State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a ºÚÁϳԹÏÍø News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat — or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price — both in the cost to taxpayers and coverage losses — according to state documents obtained by ºÚÁϳԹÏÍø News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly will lose access to monthly cash assistance for food, including those with children.

In five states alone, for state officials and reviewed by ºÚÁϳԹÏÍø News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting company Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will . Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company that operates the state’s eligibility system.

Optum — which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act — to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, . And in Illinois, will cost at least $12 million.

A Historic Mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules — .

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements — about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was as of October.

of adult Medicaid enrollees nationally are already working, according to KFF. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the .

In Wisconsin, state officials estimate could lose coverage after work requirements take effect. Not covering those people would in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP — known as CARES — in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New Hurdles for Vets and Homeless People

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults — doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year . , initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government — that is, taxpayers — to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems — as D.C. is —­ I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to ºÚÁϳԹÏÍø News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” ºÚÁϳԹÏÍø News found that Deloitte, a global consultancy that generated in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 Million Bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a .

Adding the ability to verify work status would cost up to $7 million, . By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions . Accenture’s analysis said the federal law necessitated . Making employment a condition of Medicaid benefits could cause an estimated 32,000 Iowans to lose coverage, according to a

Cutting 32,000 people from coverage in one year, a fraction of the Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level — currently .

“There is no benefit to this population,” Lock said.

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that — priced at $12 million — is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” , the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time — supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 — Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

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La legislación prohibiría que los gobiernos estatales y locales obligaran a estos centros a practicar abortos. También a derivar o informar a pacientes sobre estos servicios o a explicar opciones de anticoncepción. Y permitiría que estas organizaciones demandaran a la entidad gubernamental que violara la ley.

Los legisladores de Wyoming el 4 de marzo una ley llamada Center Autonomy and Rights of Expression Act (). Propuestas similares se presentaron este año en y . En una norma de este tipo ya fue promulgada en 2025.

La Ley CARE es una “legislación modelo” creada por la , un grupo de defensa legal cristiano conservador y antiabortista.

Una legislación similar, la , fue presentada en el Congreso el año pasado, pero no ha avanzado fuera del Comité de Energía y Comercio de la Cámara de Representantes.

El proyecto de ley de Wyoming considera que los centros de embarazo, muchos vinculados a organizaciones religiosas, necesitan protección legal porque enfrentan “ataques sin precedentes” después de que la Corte Suprema anulara Roe vs. Wade, la decisión judicial de 1973 que protegía el derecho al aborto en todo el país. Según el texto, varias legislaturas estatales han presentado proyectos de ley que de libertad de expresión y asociación de estos centros.

Sin embargo, quienes los critican afirman que los centros de crisis de embarazo se presentan falsamente ante los consumidores como clínicas médicas, aunque no están sujetos a las leyes estatales y federales que regulan los centros de salud y protegen a los pacientes.

“En todo el país, los funcionarios del gobierno apuntan cada vez más, cada vez más, contra los centros de atención para embarazadas”, argumentó Valerie Berry, directora ejecutiva de en Cheyenne, durante una audiencia en la Legislatura sobre el proyecto de ley de Wyoming. “Esta legislación no busca crear división. Busca proteger las libertades constitucionales, la libertad de expresión y la libertad de conciencia”.

Por su parte, durante la audiencia, el expresó su preocupación por otorgar a los centros de embarazo un nivel de protección que otras empresas privadas no tienen.

“Ya cuentan con medidas de protección”, reflexionó. “Lo que me preocupa es que se les otorguen medidas de protección adicionales”.

En 2022, Wellspring Health Access, la única clínica en Wyoming que realiza abortos, en un ataque intencional.

“Nosotros somos los que proporcionamos información precisa sobre salud reproductiva y por eso sufrimos las consecuencias”, dijo a ºÚÁϳԹÏÍø News Julie Burkhart, presidenta y fundadora de Wellspring Health Access.

, profesora de la Facultad de Derecho de la Universidad de California en Davis, dijo que la legislación propuesta eximiría a los centros de crisis de embarazo de tener que cumplir con los estándares a los que están obligadas las organizaciones médicas. También borraría la línea entre la defensa de una causa y la práctica médica, agregó. Y agregó que iniciativas de este tipo pueden ofrecer a los republicanos un mensaje de campaña potencialmente útil de cara a las elecciones legislativas de mitad de mandato.

“El Partido Republicano necesita una estrategia de comunicación para mostrar que se preocupa por las mujeres, incluso si prohíbe el aborto y aunque no quiera destinar recursos estatales a ayudar a las personas antes y después del embarazo”, explicó Ziegler. “La estrategia consiste en delegar eso en los centros de asesoramiento sobre el embarazo, lo que, por supuesto, aumenta el incentivo para protegerlos”.

Legislación modelo

La Alliance Defending Freedom es el mismo grupo que , que desde 1973 protegía el derecho al aborto a nivel nacional. El grupo redactó la , una legislación modelo para prohibir el aborto desde las 15 semanas, que fue la base de una ley de Mississippi de 2018 que condujo al caso Dobbs v. Jackson Women’s Health Organization a partir de la cual la Corte Suprema anuló el fallo Roe.

La alianza dijo que sus abogados no estaban disponibles para comentar la estrategia de la organización respecto al CARE Act. En el proyecto de ley, el grupo afirmó que los esfuerzos federales, estatales y locales están apuntando contra los centros de atención del embarazo en un “claro intento de socavar y obstaculizar” su trabajo y cerrarlos.

En los últimos años, algunos han sido blanco de vandalismo y amenazas.

Pero los ataques que la legislación modelo se propone abordar principalmente son los esfuerzos legales y regulatorios de algunos estados que buscan mayor supervisión de estos centros, incluida una ley de California que exige que informen claramente a los pacientes sobre sus servicios. Esa ley fue anulada cuando la Corte Suprema falló a favor de los centros de crisis, avalando el argumento de que la norma violaba sus derechos de la Primera Enmienda.

Este año, la Corte Suprema que decidirá si los estados pueden citar a estas organizaciones para obtener información sobre donantes y datos internos.

De todos modos, es poco probable que los centros de crisis de embarazo enfrenten ese tipo de medidas regulatorias en los estados conservadores donde se está considerando esta legislación. Un legislador de Wyoming lo reconoció durante la audiencia del comité en febrero.

Diferentes servicios

En esa misma audiencia, quien encabeza el comité que patrocina el proyecto de ley, presentó la medida como “muy importante, especialmente con nuestro ‘desierto de maternidad’”, refiriéndose a la falta de acceso a servicios de atención de salud materna.

Algunos centros de crisis de embarazo pueden contar con pocos profesionales con licencia, pero son la minoría. Muchos ofrecen recursos gratuitos, como pañales, ropa para bebé y otros artículos, a veces a cambio de aceptar asesorías o clases de crianza.

Las clínicas de Planned Parenthood, en contraste, ofrecen una variedad de servicios de salud, como pruebas y tratamiento para infecciones de transmisión sexual, atención primaria y exámenes para detectar cáncer cervical. Además, están reguladas como organizaciones con licencia médica.

Desde que el fallo Roe fue anulado, el movimiento por el derecho al aborto ha enfrentado desafíos importantes. La ley de los republicanos, One Big Beautiful Bill Act, que el presidente Donald Trump promulgó el verano pasado, a proveedores de abortos. Esa medida contribuyó a que Planned Parenthood tuviera que cerrar el año pasado.

Para 2024, operaban en todo el país, según un mapa creado por investigadores de la Universidad de Georgia, en comparación con las que ofrecían abortos a finales de 2025.

, una organización de investigación afiliada a la organización contra el aborto SBA Pro-Life America, ha sugerido que los centros de embarazo podrían ayudar a llenar el vacío dejado por el cierre de clínicas de Planned Parenthood.

Ziegler aseguró que eso dejaría a las pacientes expuestas a riesgos médicos.

El creciente poder de los centros

Las iniciativas anteriores en , Colorado y Vermont para regular los centros de crisis de embarazo surgieron a raíz de la preocupación por denuncias de , y dudas sobre la .

En 2024, un en cinco estados que investigaran si los centros estaban engañando a las pacientes haciéndoles creer que su información personal estaba protegida bajo la Health Insurance Portability and Accountability Act (HIPAA), y que averiguaran  cómo estaban utilizando la información de los pacientes.

Los tribunales, incluida la Corte Suprema, han fallado con frecuencia que argumentan que estos intentos de regulación violan sus derechos de la Primera Enmienda a la libertad de expresión y la libertad religiosa.

Los centros de crisis para embarazadas también han recibido una avalancha de fondos desde que se revocó Roe.

Al menos incluidos centros de crisis de embarazo, según el Lozier Institute.

Seis estados distribuyen una parte de sus fondos federales del programa Temporary Assistance for Needy Families (TANF) —pagos en efectivo destinados a familias de bajos ingresos con niños— a centros de crisis de embarazo. Texas, Florida, Tennessee y Oklahoma han proporcionado decenas de millones de dólares para estas organizaciones.

Un análisis encontró que los centros de crisis de embarazo también recibieron entre 2017 y 2023, incluidos fondos del paquete de ayuda de 2020 promulgado como ley durante el primer mandato de Trump en medio de la pandemia de covid.

A pesar de los desafíos que enfrentan las clínicas que ofrecen abortos, Burkhart, directora del centro Wellspring en Wyoming, dijo que es importante seguir garantizando la atención a quienes la necesitan. Ella ha ayudado a abrir clínicas en zonas rurales de otros estados conservadores y ha señalado que esas clínicas siguen recibiendo pacientes.

“Eso me demuestra que, sin importar tu religión o tu partido político, hay momentos en la vida de las personas en los que necesitan atención de salud reproductiva brindada por profesionales calificados”, dijo. “Eso incluye el aborto”.

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The legislation would prohibit state and local governments from requiring crisis pregnancy centers to perform abortions, provide referrals for abortion services, or inform patients about such services or contraception options. It also would allow crisis pregnancy centers to sue the violating government entity.

Wyoming lawmakers of the Center Autonomy and Rights of Expression Act, or , on March 4. Other versions have advanced in and this year. One was in 2025. The CARE Act is “model legislation” created by the , an anti-abortion, conservative Christian legal advocacy group.

A similar proposal, the , was introduced in Congress last year but hasn’t moved out of the House Energy and Commerce Committee.

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• Click here to hear Boyd-Barrett on .
• Read Boyd-Barrett’s “‘I Can’t Tell You’: Attorneys, Relatives Struggle To Find Hospitalized ICE Detainees.”

Céline Gounder, ºÚÁϳԹÏÍø News’ editor-at-large for public health, discussed the neurodegenerative disease ALS on CBS News’ CBS Mornings on Feb. 20.

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ºÚÁϳԹÏÍø News senior correspondent Aneri Pattani discussed Elyse Stevens, a New Orleans doctor who faced investigation because of her patient-centered approach to substance use disorders, on The Lens’ Behind The Lens podcast on Feb. 20.

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ºÚÁϳԹÏÍø News chief rural correspondent Sarah Jane Tribble discussed major cuts to Medicaid on WBUR’s Here & Now on Feb. 19. Tribble also discussed Alabama’s plan for robotic ultrasounds on The Daily Yonder’s The Yonder Report on Feb. 19.

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La mujer de 59 años, que vive en Harrisburg, Carolina del Norte, cerró el año pasado su escuela de artes circenses sin fines de lucro porque ya no veía lo suficientemente bien como para estar al día con todo el papeleo administrativo. Luego trabajó un tiempo haciendo masas en una pizzería. Ahora clasifica materiales reciclables, como latas y botellas, en un lugar de conciertos local. Es su principal fuente de ingresos, pero el trabajo no es durante todo el año.

“Este lugar me conoce, y este lugar me quiere”, dijo Kelley sobre su empleador. “Aquí no tengo que explicar por qué no puedo leer”.

Kelley vive en una casa rodante y sobrevive con menos de $10.000 al año. Dice que eso es posible, en parte, gracias a su cobertura de salud de Medicaid, que le cubre medicamentos para la artritis y la ansiedad, y le permite ir al doctor para controlar su hipertensión.

Pero le preocupa perder esa cobertura el año que viene, cuando entren en vigencia nuevas reglas que exigirán a millones de personas como ella trabajar, hacer voluntariado, ir a la escuela o realizar otras actividades que califiquen durante al menos 80 horas al mes.

“Ahora mismo tengo miedo”, dijo.

Antes de que se promulgaran los cambios para acceder a esta cobertura, legisladores republicanos sugirieron que hombres jóvenes y desempleados estaban abusando del programa gubernamental de salud que ofrece cobertura médica a millones de personas con bajos ingresos o con alguna discapacidad.

Medicaid no está pensado para “hombres de 29 años sentados en el sofá jugando videojuegos”, dijo Mike Johnson, presidente de la Cámara de Representantes, .

Pero en realidad, los adultos de entre 50 y 64 años, especialmente las mujeres, son quienes probablemente por las nuevas reglas, según explicó Jennifer Tolbert, subdirectora del Programa sobre Medicaid y Personas sin Seguro de KFF, una organización sin fines de lucro de información sobre salud de la cual ºÚÁϳԹÏÍø News forma parte.

Para Kelley y otras personas, los requisitos laborales crearán obstáculos para mantener su cobertura, explicó Tolbert. Muchos podrían perder Medicaid, poniendo en riesgo su salud física y financiera.

A partir de enero de 2027, unos 20 millones de estadounidenses de bajos ingresos en 42 estados y el Distrito de Columbia tendrán que cumplir con los requisitos de actividad para obtener o conservar esta cobertura.

Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming no ampliaron sus programas de Medicaid para cubrir a más adultos de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), por lo que no tendrán que implementar las reglas de trabajo.

La no partidista Oficina de Presupuesto del Congreso, prevé que las reglas de trabajo resulten en al menos 5 millones de personas menos bajo Medicaid en la próxima década.

, estas reglas son el principal factor de pérdida de cobertura dentro de la ley presupuestaria republicana, la cual recorta cerca de $1.000 millones para compensar reducciones de impuestos que benefician principalmente a personas con mayores ingresos y para aumentar la seguridad fronteriza.

“Estamos hablando de ahorrar dinero a costa de vidas humanas”, dijo Jane Tavares, investigadora en gerontología de la Universidad de Massachusetts en Boston. “El requisito de trabajo es solo una herramienta para lograr eso”.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos, dijo que exigir a los “adultos sin discapacidades” que trabajen garantiza la “sostenibilidad a largo plazo” de Medicaid, mientras protege a las personas más vulnerables.

Las personas con discapacidades, quienes cuidan a familiares, personas embarazadas o en posparto, veteranos con discapacidades totales y otras personas que enfrentan dificultades médicas o personales están exentas de la regla de trabajo, indicó Nixon a ºÚÁϳԹÏÍø News.

La expansión de Medicaid ha sido un salvavidas para adultos de mediana edad que, de otro modo, no tendrían seguro médico, . Medicaid cubre a 1 de cada 5 estadounidenses de entre 50 y 64 años, dándoles acceso a atención médica hasta que califican para Medicare a los 65 años.

Entre las mujeres beneficiarias de Medicaid, las que tienen entre 50 y 64 años enfrentan más desafíos para conservar su cobertura que las más jóvenes, y suelen tener una mayor necesidad de servicios de salud, explicó Tolbert.

Estas mujeres de mediana edad tienen menos probabilidades de trabajar el número requerido de horas porque muchas son cuidadoras familiares o tienen problemas de salud que limitan su capacidad para trabajar, agregó.

Tavares y otros investigadores hallaron que de la población total de Medicaid que se considera “apta para trabajar” no trabaja. Este grupo está compuesto en su mayoría por mujeres muy pobres que han salido de la fuerza laboral para convertirse en cuidadoras. Entre ellas, 1 de cada 4 tiene 50 años o más.

“No son adultos jóvenes saludables simplemente perdiendo el tiempo”, escribieron los investigadores.

Además, dificultar el acceso a la cobertura de Medicaid “podría en realidad dificultar que estas personas trabajen”, ya que sus problemas de salud no recibirían tratamiento, advirtió Tolbert. De todas formas, si este grupo pierde la cobertura, sus condiciones crónicas igual necesitarán atención, señaló.

Muchos adultos empiezan a tener problemas de salud antes de ser elegibles para Medicare.

Si las personas mayores no tienen recursos para tratar sus problemas de salud antes de los 65 años, llegarán más enfermas a Medicare, lo que podría generar mayores costos para ese programa, apuntaron expertos en políticas de salud.

Muchas personas de entre 50 y principios de los 60 años ya no trabajan porque son cuidadoras de tiempo completo de hijos o familiares mayores, explicaron defensores, quienes se refieren a este grupo como “la generación sándwich”.

La ley presupuestaria republicana permite que algunos cuidadores queden exentos de las reglas de trabajo de Medicaid, pero las excepciones son “muy limitadas”, dijo Nicole Jorwic, directora de programas del grupo Caring Across Generations.

Le preocupa que personas que deberían calificar para una exención queden fuera por errores o complicaciones.

“Vamos a ver a más cuidadores familiares enfermándose, dejando de atender su propia salud y a más familias enfrentando crisis”, dijo Jorwic.

Paula Wallace, de 63 años, residente de Chidester, Arkansas, dijo que trabajó la mayor parte de su vida adulta y ahora dedica sus días a cuidar a su esposo, quien tiene cirrosis avanzada.

Después de años sin seguro, recientemente obtuvo cobertura gracias a la expansión de Medicaid en su estado, lo que significa que tendrá que cumplir con los nuevos requisitos laborales para conservarla. Pero le cuesta imaginar cómo podrá hacerlo.

“Como soy su única cuidadora, no puedo salir a trabajar fuera de casa”, dijo.

Su esposo recibe beneficios del Seguro por Incapacidad del Seguro Social, explicó, y la ley dice que ella debería quedar exenta de los requisitos de trabajo como cuidadora de tiempo completo de una persona con discapacidad.

Pero las autoridades federales aún no han emitido instrucciones específicas sobre cómo definir esa exención. Y la experiencia de Arkansas y Georgia —los únicos estados que han implementado programas de trabajo en Medicaid— muestra que muchas personas beneficiarias tienen dificultades para navegar sistemas de beneficios complejos.

“Estoy muy preocupada”, dijo Wallace.

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The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House .

But, in reality, adults ages 50 to 64, particularly women, are likely to be , said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, .

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told ºÚÁϳԹÏÍø News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to . Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you're going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And experience from Arkansas and Georgia ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

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Kaitlin Cooke of Cartersville, Georgia, was contemplating suicide when she started calling a statewide mental health crisis line in 2018. She said she would sneak outside and call the hotline behind her car, where her boyfriend would not hear her.

The counselors who answered her calls were there for her when no one else was, she said. Each time she called, they spoke to her for at least 45 minutes. And they told her that life “does get better.”

“If it weren’t for this resource, I might have been a statistic,” said Cooke, now 31, who found a local therapist.

Starting in March, the call response record for that resource, the Georgia Crisis and Access Line, and its newer national counterpart, the 988 Suicide & Crisis Lifeline, plummeted in the state. The 988 line was created during President Donald Trump’s first term.

National data shows Georgia is one of several states that have struggled to keep their rates of disconnected or rerouted 988 calls low. Disconnected calls typically involve the caller hanging up, possibly after a long wait time. States are largely responsible for funding and staffing their 988 systems, with some money from the federal government. Mental health experts said proper funding for the 988 system in a state, through a well-staffed response network, can influence whether a caller is connected to a local counselor — or chooses to hang up.

The future of mental health services appears uncertain amid massive changes from the Trump administration, including Medicaid cuts that could limit access to care. The cuts could also lead states to consider reducing their allocations to crisis lines, said Heather Saunders, senior research manager for the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

The stakes couldn’t be higher for callers experiencing severe mental health crises.

“Some of the callers are actively experiencing suicidal thoughts,” Saunders said. “Sometimes they actively have a suicide plan and it’s a very urgent situation.”

Alarm About Call Abandonment Rate

Georgia has contracted with Carelon Behavioral Health, a unit of insurance giant Elevance Health, to run its crisis lines. When Carelon dropped a subcontractor that managed staffing the lines, performance plunged. Abandoned calls spiked, which means more callers were hanging up or disconnecting before a counselor answered the phone, Kevin Tanner, commissioner of the state Department of Behavioral Health and Developmental Disabilities, pointed out in a letter to Carelon.

The state requires a call abandonment rate of 3% or less, and, Tanner wrote, the current rate was 18%. After sending the letter, the state narrowed its definition of abandoned calls, lowering the current rate. The state now counts only calls disconnected after being on hold for more than 30 seconds and not those rerouted to backup centers.

Carelon officials have acknowledged the dip in performance. They said it reflected a “necessary” transition from the company’s vendor and that they were hiring more staff to ensure the crisis lines could handle the demand. Carelon spokesperson Hieu Nguyen said the company is “committed to ensuring that every Georgian in crisis can access help through 988,” noting that calls not answered locally are routed to national backup centers.

With the help of some federal funding, Georgia is paying Carelon $17 million annually to manage 988 and its predecessor, the Georgia Crisis and Access Line, which is still operating. Crisis calls go to the same response team, whether someone calls 988 or the original state line. Carelon and state officials declined to disclose how much of the money went to the subcontractor, Behavioral Health Link, with Carelon saying it is proprietary information. The state can extend its contract with Carelon to 2032.

Camille Taylor, a spokesperson for the state Department of Behavioral Health and Developmental Disabilities, said in December that Carelon had improved its call response performance but that the state continues to monitor the company’s answer rates.

‘Enormous’ Staffing Challenges

Launched in 2022, the national 988 Suicide & Crisis Lifeline connects people experiencing mental health problems, emotional distress, or alcohol or drug use concerns to trained counselors. The free hotline, with the three-digit number mirroring the ease of dialing 911, aims to help avert mental health crises and reduce suicide risk. It also supports people who call for someone they care about.

“All behavioral health is having enormous challenges in terms of staffing,” said Margie Balfour, an Arizona psychiatrist and a member of a national 988 advisory committee. Being a crisis line counselor “is a very stressful job,” she said. “You’re talking to people at the peak of their crisis.”

In December, Georgia ranked near the bottom of the 50 states in percentage of calls answered that it kept in state, according to Vibrant Emotional Health, which administers the 988 line nationally. A high number of Georgia calls were routed to national call centers, data showed.

The latest national data also showed how different the response times to a 988 call can be. In December, it took one second on average if someone called from Mississippi. It took 74 seconds for a caller from Virginia.

While the unofficial industry target rate for answering in-state calls is 90%, more than half the states fell below that mark in December, according to the . In Georgia, the tracking data for 988 showed that more than 80% of crisis calls were answered within the state — until March, when the number dropped to 73%. Then it fell again in April, to 62%. The rate rose to 72% in October and reached 79% in December.

Local counselors “should be more familiar with the state infrastructure, mental health system, and resources that are available to people who live in the state,” said Saunders of KFF.

Pierluigi Mancini, interim president and CEO of Mental Health America, said it’s unlikely that an out-of-state counselor would know much about that state’s mental health system and providers. The service also sends many predominantly Spanish-speaking callers to out-of-state call centers, possibly hindering their connection to local help, Mancini said.

Since the 988 rollout, the volume of calls, texts, and chats to the crisis line by November, from killing themselves.

More than 49,000 Americans died by suicide in 2023. Nearly 17 million Americans ages 12 and older said in 2024 they had in the previous year, according to the National Survey on Drug Use and Health.

For Generation Z adults, the oldest of whom are now reaching their late 20s, suicide is taking more lives than a decade ago when millennials were the same age, according to a of federal death statistics. The largest increase in suicide rates for the age group was in Georgia, which jumped 65% from 2014 to 2024.

Mike Hogan, a consultant who ran mental health systems in three states, said recent Georgia data reflects “a bungled transition. It looks like performance fell off a cliff.”

For people calling a crisis line, he said, “counselors, with the right training, can talk people down and away from the suicidal crisis.”

Balfour noted that 988 has bipartisan support. The system can be improved, she said, emphasizing that it’s still an important resource that’s effectively helping people in crisis.

“988 is a success,” Balfour said. “And it’s work in progress.”

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It’s feeding time for the animals on this property outside Nashville, Tennessee. An albino raccoon named Cricket reaches through the wires of its cage to grab an animal cracker, an appetizer treat right before the evening meal.

“Cricket is blind,” said Robert Sory, who is trying to open a nonprofit animal sanctuary along with his wife, Emily. “A lot of our animals come to us with issues.”

The menagerie in Thompson’s Station includes Russian foxes, African porcupines, emus, bobcats, and some well-fed goats.

The Sorys are passionate about their pets and seem to put the animals’ needs before their own.

Both Robert and Emily started 2026 without health insurance.

Robert had been covered through a marketplace plan subsidized through the Affordable Care Act. His share of the monthly premiums was $0. When he looked up the rates for 2026, he saw that a barebones “bronze”-level plan would cost him at least $70 a month. He decided to forgo coverage altogether.

“When you don’t have any income coming in, it doesn’t matter how cheap it is,” he said. “It’s not affordable.”

Dumping Coverage

Marketplace plans from the Affordable Care Act no longer feel very affordable to many people, because Congress did not extend a package of enhanced subsidies that expired at the end of 2025. Last week, the House did pass legislation to extend the expired subsidies, and negotiations have moved to the Senate. Without a deal, an estimated will go without coverage this year.

But even without a health plan, people will still need medical care. Many, like the Sorys, have been thinking through their plan B to maintain their health.

The Sorys both lost jobs in November, within days of each other. Robert worked as a farmhand. Emily worked at a staffing firm and lost her insurance along with her position.

“It’s a horrible, horrible market right now. Really tough,” she said.

The first time she had to pay out-of-pocket for her three monthly prescriptions, the cost was $184.

“To equate that to kind of how we think about it, you’re talking about 350 pounds of food for these animals,” Robert said. He pointed to his bobcats, who eat only meat.

Workarounds for the Newly Uninsured

To keep kibble in the food bowls, the Sorys are prepping for an uninsured future. They see the same psychiatrist and met with him to make a plan. He was willing to work with them by charging $125 per visit. They’ll have to go every three months to keep their prescriptions current.

And if other medical problems emerge? They’re hoping for the best.

“I’m not somebody who gets sick super often, thank God,” Robert said. “And if I do, generally I go to an emergency room where they’re going to bill me later.” Robert said he would arrange a repayment plan for bills like that.

Emily has costly health conditions and has already taken on substantial medical debt. “It’s just sitting there, and I’ve racked up money,” she said. “But I’ve had to go to the doctor.”

Donated Drugs and Sliding Scales

Hospitals and clinics are of newly uninsured patients. They’re also concerned that people won’t know about alternative ways to get medical care.

“We don’t have marketing dollars, so you’re not going to see big billboards or radio ads,” said , CEO of in Nashville. It’s one of the country’s 1,400 federally qualified health centers, also called FQHCs.

FQHCs are by the federal government. Although they do not usually offer free care, their fees tend to be lower or on a sliding scale.

Uninsured people who get care receive a bill, Beard said, “but the bill will be based on their ability to pay.”

FQHCs often have on-site pharmacies, and some offer prescription medications free of charge through a partnership with the , a Nashville-based nonprofit.

Many hospital pharmacies also partner with the nonprofit, which has donated by pharmaceutical companies to 277 sites in 38 states. must make the medicine available free of charge to people without insurance who have annual incomes below 300% of the federal poverty limit.

The organization primarily sources medications for chronic conditions such as high blood pressure, diabetes, and mental health. Demand is expected to outstrip supply in the new year, according to .

“We’re projecting and engaging with our manufacturers and asking them, ‘Are you willing to help support, for this future status that we are anticipating?’” he said. “By and large,” he said, pharmaceutical companies have said they’re willing to step up.

“It’s a continuous conversation that we’re having,” Cornwell said.

A Medicaid ‘Gap’ in 10 States

Hospitals will also have to find a way to care for more patients who cannot pay. Industry groups such as the have been vocal about the threat to hospitals’ financial health and have urged Congress to extend the enhanced subsidies, which take the form of tax credits.

The impact might be most acute in states like Tennessee that have not expanded Medicaid to cover people who work but do not have job-based insurance and cannot afford it on their own.

Ten states have chosen not to expand Medicaid to uninsured, low-income adults — an optional provision of the ACA that is mainly paid for by federal funds.

This Medicaid “gap” is , at the high end of the spectrum, by as much as 65% in Mississippi and by 50% in South Carolina, according to the Urban Institute.

As Emily Sory pets a Russian fox, she admits she is keenly aware that she will soon become part of this growing population. After all, her last job involved health care staffing. Her mother is a nurse.

“I understand the system. And I get it’s people like me that don’t pay their bill are why it suffers. And I feel bad,” she said. “But at the same time, I don’t have the money to pay it.”

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The friend’s Guatemalan tenant, who didn’t know she was pregnant, had just delivered a premature baby in the New Orleans house. The parents lacked legal residency, and the mother refused to go to a hospital for fear of being detained by federal immigration officers.

“There’s blood everywhere, and the baby’s dead,” Rosales-Fajardo recalled her friend saying.

Rosales-Fajardo put on her sandals, grabbed surgical gloves, and rushed to the house.

Rosales-Fajardo, herself an immigrant from Brazil, is a grassroots organizer and advocate in the New Orleans East community, where many immigrants live. She has no formal medical training, but she has experience with delivering babies.

She scanned the room when she arrived. A 3-year-old child stood to one side while the mother sat on the edge of the bed. The father held their swaddled newborn son, who wasn’t breathing and was wrapped in blood-soaked towels.

“The baby was completely gray,” Rosales-Fajardo later said.

Rosales-Fajardo wiped fluid away from his small mouth and rubbed his back before performing tiny chest compressions and breathing air into his lungs.

She told the parents she had to call 911 to get the mother and newborn to a hospital for care. The baby was out, but the delivery wasn’t over.

“I assured her. I promised her that she was going to be safe,” Rosales-Fajardo said.

Fear hung over the room. Still, she made the call and continued performing CPR. Finally, the newborn revived and squirmed in Rosales-Fajardo’s arms. When the ambulance arrived, the mother tried to keep her husband from riding with her, terrified they would both be arrested. He went, anyway.

“These are hard-working people,” Rosales-Fajardo said. “All they do is work to provide for their family. But they were almost at risk of losing their child rather than call 911.”

Putting Safety Over Health

Nearly two weeks into the Department of Homeland Security’s Operation Catahoula Crunch, which launched Dec. 3, health professionals and community advocates in Louisiana and Mississippi report that a significantly higher-than-usual number of immigrant patients have skipped health care appointments and experienced heightened stress levels.

According to a , DHS said it had arrested more than 250 people as of Dec. 11. Though federal officials say they’re targeting criminals, that most of the 38 people arrested in the first two days of the New Orleans operation had no criminal record.

Since President Donald Trump took office in January, immigrant families nationwide have become more likely to skip or delay health care, due in part to concerns about their legal status, according to a by KFF and The New York Times.

The survey found that nearly 8 in 10 immigrants likely to be living in the U.S. without legal permission say they’ve experienced negative health impacts this year, from increased anxiety to sleeping problems to worsened health conditions such as high blood pressure or diabetes. The federal immigration raids in California, Illinois, North Carolina, and now Louisiana and Mississippi add to the health care barriers that these families already face, including access to services, language barriers, lack of insurance, and high costs.

That hesitancy to receive even emergency care appears justified amid the ongoing raids. Hospitals and health facilities generally must allow federal agents in areas where the public is allowed, . In California this year, federal agents have staked out , shown up at community clinics, and guarded detainees in . Even driving to and from appointments poses a risk, as traffic stops are a popular place for immigration agents to make arrests.

University Medical Center nurse Terry Mogilles said that immigrants typically make up at least half the patients in her orthopedic trauma clinic in New Orleans, many of them with construction-related, bone-crushing injuries that require surgery. But now, Mogilles said, many of those patients aren’t coming in for follow-up appointments, despite the risk of infection.

“When we call, we can’t get through,” Mogilles said. “It is so upsetting because we have no idea what’s happening to them post-op.”

A Chill Spreads in the South

Federal officials said the Catahoula Crunch operation extends to southern Mississippi, though the bulk of the initial arrests have occurred in the Greater New Orleans area. Immigrant families throughout Mississippi are hunkering down in anticipation.

Michael Oropeza, executive director of El Pueblo, a nonprofit serving low-income immigrant communities in Biloxi and Forest, said the organization has witnessed families delay care, cancel children’s checkups, and go without refilling medication.

“It’s not because they don’t value their health; it’s because they don’t feel safe,” Oropeza said. “When hospitals and clinics are no longer that safe place, people withdraw trust that took years to build up. It can disappear overnight.”

Maria, a Biloxi resident from Honduras, said, in Spanish, she and her two children have missed routine doctors’ appointments because they are “terrified” to leave the house amid an increased presence of federal immigration officers. Her husband, who is authorized to work in the U.S., was detained for two months this year.

Her children are U.S. citizens. They previously qualified for Medicaid, but Maria opted to disenroll them three years ago out of concern that using public benefits would jeopardize her family’s residency applications, she said. The family now pays for their children’s care out-of-pocket.

When it feels safe to attend doctors’ appointments again, Maria said, her priority will be seeking mental health care to address the stress her family has endured.

“I definitely need to see a doctor to get checked out, because I don’t feel well,” she said, describing her anxiety, depression, and insomnia.

In Louisiana, Marcela Hernandez of , a nonprofit that provides direct aid to immigrants, said many of the families she works with live . Sheltering at home and missing work only adds to the stress. Hernandez said she received 800 calls for food in two days from families afraid to leave home.

The federal operation in Louisiana and Mississippi , according to the AP. The longer it goes on, Hernandez said, the more she worries evictions will come next as people can’t pay rent, further traumatizing a community whose members often had to make difficult and dangerous journeys to flee hardships in their countries of origin to reach the U.S.

“You don’t leave your country knowing that you’re gonna get raped on the way just simply because you wanna come and meet Mickey Mouse,” she said.

Rosales-Fajardo, who runs a nonprofit called El Pueblo NOLA, said families tell her how children have started urinating on themselves due to stress and fear. Nationally, immigrants who are likely to lack legal status report that some of their children have had problems sleeping and that they’ve seen changes in school performance or behavior, according to the KFF and New York Times survey.

Community groups said they hope people step up locally to deliver food and hygiene products to immigrant homes, and that health care professionals provide more at-home or telehealth visits.

Like at other hospitals, UMC’s waiting rooms are considered public spaces, Mogilles noted. But the nurses union is calling for the hospital to create safe spaces for patients that federal agents can’t access and clearer policies to protect health care workers who shield patients. Post-op appointments can’t be done virtually, so patients need to feel safe enough to come in, Mogilles said.

Prenatal and postnatal care is also challenging to provide virtually, leaving the health of new and expecting mothers vulnerable, said Latona Giwa, executive director of Repro TLC, a national sexual and reproductive health training nonprofit.

Since the in September, Giwa said, the clinics and health providers her organization works with have reported that 30% of patients had missed appointments. She said pharmacies saw a 40% drop in medication pickups.

“What we know about management of chronic conditions, especially in pregnancy, but in general, is that even missing one appointment can impact the trajectory of that condition and worsen a patient’s outcomes,” Giwa said.

In Louisiana, which already has , the fear of arrest could exacerbate the crisis worsened by the overturning of Roe v. Wade and threaten lives. She’s especially concerned about families with preterm babies in the neonatal intensive care unit, or NICU.

“Imagine your child is in the hospital, and so vulnerable, and you are terrified to go visit and care for your newborn infant because you’re worried about being deported,” Giwa said, noting that a newborn’s health partly relies on parental visits.

That’s the position the Guatemalan family in New Orleans is navigating.

On a recent day in December, Rosales-Fajardo acted as the family’s translator and advocate on their first visit to see their son in the NICU at a hospital on Lake Pontchartrain’s Northshore. Hospital staffers told the parents they would need to make the long and risky trip to the hospital repeatedly for at least a month to provide skin-to-skin contact and breast milk.

Rosales-Fajardo drove the parents, who were afraid to travel alone out of fear of being pulled over and arrested on a bridge. She said she’ll keep driving them as long as she needs to.

“Whenever they see a Hispanic driving or anything like that, that’s suspicious to them,” she said of federal agents.

But the baby is safe and healthy. And the parents have named Rosales-Fajardo his godmother.

Gwen Dilworth of Mississippi Today and Christiana Botic of Verite News contributed to this report.

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The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs , according to KFF.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from a person’s health records, for instance, to determine medical frailty. But information from a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a Nov. 3 letter to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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