evidencia.

Los asesores de MiSalud también pueden intentar romper con estereotipos.

Por ejemplo, Álvarez dijo que la arraigada cultura machista de México puede traducirse en la idea de que “los hombres no van al médico”. Mientras tanto, agregó, las mujeres pueden descuidar su salud porque priorizan las necesidades de otros miembros de la familia.

Los asesores también intentan eliminar al estigma que rodea a la búsqueda de tratamiento de salud mental. “Muchos de nuestros ‘socios’ se han sentido extremadamente incómodos o recelosos ante los profesionales de salud mental”, dijo Rubén Benavides Crespo, asesor de MiSalud en este campo y psicólogo titulado en México.

La aplicación intenta romper el hielo facilitando la reserva de las consultas de asesoramiento y haciendo preguntas del estilo de si alguien tiene problemas para dormir, en lugar de invocar términos más preocupantes o potencialmente estigmatizantes como ansiedad o depresión.

Los representantes de MiSalud informaron que la aplicación experimentó un aumento del 50% en las solicitudes de apoyo para la salud mental tras las elecciones presidenciales de noviembre. Sin embargo, una solicitud más común es el asesoramiento para el duelo, a menudo tras la pérdida de un ser querido.

“La pérdida requiere adaptación”, señaló Benavides.

Para Sam Chaidez, director de operaciones de una planta de Taylor Farms en Gonzales, California, MiSalud es un apoyo adicional para el control de peso.

Hijo de trabajadores del campo, Chaidez se graduó en la Universidad de California en Davis y regresó al Valle de Salinas para trabajar en la empresa en 2007.

En 2019, Chaidez, que acababa de ser padre, empezó a comprender el riesgo de padecer diabetes y otros problemas de salud gracias al programa de bienestar de Taylor Farms. A partir de la dieta y el ejercicio y, más recientemente, al asesoramiento de MiSalud, Chaidez ha perdido 150 libras (68 kilos).

Ahora anima a sus compañeros de trabajo a caminar con él a la hora de comer, y atribuye a los asesores de MiSalud el mérito de haberlo ayudado a no recuperar el peso perdido y a mantenerse sano. “Ha sido una gran ayuda”, señaló.

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The introduction of the continuous glucose monitor (CGM) made that unnecessary. The small device, typically attached to the arm, has a sensor under the skin that sends readings to an app on a phone or other wireless device. The app shows blood sugar levels at a glance and sounds an alarm when they move out of a normal range.

Blood sugar that’s too high could call for a dose of insulin — delivered by injection or the touch of a button on an insulin pump — to stave off potentially life-threatening complications including loss of consciousness, while a sip of juice could remedy blood sugar that’s too low, preventing problems such as dizziness and seizures.

Schools around the country say teachers listen for CGM alarms from students’ phones in the classroom. Yet many parents say that there’s no guarantee a teacher will hear an alarm in a busy classroom and that it falls to them to ensure their child is safe when out of a teacher’s earshot by monitoring the app themselves, though they may not be able to quickly contact their child.

Parents say school nurses or administrative staff should remotely monitor CGM apps, making sure someone is paying attention even when a student is outside the classroom — such as at recess, in a noisy lunchroom, or on a field trip.

But many schools have resisted, citing staff shortages and concerns about internet reliability and technical problems with the devices. About one-third of schools do not have a full-time nurse, according to a 2021 survey by the National Association of School Nurses, though other staffers can be trained to monitor CGMs.

Caring for children with Type 1 diabetes is nothing new for schools. Before CGMs, there was no alarm that signaled a problem; instead, it was caught with a time-consuming finger-prick test, or when the problem had progressed and the child showed symptoms of complications.

With the proliferation of insulin pumps, many kids can respond to problems themselves, reducing the need for schools to provide injections as well.

Parents say they are not asking schools to continuously monitor their child’s readings, but rather to ensure that an adult at the school checks that the child responds appropriately.

“People at the [school] district don’t understand the illness, and they don’t understand the urgency,” said Julie Calidonio of Lutz, Florida.

Calidonio’s son Luke, 12, uses a CGM but has received little support from his school, she said. Relying on school staff to hear the alarms led to instances in which no one was nearby to intervene if his blood sugar dropped to critical levels.

“Why have this technology that is meant to prevent harms, and we are not acting on it,” she said.

Corey Dierdorff, a spokesperson for the Pasco County School District, where Luke attends school, said in a statement to ºÚÁϳԹÏÍø News that staff members react when they hear a student’s CGM sound an alert. Asked why the district won’t agree to have staff remotely monitor the alarms, he noted concerns about internet reliability.

In September, Calidonio filed a complaint with the U.S. Justice Department against the district, saying its inability to monitor the devices violates the Americans with Disabilities Act, which requires schools to make accommodations for students with diabetes, among other conditions. She is still awaiting a decision.

The complaint comes about four years after the Connecticut U.S. attorney’s office determined that having school staffers monitor a student’s CGM was a “reasonable accommodation” under the ADA. That determination was made after four students filed complaints against four Connecticut school districts.

“We fought this fight and won this fight,” said Jonathan Chappell, one of two attorneys who filed the complaints in Connecticut. But the decision has yet to affect students outside the state, he said.

Chappell and Bonnie Roswig, an attorney and director of the nonprofit Center for Children’s Advocacy Disability Rights Project, both said they have heard from parents in 40 states having trouble getting their children’s CGMs remotely monitored in school. Parents in 10 states have filed similar complaints, they said.

CGMs today are used by most of the estimated 300,000 people in the U.S. with Type 1 diabetes under age 20, health experts say. Also known as juvenile diabetes, it is an autoimmune disease typically diagnosed in early childhood and treated with daily insulin to help regulate blood sugar. It affects under 20, according to the American Academy of Pediatrics.

(CGMs are also used by those with Type 2 diabetes, a different disease tied to risk factors such as diet and exercise that affects tens of millions of people — including a growing number of children, though it is usually not diagnosed until the early teens. Most people with Type 2 diabetes do not take insulin.)

Students with diabetes or another disease or disability typically have a health care plan, developed by their doctor, that works with a school-approved plan to get the support they need. It details necessary accommodations to attend school, such as allowing a child to eat in class or ensuring staff members are trained to check blood glucose or give a shot of insulin.

For children with Type 1 diabetes, the plan usually includes monitoring CGMs several times a day and responding to alarms, Roswig said.

Lynn Nelson, president-elect of the National Association of School Nurses, said when doctors and parents deem a student needs their CGM remotely monitored, the school is obligated under the ADA to meet that need. “It is legally required and the right thing to do.”

Nelson, who also manages school nurse programs in Washington state, said schools often must balance the students’ needs with having enough administrative staff.

“There are real workforce challenges, but that means schools have to go above and beyond for an individual student,” she said.

Henry Rodriguez, a pediatric endocrinologist at the University of South Florida and a spokesperson for the American Diabetes Association, said remote monitoring can be challenging for schools. While they advocate for giving every child what they need to manage their diabetes at school, he said, schools can be limited by a lack of support staff, including nurses.

The association last year updated its policy around CGMs, stating: “School districts should remove barriers to remote monitoring by school nurses or trained school staff if this is medically necessary for the student.”

In San Diego, Taylor Inman, a pediatric pulmonologist, said her daughter, Ruby, 8, received little help from her public school after being diagnosed with Type 1 diabetes and starting to use a CGM.

She said alerts from Ruby’s phone often went unheard outside the classroom, and she could not always reach someone at the school to make sure Ruby was reacting when her blood sugar levels moved into the abnormal range.

“We kept asking for the school to follow my daughter’s CGM and were told they were not allowed to,” she said.

In a 2020 memo to school nurses that remains in effect, Howard Taras, the San Diego Unified School District’s medical adviser, said if a student’s doctor recommends remote monitoring, it should be done by their parents or doctor’s office staff.

CGM alarms can be “disruptive to the student’s education, to classmates and to staff members with other responsibilities,” Taras wrote.

“Alarms are closely monitored, even those that occur outside of the classroom,” Susan Barndollar, the district’s executive director of nursing and wellness, said in a statement. Trained adults, including teachers and aides, listen for the alarms when in class, at recess, at gym class, or during a field trip, she said.

She said the problem with remote monitoring is that staff in the school office doing the monitoring may not know where the student is to tend to them quickly.

Inman said last year they paid $20,000 for a diabetes support dog trained to detect high or low blood sugar and later transferred Ruby to a private school that remotely tracks her CGM.

“Her blood sugar is better controlled, and she is not scared and stressed anymore and can focus on learning,” she said. “She is happy to go to school and is thriving.”

Some schools have changed their policies. For more than a year, several parents lobbied Loudoun County Public Schools in Northern Virginia to have school nurses follow CGM alerts from their own wireless devices.

The district board approved the change, which took effect in August and affects about 100 of the district’s more than 80,000 students.

Before, Lauren Valentine would get alerts from 8-year-old son Leo’s CGM and call the school he attends in Loudoun County, not knowing if anyone was taking action. Valentine said the school nurse now tracks Leo’s blood sugar from an iPad in the clinic.

“It takes the responsibility off my son and the pressure off the teacher,” she said. “And it gives us peace of mind that the school clinic nurses know what is happening.”

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La llegada del monitor continuo de glucosa (MCG) hizo que eso ya no fuera necesario. El pequeño dispositivo, que normalmente se coloca en el brazo, tiene un sensor bajo la piel que envía lecturas a una aplicación en un teléfono u otro dispositivo inalámbrico. La aplicación muestra los niveles de azúcar en sangre en un instante, y emite una alarma cuando están fuera del rango normal.

Un nivel de azúcar en sangre demasiado alto podría requerir una dosis de insulina —con una inyección o solo tocando un botón en una bomba de insulina— para evitar complicaciones potencialmente mortales, como la pérdida del conocimiento. Un sorbo de jugo podría solucionar un nivel muy bajo de azúcar en sangre, previniendo problemas como mareos y convulsiones.

En las escuelas, los maestros están atentos a las alarmas de los MCG de los teléfonos de los alumnos. Sin embargo, muchos dicen que no hay garantía de que un maestro escuche una alarma en un aula ruidosa, y que les corresponde a ellos como padres garantizar la seguridad de sus hijos, supervisando ellos mismos la aplicación, aunque no puedan ponerse en contacto rápidamente.

Los padres dicen que las enfermeras escolares y el personal administrativo deberían supervisar de forma remota las aplicaciones de MCG, asegurándose de que alguien esté atento incluso cuando el estudiante esté fuera del aula, en el recreo, en un comedor ruidoso o en una excursión.

Pero muchas escuelas se han resistido, argumentando escasez de personal y preocupación por la fiabilidad de internet y los problemas técnicos con los dispositivos.

“La gente del distrito [escolar] no entiende la enfermedad, y no entiende la urgencia”, dijo Julie Calidonio, de Lutz, Florida.

El hijo de Calidonio, Luke, de 12 años, usa un MCG, pero ha recibido poco apoyo de su escuela, según la madre: nadie escuchaba la alarma o intervenía si su nivel de azúcar en sangre bajaba a niveles críticos.

“¿Por qué tenemos esta tecnología que está diseñada para prevenir daños y no la utilizamos?”, preguntó.

Corey Dierdorff, vocera del Distrito Escolar del condado de Pasco, donde Luke va a la escuela, dijo a ºÚÁϳԹÏÍø News que el personal reacciona cuando escuchan que el MCG de un estudiante emite una alerta. Cuando se le preguntó por qué el distrito no acepta que el personal supervise las alarmas de forma remota, dijo que duda de la eficacia de internet.

En septiembre, Calidonio presentó una denuncia ante el Departamento de Justicia contra el distrito, alegando que su incapacidad para supervisar los dispositivos viola la Ley de Estadounidenses con Discapacidades (ADA), que exige a las escuelas adaptarse para ayudar a los estudiantes que viven con diabetes, entre otras afecciones. Todavía está a la espera de una decisión.

La denuncia ocurrió unos cuatro años después que la fiscalía federal de Connecticut determinara que supervisar el MCG de un alumno en la escuela era una “adaptación razonable” bajo ADA. Esa determinación se tomó después que cuatro estudiantes presentaran denuncias contra cuatro distritos escolares de Connecticut.

“Luchamos y ganamos esta batalla”, dijo Jonathan Chappell, uno de los dos abogados que presentaron las denuncias en Connecticut. Pero la decisión aún no ha impactado en estudiantes en otros estados, agregó.

Chappell y Bonnie Roswig, abogada y directora de la organización sin fines de lucro Center for Children’s Advocacy Disability Rights Project, explicaron que han escuchado de padres en 40 estados que tienen problemas para que las escuelas monitoreen de manera remota los MCG de sus hijos.

Expertos en salud afirman que, en la actualidad, la mayoría de las aproximadamente 300.000 personas menores de 20 años con diabetes tipo 1 en Estados Unidos utilizan MCG. También conocida como diabetes juvenil, es una enfermedad autoinmune que suele diagnosticarse en la primera infancia y que se trata con insulina diaria para ayudar a regular el azúcar en sangre.

(Los MCG también se utilizan en casos de diabetes tipo 2, una afección diferente vinculada a factores de riesgo como la dieta y el ejercicio que afecta a millones de personas, incluyendo un número creciente de niños, aunque por lo general no se diagnostica hasta principios de la adolescencia. La mayoría de las personas con diabetes tipo 2 no utilizan insulina).

Los estudiantes que viven con diabetes, u otra afección o discapacidad, suelen tener un plan de salud desarrollado por su médico, que funciona con otro aprobado por la escuela para tener el apoyo que necesitan. Detalla adaptaciones necesarias, como permitir que un niño coma en el aula o asegurarse que el personal esté capacitado para controlar la glucosa o administrar una inyección de insulina.

Para los niños con diabetes tipo 1, el plan suele incluir monitorear los MCG varias veces al día y responder a las alarmas, indicó Roswig.

Lynn Nelson, presidenta electa de la National Association of School Nurses, dijo que cuando los médicos y los padres consideran que un estudiante necesita que su MCG sea monitoreado de forma remota, la escuela está obligada, bajo ADA, a satisfacer esa necesidad. “Es un requisito legal y es lo correcto”.

Nelson, que también gestiona programas de enfermería escolar en el estado de Washington, señaló que las escuelas a menudo deben equilibrar las necesidades de los estudiantes con la disponibilidad de personal.

“Hay verdaderos desafíos en materia de personal, pero eso significa que las escuelas tienen que hacer todo lo posible, y más, por ayudar a cada estudiante”, afirmó.

Henry Rodríguez, endocrinólogo pediátrico de la Universidad del Sur de Florida y vocero de la American Diabetes Association, dijo que este monitoreo puede ser un reto para las escuelas. Aunque abogan para que cada niño reciba lo que necesita para controlar su diabetes en la escuela, según Rodríguez, las escuelas pueden verse limitadas por la falta de personal de apoyo, incluidas enfermeras.

El año pasado, la asociación actualizó su política sobre los MCG estableciendo que “los distritos escolares deben eliminar las barreras para que las enfermeras escolares o el personal escolar capacitado monitoree los MCG de manera remota, si esto es médicamente necesario para el estudiante”.

En San Diego, Taylor Inman, neumonóloga infantil, dijo que su hija Ruby, de 8 años, recibió poca ayuda de su escuela pública después que le diagnosticaran diabetes tipo 1 y empezara a usar uno de estos dispositivos.

Contó que las alertas del teléfono de Ruby a menudo no se escuchaban fuera del aula, y que no siempre podía comunicarse con alguien para asegurarse de que Ruby reaccionaba cuando sus niveles de azúcar en sangre se volvían anormales.

“Seguimos pidiendo a la escuela que siguiera el MCG de mi hija y nos dijeron que no estaban autorizados a hacerlo”, afirmó.

En un memorando de 2020 enviado a las enfermeras escolares, que sigue vigente, Howard Taras, asesor médico del Distrito Escolar Unificado de San Diego, comunicó que si el médico de un estudiante recomienda el monitoreo remoto, debe hacerlo un padre o personal del consultorio del médico.

Las alarmas del MCG pueden ser “perturbadoras para la educación del estudiante, para los compañeros de clase y para los miembros del personal con otras responsabilidades”, escribió Taras.

Susan Barndollar, directora ejecutiva de enfermería y bienestar del distrito aseguró en un comunicado que el problema con la supervisión remota es que el personal de la oficina de la escuela que la realiza puede no saber dónde está el estudiante para asistirlo rápidamente.

Inman dijo que el año pasado pagaron $20.000 por un perro de apoyo para la diabetes entrenado para detectar niveles altos o bajos de azúcar en sangre y luego transfirieron a Ruby a una escuela privada que rastrea de forma remota su MCG.

“Su nivel de azúcar en sangre está mejor controlado, ya no está asustada ni estresada y puede concentrarse en aprender”, dijo Inman. “Está feliz de ir a la escuela y está progresando mucho”.

Algunas escuelas han cambiado sus políticas. Durante más de un año, varios padres presionaron a las escuelas públicas del condado de Loudoun, en el norte de Virginia, para que las enfermeras escolares siguieran las alertas del MCG desde sus propios dispositivos inalámbricos.

La junta del distrito aprobó el cambio, que entró en vigencia en agosto y afecta a cerca de 100 de los más de 80.000 estudiantes del distrito.

Antes, Lauren Valentine recibía alertas del MCG de su hijo Leo, de 8 años, y llamaba su escuela, en el condado de Loudoun, sin saber si alguien estaba tomando medidas. Valentine dijo que la enfermera del colegio ahora controla el azúcar en sangre de Leo desde un iPad en la clínica.

“Le quita la responsabilidad a mi hijo y la presión al maestro”, afirmó. “Y nos da tranquilidad que las enfermeras de la clínica escolar sepan lo que está pasando”.

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So when the University of North Carolina-Charlotte professor learned that Ozempic — developed to treat Type 2 diabetes — helped people lose weight and keep it off, Blanchard was determined to try it.

The state employee’s health insurance initially covered the prescription with Blanchard kicking in a $25 copayment. Over the next seven months, she said, she lost 45 pounds and lowered her blood pressure and cholesterol. The most significant benefits, though, were psychological.

“It stopped the food noise in my head, relieved my anxiety, and I was no longer drinking like a fish,” said Blanchard, now 60. “I’d have a glass of wine, and then that’s it.”

But North Carolina suffered from sticker shock as Blanchard shed pounds and thousands of others on the state insurance program — which covers more than 76,000 employees across 178 agencies, plus their dependents — tried to do the same. Ozempic and other glucagon-like peptide-1 (GPL-1) agonist medications accounted for 10% of the state employee health plan’s annual prescription drug spending, according to a North Carolina State Health Plan fact sheet. The state treasurer projected the class of drugs would cost the state this year, with costs jumping to more than $1 billion over the next six years.

“This exceeds the amount the State Health Plan spends on cancer, rheumatoid arthritis, and chemotherapy medications,” the said in a March statement.

The health plan’s board of trustees eliminated coverage of this class of medications for weight loss starting in April. The plan continues to cover the drug for Type 2 diabetes management.

But in a twist this August, a separate part of North Carolina’s government allowed the Medicaid program to start covering the drugs for weight loss — not just diabetes — for the state’s poorest residents, who are disproportionately affected by obesity and related diseases. The state’s Medicaid program covers more than 2 million people.

And now the outgoing Biden administration wants to follow suit, proposing on Nov. 26 for the federal government to cover the medications to treat obesity for Medicaid patients nationwide, in addition to Medicare patients.

Still, the North Carolina coverage change left state employees like Blanchard facing a stark choice — stop taking what she views as a miracle drug or pay as much as $1,200 out-of-pocket each month.

“They know diets don’t work long-term for weight loss, yet they are denying coverage for a medication that has been effective,” Blanchard said. “It’s indicative of a profit-driven mindset that is more about cost savings than prioritizing patients’ health.”

The coverage switch highlights concerns about the cost of these medications and ongoing questions about who should get to have such drugs covered by insurance.

Several other states are also trying to reel in the expense of the medications. West Virginia to cover the drugs for its state employees. Connecticut state employees who are prescribed the drugs must .

The high prices have also raised concerns about the cost for taxpayer-funded health care programs, such as Medicare. The Centers for Medicare & Medicaid Services estimated that coverage under the Biden proposal would cost about $40 billion over 10 years, including an extra $3.8 billion for states. But the requirement wouldn’t take effect until after President-elect Donald Trump takes office Jan. 20, giving his administration a chance to change it.

GLP-1 agonist medications, known by the brand names Ozempic, Trulicity, and Wegovy, have proved to be effective for weight loss as well as managing Type 2 diabetes. They work by triggering the pancreas to release insulin, slowing the rate at which the stomach empties, increasing satiety, and regulating appetite by sending signals to the brain to tell the body it is satisfied. But patients typically need to stay on the medications to maintain their weight loss, meaning they face long-term costs.

In clinical trials, patients taking Ozempic also showed significant reductions in cardiovascular problems such as heart attacks and strokes, even those without diabetes, or before weight loss started, said Duke University cardiologist and researcher .

Making these drugs available through Medicaid is in the state’s long-term financial interest, said Kody Kinsley, secretary of the North Carolina Department of Health and Human Services, which doesn’t oversee the state employee health plan. Unlike private or employer insurance plans, the Medicaid program receives generous rebates on these types of drugs, significantly reducing the cost, he said.

Calling North Carolina the buckle of the “Barbecue Belt,” Kinsley noted that state’s obesity rate exceeds the national average. The latest analysis from at the University of Chicago showed that 45% of adults in the state had a body mass index above 30, the threshold for clinical obesity, compared with 42% nationwide. That number was 55% for non-Hispanic Black adults in the state.

In addition, Kinsley said, with Medicaid the primary payer for long-term care, covering the drugs helps Medicaid’s bottom line by reducing the need for nursing home care often driven by unmanaged chronic diseases.

“We’re trying to put our dollars where they will lower costs in the long run,” he said. “I spend almost a billion dollars a year on obesity-related diseases. If I can reduce that spend by even 1%, then these drugs are a no-brainer.”

But what about people who aren’t on Medicaid? Duke’s Shah said the U.S. health care system needs to eliminate hurdles that make it difficult to obtain the drugs. Besides making the medication more affordable, he said, it should encourage the use of weight loss drugs and treatment of obesity as a chronic disease instead of stigmatizing it as a moral failing.

“Whether it is drug cost, conditions that require the payer to approve them, the patient’s health insurance plan, or the unaffordability of a plan that would cover weight loss, there are real-world barriers in our health care system,” Shah said.

Family medicine physician Melissa Jones of Charlotte said she has often seen a bias against people in her weight management practice when they try to get these medications covered by private insurance.

“There’s no shame in saying ‘I have high blood pressure’ or ‘I inherited this condition from my family,’” Jones said. “But for some reason, there’s shame associated with saying, ‘I struggle with my weight.’”

Although Blanchard can’t get her Ozempic covered anymore as a state employee, a concierge doctor gave her a prescription for a nonbrand version of the anti-obesity medications from a compounding pharmacy, available for now because of shortages of the brand-name versions. Though she believes it is less effective, she pays $225 a month for it.

“I can handle that,” she said.

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Así que cuando esta profesora de la Universidad de Carolina del Norte-Charlotte se enteró de que Ozempic —desarrollado para tratar la diabetes tipo 2— ayudaba a las personas a perder peso, y mantenerlo, Blanchard supo que tenía que probarlo.

El seguro de salud para empleados estatales inicialmente cubrió la receta, y Blanchard solo tuvo un copago de $25. Dijo que en los siguientes siete meses perdió 45 libras y bajó su presión arterial y su nivel de colesterol.

Sin embargo, los beneficios más significativos fueron psicológicos.

“Paró el ruido que hacía la comida en en mi cabeza, alivió mi ansiedad, y dejé de beber como un pez”, dijo Blanchard, quien ahora tiene 60 años. “Ahora tomo una copa de vino y ya”.

Sin embargo, Carolina del Norte tuvo un shock al ver que Blanchard bajaba de peso y miles de otros empleados en el mismo seguro de salud estatal, que cubre a 76.000 empleados de 178 agencias, más a sus dependientes, intentaban hacer lo mismo.

Ozempic, y otros medicamentos similares, representaron el 10% del gasto anual en medicinas recetadas del seguro estatal, según una hoja informativa del Plan de Salud de Carolina del Norte. El tesorero estatal proyectó que esta clase de medicamentos costaría al estado , y los costos aumentarían a más de $1,000 millones en los próximos seis.

“Esto supera la cantidad que el Plan de Salud del Estado gasta en medicamentos para el cáncer, la artritis reumatoide y la quimioterapia”, dijo el en una declaración en marzo.

La junta de fideicomisarios del plan de salud eliminó la cobertura de esta clase de medicamentos para la pérdida de peso a partir de abril. El plan continúa cubriendo el fármaco para el manejo de la diabetes tipo 2.

Pero, en un giro de los acontecimientos en agosto, otra parte del gobierno de Carolina del Norte permitió que el programa de Medicaid comenzara a cubrir estos medicamentos para la pérdida de peso, no solo para la diabetes, para los residentes más pobres del estado, que están desproporcionadamente afectados por la obesidad y enfermedades relacionadas. En el estado, Medicaid cubre a más de 2 millones de personas.

Ahora, la administración saliente de Biden quiere seguir su ejemplo: el 26 de noviembre propuso que el gobierno federal cubra los medicamentos para tratar la obesidad en pacientes de Medicaid en todo el país, sumándose a los pacientes de Medicare que ya pueden utilizarlos.

A pesar de esto, el cambio en la cobertura en Carolina del Norte dejó a empleados estatales como Blanchard enfrentándose a una dura elección: dejar de tomar lo que ella considera un medicamento milagroso o pagar hasta $1,200 de su bolsillo cada mes.

“Saben que las dietas no funcionan a largo plazo para la pérdida de peso, sin embargo, están negando la cobertura de un medicamento que ha sido efectivo”, dijo Blanchard. “Resalta una mentalidad orientada a las ganancias, más enfocada en ahorrar costos que en priorizar la salud de los pacientes”.

El cambio en la cobertura destaca preocupaciones sobre el costo de estos medicamentos y las preguntas sobre si las aseguradoras deben cubrirlos.

Varios otros estados también están tratando de controlar el costo de estos medicamentos. West Virginia para cubrir a sus empleados estatales. En Connecticut, los empleados estatales a los que se les han recetado estos medicamentos de manejo del estilo de vida.

Los altos precios también han suscitado preocupaciones sobre el costo para programas de salud financiados por los contribuyentes, como Medicare.

Los Centros de Servicios de Medicare y Medicaid (CMS) estimaron que la cobertura bajo la propuesta de Biden costaría alrededor de $40,000 millones en 10 años, incluyendo un costo adicional de $3,800 millones para los estados.

Sin embargo, el requisito no entraría en vigencia hasta después que el presidente electo Donald Trump asuma el cargo el 20 de enero, dándole a su administración la oportunidad de cambiarlo.

Los medicamentos agonistas GLP-1, conocidos por los nombres comerciales Ozempic, Trulicity y Wegovy, han demostrado ser efectivos para la pérdida de peso y para el manejo de la diabetes tipo 2. Funcionan desencadenando la liberación de insulina por el páncreas, ralentizando el vaciado del estómago, aumentando el nivel de saciedad y regulando el apetito al enviar señales al cerebro para indicar que el cuerpo está satisfecho.

Sin embargo, los pacientes suelen necesitar seguir tomando estos medicamentos para mantener la pérdida de peso, lo que implica costos a largo plazo.

En ensayos clínicos, los pacientes que tomaron Ozempic también mostraron reducciones significativas en problemas como ataques cardíacos y accidentes cerebrovasculares, incluso aquellos sin diabetes o antes de comenzar a perder peso, dijo , cardiólogo e investigador de la Universidad de Duke.

Hacer que estos medicamentos estén disponibles a través de Medicaid es un interés financiero a largo plazo para el estado, dijo Kody Kinsley, secretario del Departamento de Salud y Servicios Humanos de Carolina del Norte. A diferencia de los planes privados o de empleadores, Medicaid recibe generosos descuentos en este tipo de medicamentos, reduciendo significativamente el costo, explicó.

Apodando a Carolina del Norte “el cinturón de la barbacoa,” Kinsley señaló que la tasa de obesidad del estado supera el promedio nacional. El último en la Universidad de Chicago mostró que el 45% de los adultos en el estado tenían un índice de masa corporal superior a 30, el umbral para la obesidad clínica, en comparación con el 42% a nivel nacional. Para los adultos negros no hispanos en el estado, esa cifra era del 55%.

Además, Kinsley dijo que, siendo Medicaid el principal pagador del cuidado a largo plazo, cubrir estos medicamentos ayuda a reducir la necesidad de atención en hogares de adultos mayores, a menudo impulsada por enfermedades crónicas mal manejadas.

“Estamos tratando de invertir nuestros recursos donde reduzcan costos a largo plazo”, afirmó. “Gasto casi mil millones de dólares al año en enfermedades relacionadas con la obesidad. Si puedo reducir ese gasto incluso en un 1%, estos medicamentos son lo más lógico”.

Pero, ¿qué pasa con las personas que no están en Medicaid? Shah, de Duke, dijo que el sistema de salud de Estados Unidos necesita eliminar las barreras que dificultan la obtención de estos medicamentos. Además de hacer que los medicamentos sean más asequibles, agregó, debería alentarse el uso de medicamentos para la pérdida de peso y el tratamiento de la obesidad como una enfermedad crónica, en lugar de estigmatizarla como un fracaso moral.

“Ya sea el costo del medicamento, las condiciones que requieren la aprobación del pagador, la cobertura médica del paciente o la inaccesibilidad de un plan que cubriría la pérdida de peso, hay barreras reales en nuestro sistema de salud”, explicó Shah.

Melissa Jones, médica de familia de Charlotte, dijo que a menudo ha observado un sesgo contra las personas en su práctica de manejo del peso cuando intentan que los seguros privados cubran estos medicamentos.

“No hay vergüenza en decir ‘tengo presión arterial alta’ o ‘heredé esta condición de mi familia,’” comentó Jones. “Pero, por alguna razón, hay vergüenza en decir, ‘Lucho con mi peso’”.

Aunque Blanchard ya no puede obtener la cobertura de Ozempic como empleada estatal, un médico de atención personalizada le recetó una versión del medicamento anti-obesidad producido en una farmacia de compuestos, disponible por ahora debido a la escasez de las versiones de marca. Aunque cree que es menos efectivo, paga $225 al mes por ella.

“Puedo manejar eso”, dijo.

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