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 known as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a ºÚÁϳԹÏÍø News investigation showed.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax-and-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 showÌýgovernment agenciesÌýwill spend millionsÌýto saveÌýconsiderablyÌýmoreÌýbyÌýremovingÌýpeople fromÌýhealth benefits.ÌýWhile statesÌýsignÌýeligibility system contracts with companiesÌýandÌýwork with them to manageÌýupdates, the federal governmentÌýfootsÌýmost of the bill.

The law’s Medicaid policies will causeÌýÌýtoÌýbecome uninsuredÌýby 2034, according to the nonpartisan Congressional Budget Office.ÌýRoughlyÌýÌýwill loseÌýaccess toÌýmonthly cashÌýassistanceÌýforÌýfood, including those with children.Ìý

In five statesÌýalone,ÌýÌýfor state officialsÌýand reviewed by ºÚÁϳԹÏÍø NewsÌýshow that changesÌýwill cost at least $45.6ÌýmillionÌýcombined.Ìý

The lawÌýrequires most statesÌýtoÌýtieÌýMedicaid coverageÌýfor some adultsÌýtoÌýhavingÌýaÌýjob,ÌýandÌýimposes other restrictions that will make it harder forÌýpeopleÌýwith low incomesÌýto stay enrolled.ÌýSNAP restrictions began to take effect in 2025. Major Medicaid provisionsÌýbeginÌýlater this year.Ìý

DocumentsÌýprepared by consulting company DeloitteÌýestimateÌýthat a pair ofÌýcomputer systemÌýchangesÌýforÌýMedicaid work requirementsÌýin WisconsinÌýwillÌýÌý. Two other changesÌýrelatedÌýto the state’s SNAP program will cost an additional $4.2Ìýmillion, 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 thatÌýoperatesÌýthe state’sÌýeligibility system.Ìý

OptumÌý—ÌýwhichÌýoperatesÌýthe platform Vermont residents useÌýfor Medicaid and marketplaceÌýhealthÌýplans under the Affordable Care ActÌý—ÌýÌýÌýÌýÌýtoÌýevaluate andÌýincorporateÌýnewÌýhealthÌýcoverage restrictions.Ìý

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

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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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Después de que Robert F. Kennedy Jr., secretario del Departamento de Salud y Servicios Humanos (HHS, por sus siglas en inglés), despidiera a Susan Monarez, directora de los Centros para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglé), por negarse a lo que sus abogados calificaron , Newsom para ayudar a modernizar el sistema de salud pública de California.

También dio trabajo a Debra Houry, ex directora científica y médica de la agencia, quien había renunciado en protesta pocas horas después del despido de Monarez.

Newsom también se asoció con los gobernadores demócratas Tina Kotek, de Oregon; Bob Ferguson, de Washington; y Josh Green, de Hawaii para formar la , una agencia regional de salud pública.

Los gobernadores que sus recomendaciones “defenderán la integridad científica en la salud pública mientras Trump destruye” la credibilidad de los CDC. Newsom argumentó que crear la alianza independiente era vital mientras Kennedy lidera el retroceso de las recomendaciones nacionales de vacunación de la administración Trump.

Más recientemente, California se convirtió en el primer estado en de respuesta a brotes coordinada por la Organización Mundial de la Salud (OMS), seguido por Illinois y Nueva York. Colorado y Wisconsin indicaron que planean unirse.

Esto ocurrió después de que el presidente Donald Trump a Estados Unidos de la agencia, argumentando que la OMS “se ha desviado de su misión principal y ha actuado en contra de los intereses de Estados Unidos para proteger al público estadounidense en múltiples ocasiones”.

Newsom dijo que unirse al consorcio liderado por la OMS permitirá a California responder más rápido a brotes de enfermedades contagiosas y a otras amenazas a la salud pública.

Aunque otros gobernadores demócratas y líderes de salud pública han criticado abiertamente al gobierno federal, pocos han sido tan directos como Newsom, quien considera postularse a la presidencia en 2028 y está en su segundo y último mandato como gobernador.

Miembros de la comunidad científica han elogiado su esfuerzo por construir una defensa de salud pública frente a los recortes de financiamiento y la reducción de las recomendaciones de vacunas por parte del gobierno federal.

Lo que está haciendo Newsom “es una gran idea”, dijo Paul Offit, crítico de Kennedy y experto en vacunas que anteriormente formó parte del comité asesor de vacunas de la Administración de Alimentos y Medicamentos (FDA, por sus siglas en inglés), pero fue removido bajo la administración Trump en 2025.

“La salud pública se ha puesto de cabeza”, dijo Offit. “Tenemos a un activista antivacunas y negador de la ciencia al frente del Departamento de Salud y Servicios Humanos. Es peligroso”.

La Casa Blanca no respondió a preguntas sobre la postura de Newsom y el HHS rechazó solicitudes para entrevistar a Kennedy.

En cambio, funcionarios federales de salud criticaron a los demócratas en general y argumentaron que los estados gobernados por demócratas están participando en fraude y mala administración de fondos federales en programas de salud pública.

Emily Hilliard, vocera del HHS, dijo que la administración está actuando contra “estados gobernados por demócratas que impulsaron confinamientos sin base científica, mandatos de máscaras para niños pequeños y estrictas tarjetas de vacunación durante la era del covid”. Señaló que esas medidas “han erosionado completamente la confianza del pueblo estadounidense en las agencias de salud pública”.

Salud pública guiada por la ciencia

Desde que Trump regresó al poder, Newsom ha criticado al presidente y a su administración por impulsar políticas que considera una amenaza para la salud y la seguridad públicas. Ha calificado a los líderes federales como “extremistas” que intentan “usar los CDC como arma y difundir desinformación”.

También a funcionarios federales por vincular erróneamente a las vacunas con el autismo y que la administración está poniendo en peligro la vida de bebés y niños pequeños al reducir las recomendaciones de vacunas infantiles. Además, argumentó que la Casa Blanca está generando “caos” en el sistema de salud pública de Estados Unidos al retirarse de la OMS.

El gobernador rechazó una solicitud de entrevista. Marissa Saldivar, vocera de Newsom, dijo que es una prioridad del gobernador “proteger la salud pública y brindar a las comunidades orientación basada en ciencia y evidencia, no en política ni conspiraciones”.

Las acciones de la administración Trump han generado incertidumbre financiera que, según funcionarios locales, ha reducido la moral dentro de los departamentos de salud pública y ha dejado a los estados menos preparados para brotes de enfermedades y .

El año pasado, la Casa Blanca propuso recortar el gasto del HHS en , incluidos . En enero, el Congreso rechazó en gran medida esos recortes, aunque para programas centrados en determinantes sociales de la salud, como el acceso a alimentos, vivienda y educación.

La administración Trump anunció que retiraría en fondos de salud pública de California, Colorado, Illinois y Minnesota, argumentando que los estados liderados por demócratas financiaban iniciativas “woke” que no reflejaban las prioridades de la Casa Blanca.

En cuestión de días, y un juez el recorte.

“De repente siguen cancelando subvenciones y luego se revierte en los tribunales”, dijo Kat DeBurgh, directora ejecutiva de la Asociación de Oficiales de Salud de California. “Gran parte del daño ya está hecho porque los condados ya dejaron de hacer el trabajo”.

Según un análisis de 2025 de KFF, una organización sin fines de lucro de información sobre salud que incluye a ºÚÁϳԹÏÍø News, el financiamiento federal representa de los presupuestos de los departamentos de salud estatales y locales en todo el país. Ese dinero se destina a combatir el VIH y otras infecciones de transmisión sexual, prevenir enfermedades crónicas y fortalecer la preparación en salud pública y la respuesta a enfermedades contagiosas.

Los fondos federales representan $2.400 millones del presupuesto de salud pública de $5.300 millones de California, lo que dificulta que Newsom y los legisladores estatales compensen posibles recortes. Ese dinero ayuda a financiar operaciones estatales y es vital para los departamentos de salud locales.

Los recortes afectan a todos

Barbara Ferrer, directora de salud pública del condado de Los Ángeles, dijo que si el gobierno federal logra recortar esos $600 millones, el condado —con casi 10 millones de residentes— perdería unos $84 millones en los próximos dos años, además de otras subvenciones para la prevención del VIH y otras infecciones de transmisión sexual.

Ferrer señaló que el condado depende de casi $1.000 millones en financiamiento federal al año para rastrear y prevenir enfermedades contagiosas y combatir problemas crónicos de salud, incluidos la hipertensión y la diabetes. El condado el cierre de que ofrecían vacunación y pruebas de enfermedades, en gran parte por pérdidas de financiamiento relacionadas con recortes a subvenciones federales.

“Es una estrategia mal informada”, dijo Ferrer. “La salud pública no se preocupa por si tu afiliación política es republicana o demócrata. No se preocupa por tu estatus migratorio ni por tu orientación sexual. La salud pública tiene que estar disponible para todos”.

Un solo caso de sarampión requiere que los trabajadores de salud pública rastreen a unas 200 personas que pudieron haber estado en contacto con el paciente, dijo Ferrer.

Estados Unidos , pero está cerca de perder ese estatus debido al escepticismo sobre las vacunas y a la desinformación difundida por sus críticos. El año pasado hubo , la mayor cifra desde 1991, con un 93% en personas no vacunadas o cuyo estado de vacunación era desconocido.

Este año, la enfermedad altamente contagiosa se ha reportado en , y en .

Funcionarios de salud pública esperan que la West Coast Health Alliance ayude a contrarrestar las políticas de Trump al generar confianza mediante recomendaciones de salud pública basadas en evidencia.

“Lo que estamos viendo del gobierno federal son políticas partidistas en su peor forma y represalias por diferencias sobre políticas públicas; esto pone en un riesgo extraordinario la salud y el bienestar del pueblo estadounidense”, dijo Georges Benjamin, director ejecutivo de la Asociación Estadounidense de Salud Pública (APHA, por sus siglas en inglés), una coalición de profesionales de salud pública.

Un calendario de vacunación más sólido

Erica Pan, principal funcionaria de salud pública de California y directora del Departamento de Salud Pública de California, dijo que la West Coast Health Alliance está defendiendo la ciencia al recomendar un calendario de vacunación más sólido que el del gobierno federal.

California forma parte de una coalición que por su decisión de retirar las recomendaciones de siete vacunas infantiles, incluidas las de la hepatitis A, la hepatitis B, la influenza y covid-19.

Pan expresó una profunda preocupación por la situación de la salud pública, especialmente por el aumento de casos de sarampión.

“Estamos retrocediendo”, dijo Pan sobre las inmunizaciones.

Sarah Kemble, epidemióloga estatal de Hawaii, dijo que el estado se unió a la alianza después de escuchar a residentes que apoyan las vacunas y quieren tener la seguridad de que seguirán teniendo acceso a ellas.

“Recibíamos muchas preguntas de personas con ansiedad que sí entendían las recomendaciones basadas en la ciencia, pero se preguntaban: ‘¿Todavía voy a poder ir a ponerme mi vacuna?’”, dijo Kemble.

Otros estados liderados principalmente por demócratas también han formado alianzas. Pennsylvania, Nueva York, Nueva Jersey, Massachusetts y varios otros estados de la costa este se unieron para crear el .

Hilliard, del HHS, dijo que aunque los gobernadores demócratas establezcan coaliciones asesoras sobre vacunas, el Comité Asesor sobre Prácticas de Inmunización federal “sigue siendo el organismo científico que guía las recomendaciones de vacunación en este país, y el HHS garantizará que la política se base en evidencia rigurosa y ciencia de alto nivel, no en la política fallida de la pandemia”.

Influencia en estados republicanos

Por su parte, Newsom aprobó una asignación anual recurrente de casi $300 millones para apoyar al Departamento de Salud Pública de California, así como a las 61 agencias locales de salud pública en el estado. El año pasado también que autoriza al estado a emitir sus propias recomendaciones de inmunización.

La ley exige que las aseguradoras de salud en California cubran las vacunas recomendadas por el estado, incluso si el gobierno federal no las recomienda.

Jeffrey Singer, doctor y investigador principal del Cato Institute, un centro de pensamiento libertario, dijo que la descentralización puede ser beneficiosa. Esto se debe a que las campañas informativas locales que reflejan distintas ideologías políticas y prioridades comunitarias pueden tener más posibilidades de influir en el público.

Un análisis de KFF encontró que algunos estados republicanos se están sumando a estados demócratas para desvincular sus recomendaciones de vacunación del gobierno federal. Singer dijo que doctores en su estado natal de Arizona están mirando a California, más liberal, para guiarse sobre consejos de vacunación.

“La ciencia nunca está completamente establecida y hay muchas áreas de este país donde existen diferencias de opinión”, dijo Singer. “Esto puede ayudarnos a cuestionar nuestras suposiciones y aprender”.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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After Health and Human Services Secretary Robert F. Kennedy Jr. fired Centers for Disease Control and Prevention Director Susan Monarez for refusing what her lawyers called “,” Newsom to help modernize California’s public health system. He also gave a job to Debra Houry, the agency’s former chief science and medical officer, who had resigned in protest hours after Monarez’s firing.

Newsom also teamed up with fellow Democratic governors Tina Kotek of Oregon, Bob Ferguson of Washington, and Josh Green of Hawaii to form the , a regional public health agency, whose guidance would “uphold scientific integrity in public health as Trump destroys” the CDC’s credibility. Newsom argued establishing the independent alliance was vital as Kennedy leads the Trump administration’s rollback of national vaccine recommendations.

More recently, California became the a global outbreak response network coordinated by the World Health Organization, followed by Illinois and New York. Colorado and Wisconsin signaled they plan to join. They did so after President Donald Trump officially from the agency on the grounds that it had “strayed from its core mission and has acted contrary to the U.S. interests in protecting the U.S. public on multiple occasions.” Newsom said joining the WHO-led consortium would enable California to respond faster to communicable disease outbreaks and other public health threats.

Although other Democratic governors and public health leaders have openly criticized the federal government, few have been as outspoken as Newsom, who is considering a run for president in 2028 and is in his second and final term as governor. Members of the scientific community have praised his effort to build a public health bulwark against the Trump administration’s slashing of funding and scaling back of vaccine recommendations.

What Newsom is doing “is a great idea,” said Paul Offit, an outspoken critic of Kennedy and a vaccine expert who formerly served on the Food and Drug Administration’s vaccine advisory committee but was removed under Trump in 2025.

“Public health has been turned on its head,” Offit said. “We have an anti-vaccine activist and science denialist as the head of U.S. Health and Human Services. It’s dangerous.”

The White House did not respond to questions about Newsom’s stance and HHS declined requests to interview Kennedy. Instead, federal health officials criticized Democrats broadly, arguing that blue states are participating in fraud and mismanagement of federal funds in public health programs.

HHS spokesperson Emily Hilliard said the administration is going after “Democrat-run states that pushed unscientific lockdowns, toddler mask mandates, and draconian vaccine passports during the covid era.” She said those moves have “completely eroded the American people’s trust in public health agencies.”

Public Health Guided by Science

Since Trump returned to office, Newsom has criticized the president and his administration for engineering policies that he sees as an affront to public health and safety, labeling federal leaders as “extremists” trying to “weaponize the CDC and spread misinformation.” He has for erroneously linking vaccines to autism, the administration is endangering the lives of infants and young children in scaling back childhood vaccine recommendations. And he argued that the White House is unleashing “chaos” on America’s public health system in backing out of the WHO.

The governor declined an interview request. Newsom spokesperson Marissa Saldivar said it’s a priority of the governor “to protect public health and provide communities with guidance rooted in science and evidence, not politics and conspiracies.”

The Trump administration’s moves have triggered financial uncertainty that local officials said has reduced morale within public health departments and left states unprepared for disease outbreaks and . The White House last year proposed cutting HHS spending , including . Congress largely rejected those cuts last month, although funding for programs focusing on social drivers of health, such as access to food, housing, and education, .

The Trump administration announced that it would claw back in public health funds from California, Colorado, Illinois, and Minnesota, arguing that the Democratic-led states were funding “woke” initiatives that didn’t reflect White House priorities. Within days, and a judge the cut.

“They keep suddenly canceling grants and then it gets overturned in court,” said Kat DeBurgh, executive director of the Health Officers Association of California. “A lot of the damage is already done because counties already stopped doing the work.”

Federal funding has accounted for of state and local health department budgets nationwide, with money going toward fighting HIV and other sexually transmitted infections, preventing chronic diseases, and boosting public health preparedness and communicable disease response, according to a 2025 analysis by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Federal funds account for $2.4 billion of California’s $5.3 billion public health budget, making it difficult for Newsom and state lawmakers to backfill potential cuts. That money helps fund state operations and is vital for local health departments.

Funding Cuts Hurt All

Los Angeles County public health director Barbara Ferrer said if the federal government is allowed to cut that $600 million, the county of nearly 10 million residents would lose an estimated $84 million over the next two years, in addition to other grants for prevention of HIV and other sexually transmitted infections. Ferrer said the county depends on nearly $1 billion in federal funding annually to track and prevent communicable diseases and combat chronic health conditions, including diabetes and high blood pressure. Already, the the closure of that provided vaccinations and disease testing, largely because of funding losses tied to federal grant cuts.

“It’s an ill-informed strategy,” Ferrer said. “Public health doesn’t care whether your political affiliation is Republican or Democrat. It doesn’t care about your immigration status or sexual orientation. Public health has to be available for everyone.”

A single case of measles requires public health workers to track down 200 potential contacts, Ferrer said.

The U.S. but is close to losing that status as a result of vaccine skepticism and misinformation spread by vaccine critics. The U.S. had , the most since 1991, with 93% in people who were unvaccinated or whose vaccination status was unknown. This year, the highly contagious disease has been reported at , , and .

Public health officials hope the West Coast Health Alliance can help counteract Trump by building trust through evidence-based public health guidance.

“What we’re seeing from the federal government is partisan politics at its worst and retaliation for policy differences, and it puts at extraordinary risk the health and well-being of the American people,” said Georges Benjamin, executive director of the American Public Health Association, a coalition of public health professionals.

Robust Vaccine Schedule

Erica Pan, California’s top public health officer and director of the state Department of Public Health, said the West Coast Health Alliance is defending science by recommending a vaccine schedule than the federal government. California is part of a coalition over its decision to rescind recommendations for seven childhood vaccines, including for hepatitis A, hepatitis B, influenza, and covid-19.

Pan expressed deep concern about the state of public health, particularly the uptick in measles. “We’re sliding backwards,” Pan said of immunizations.

Sarah Kemble, Hawaii’s state epidemiologist, said Hawaii joined the alliance after hearing from pro-vaccine residents who wanted assurance that they would have access to vaccines.

“We were getting a lot of questions and anxiety from people who did understand science-based recommendations but were wondering, ‘Am I still going to be able to go get my shot?’” Kemble said.

Other states led mostly by Democrats have also formed alliances, with Pennsylvania, New York, New Jersey, Massachusetts, and several other East Coast states banding together to create the .

HHS’ Hilliard said that even as Democratic governors establish vaccine advisory coalitions, the federal “remains the scientific body guiding immunization recommendations in this country, and HHS will ensure policy is based on rigorous evidence and gold standard science, not the failed politics of the pandemic.”

Influencing Red States

Newsom, for his part, has approved a recurring annual infusion of nearly $300 million to support the state Department of Public Health, as well as the 61 local public health agencies across California, and last year authorizing the state to issue its own immunization guidance. It requires health insurers in California to provide patient coverage for vaccinations the state recommends even if the federal government doesn’t.

Jeffrey Singer, a doctor and senior fellow at the libertarian Cato Institute, said decentralization can be beneficial. That’s because local media campaigns that reflect different political ideologies and community priorities may have a better chance of influencing the public.

A KFF analysis found some red states are joining blue states in decoupling their vaccine recommendations from the federal government’s. Singer said some doctors in his home state of Arizona are looking to more liberal California for vaccine recommendations.

“Science is never settled, and there are a lot of areas of this country where there are differences of opinion,” Singer said. “This can help us challenge our assumptions and learn.”

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The Millers resettled on Vancouver Island, their scenic refuge accessible only by ferry or plane. Justin went to work in the emergency room at Nanaimo Regional General Hospital, where he became one of at least 20 U.S.-trained nurses hired since April.

Fear of Trump, some of the nurses said, was why they left.

“There are so many like-minded people out there,” said Justin, who now works elbow to elbow with Americans in Canada. “You aren’t trapped. You don’t have to stay. Health care workers are welcomed with open arms around the world.”

The Millers are part of a new surge of American nurses, doctors, and other health care workers moving to Canada, and specifically British Columbia, where more than 1,000 U.S.-trained nurses have been approved to work since April. As the Trump administration enacts increasingly authoritarian policies and decimates funding for , insurance, and medical research, many nurses have felt the draw of Canada’s progressive politics, friendly reputation, and universal health care system.

Additionally, some nurses were incensed last year when the Trump administration said it would reclassify nursing as a , which would impose strict federal limits on the loans nursing students could receive.

Canada is poised to capitalize. Two of its most populous provinces, Ontario and British Columbia, have streamlined the licensing process for American nurses since Trump returned to the White House. British Columbia also launched a last year to recruit nurses from California, Oregon, and Washington state.

“With the chaos and uncertainty happening in the U.S., we are seizing the opportunity to attract the talent we need,” Josie Osborne, the province’s health minister, said in a statement announcing the campaign.

Fears Realized

Amy Miller, a nurse practitioner, said she and her husband were determined to move their children out of the country because they felt Trump’s second term would inevitably spiral into violence.

First, the Millers got nursing licenses in New Zealand, but when the job search took too long, they pivoted to Canada.

Justin was offered a job within weeks.

Amy found one within three months.

So they moved. And just a few days later, the Millers watched with horror from afar as their fears came true.

As federal immigration forces clashed with protesters in Minneapolis on Jan. 24, federal agents fatally shot an ICU nurse, Alex Pretti, as he filmed a confrontation and appeared to be trying to shield a woman who was knocked down. Video of the killing showed border agents pinning Pretti to the ground before seizing his concealed, licensed handgun and opening fire on him.

The Trump administration quickly called Pretti a “domestic terrorist” who intended to kill federal agents.ÌýThat allegation was disputed by eyewitness videos that circulated on social media and spurred widespread outrage, including from nurses and nursing organizations, some of whom invoked the profession’s duty to care for the vulnerable.

“I don’t want to say it was expected, but that’s why we are here,” Amy Miller said. “Even our oldest kid, she was like: ‘It’s OK, Mom, because we are not there anymore. We are safe here.’ So she recognizes that, and she’s not even in middle school yet.”

Both the U.S. and Canada have a severe need for nurses. The U.S. is projected to be short about 270,000 registered nurses, plus at least 120,000 licensed practical nurses, by 2028, according to from the Health Resources and Services Administration. In Canada, nursing job vacancies tripled from 2018 to 2023, when they reached nearly 42,000, according to from the Montreal Economic Institute, a Canadian think tank.

When asked to comment, the White House noted that shows the number of nurses licensed in the U.S. increased in 2025. It dismissed accounts of nurses moving to Canada as “anecdotes of individuals with severe cases of Trump derangement syndrome.”

“The American health care workforce is the finest in the world, and it continues to expand under President Trump,” White House spokesperson Kush Desai said. “Employment opportunities in the American health care system remain robust, with career advancement and pay that far exceed that of other developed nations.”

‘A Sense of Relief’

It is unknown precisely how many American nurses have moved north since Trump returned to office, because some Canadian provinces do not track or release such statistics.

British Columbia, which has done the most to recruit Americans, approved the licensing applications of 1,028 U.S.-trained nurses from when the province’s streamlined application process took effect in April 2025 through January, according to the British Columbia College of Nurses and Midwives. In all of 2023, only 112 applicants from the U.S. were approved, the agency said. In 2024, it was 127.

Increased interest from American nurses was also confirmed by nursing associations in Ontario and Alberta, as well as by the nationwide Canadian Nurses Association.

Angela Wignall, CEO of Nurses and Nurse Practitioners of British Columbia, said American nurses used to move north because they had fallen in love with Canada (or a Canadian). But more recently, she said, she had met nurses who feared the White House would spur violence and vigilantism, particularly against families that included same-sex couples.

“Some of them were living in fear of the administration, and they shared a sense of relief when crossing the border,” Wignall said. “As a Canadian, it’s heartbreaking. And also a joy to welcome them.”

Vancouver Island, which has a population of about 860,000, has gained 64 U.S.-trained nurses since April, including those at Nanaimo Regional, said Andrew Leyne, a spokesperson for the island’s health agency.

One of the nurses was Susan Fleishman, a Canadian who moved to the U.S. as a child, then worked for 23 years in American emergency rooms before leaving the country in November.

Fleishman said hateful rhetoric from Trump has fueled an angry division that has permeated and soured American life.

“It wasn’t an easy move — that’s for sure. But I think it’s definitely worth it,” she said, happily back in Canada. “I find there is a lot more kindness here. And I think that will keep me here.”

Brandy Frye, who also worked for decades in American ERs, said she moved to Vancouver Island last year after waiting to see whether Mark Carney would become Canada’s prime minister. Carney’s rise was widely viewed as a rejection of Trumpism.

Meanwhile, Frye said, the California hospital where she worked had been stripping words associated with diversity and equity out of its paperwork to appease the Trump administration. She couldn’t stand it.

“It felt like a step against everything I believe in,” Frye said. “And I didn’t feel like I belonged there anymore.”

Like many of the American nurses who have moved to Vancouver Island, Frye was first wooed to the area by a that was meant to attract tourist dollars but ended up doing much more.

About a year ago, Tod Maffin, a and former CBC Radio host, invited Americans to the port city of Nanaimo for a weekend event designed to offset the impact of Trump’s tariffs on the local economy.

Maffin said about the April event.

“A lot of them were health care workers looking for an escape route,” Maffin said. “They were there to help support our economy but also to look into Canada.”

Maffin saw an opportunity. He repurposed the event website into a recruiting tool and launched a Discord chatroom to help Americans relocate.

Maffin said he believes the campaign helped about 35 health care workers move to Vancouver Island. Volunteers in have since duplicated his website in an effort to attract their own American nurses and doctors.

“There are communities across Canada where the emergency room closes at night because one nurse is out. That’s how thin staffing is,” Maffin said.

“One new nurse in a small town, or in a midsized city like Nanaimo,” he said, “makes a difference.”

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The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022, and she uses medicated drops in both eyes to prevent more damage. She is supposed to be checked regularly, she said.

During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.

Tuszynski, who lives in central Wisconsin, had looked up beforehand whether the clinic in nearby Madison participated in her insurance plan. The insurer’s website listed the optometrist’s name with a green check mark and the words “in-network.” She assumed that meant her policy would cover the appointment.

Then the bill came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.

She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.

Tuszynski was baffled that care for a patient’s eyes would not be covered by vision insurance. She said she didn’t realize that insurers can have contracts with eye clinics to provide some services but not others.

UnitedHealthcare spokesperson Meg Sergel said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals. “I looked up my eye doctor, and it’s the same thing,” she said in an interview with ºÚÁϳԹÏÍø News.

Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

Leaders at Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.

Casey Schwarz, senior counsel for education and federal policy at the nonprofit , said such complications frequently come up when Medicare Advantage members try to use their insurance at eye clinics or dental offices.

The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries . Many offer routine vision and dental coverage that isn’t included with traditional Medicare.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,” Schwarz said.

The Resolution

After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to question the decision and filed an appeal with the company. Then, she said, she called to complain to federal officials. She also wrote to ºÚÁϳԹÏÍø News, which asked the insurer about the case.

UnitedHealthcare eventually agreed to cover the bill as if the service had been in-network. “In good faith, we made an exception,” Sergel said. However, Tuszynski was warned that if she received medical care from the clinic again, it would not be covered, because the clinic remains out-of-network for such services, Sergel said. “It doesn’t sound like that pleased her.”

Tuszynski confirmed that she is not pleased.

She said she lost sleep over the dispute and felt that it shouldn’t have taken so much effort to obtain a fair outcome. “It’s just been a horrible, difficult whirlwind,” she said.

The Takeaway

Schwarz said regulators should require insurance companies to clearly explain to customers and care providers how different procedures and services will be covered under vision, dental, and health plans. “They’re tricky,” she said.

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.

Tricia Neuman, a senior vice president with KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News, noted that Medicare’s website that can help people determine whether their doctors participate in a Medicare Advantage plan.

“This is helpful and a step forward, but information about provider networks is not always correct,” Neuman said. “Errors can come at a cost to enrollees, unless they are willing and able to take on their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and at doctors’ offices, so she’s familiar with billing issues, she said. “If I can’t sort through all this, how can anybody else do it?”

She knows her $340 bill was much smaller than the medical debts many other people face. But she said it was a serious amount of money to her, and she was glad she objected to the insurer’s contention that the bill shouldn’t be covered.

“I have a strong feeling about right and wrong — and this is just wrong,” she said.

For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying no separate premium for her old Medicare Advantage plan.

Now she won’t have to worry about private insurers’ limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison eye clinic.

However, she no longer has insurance coverage for eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. “Hopefully, those will last me a while,” she said.

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O bien ya terminaste un par de semanas de rehabilitación. ¿Podrás manejar una rutina complicada de medicamentos, además de hacer las compras y cocinar?

Tal vez te caíste en la ducha y ahora tu familia quiere que consigas ayuda para bañarte y vestirte.

Por supuesto, hay centros que brindan ese tipo de asistencia, pero la mayoría de las personas mayores no quiere irse a vivir a esos lugares. Quieren quedarse en casa.

Y ahí está el problema.

Cuando las personas mayores comienzan a tener dificultades con las actividades diarias, ya sea porque se han vuelto más frágiles, por el avance de enfermedades crónicas o por la pérdida de una pareja o acompañante, la mayoría no quiere mudarse.

Desde hace décadas, el mayor tiempo posible.

Eso significa que necesitan cuidado en casa, ya sea proporcionado por familiares, amigos, cuidadores pagos o por una combinación de ellos. Pero el cuidado remunerado en casa es una parte especialmente afectada del sistema de atención a largo plazo, que está atravesando una escasez de personal cada vez más grave, justo cuando la población envejecida impulsa una demanda creciente.

“Es una crisis”, definió la doctora Madeline Sterling, médica de atención primaria en Weill Cornell Medicine y directora de la Iniciativa sobre el Trabajo de Cuidados en el Hogar () de la Universidad de Cornell. “No funciona bien para quienes forman parte del sistema”, ya sean pacientes (que también pueden ser personas jóvenes con discapacidades), familiares o cuidadores en el hogar.

“No se trata de algo que vaya a pasar en una década”, señaló Steven Landers, director ejecutivo de la Alianza Nacional para la Atención en el Hogar (National Alliance for Care at Home), una organización del sector. “Haz una búsqueda en Indeed.com en cualquier ciudad de Estados Unidos para encontrar asistentes de atención en el hogar, y verás tantas vacantes que te vas a quedar con la boca abierta”.

Pero aun en ese panorama desalentador, hay algunas alternativas que muestran resultados prometedores al mejorar tanto las condiciones laborales en el sector como la atención a los pacientes. Y están creciendo.

Un poco de contexto. Desde hace años, investigadores y administradores del sistema de atención a personas mayores vienen advirtiendo sobre esta crisis inminente. El cuidado en el hogar ya es una de las ocupaciones de más rápido crecimiento en el país: el año pasado había 3,2 millones de asistentes de salud en el hogar y de cuidado personal, frente a 1,4 millones una década atrás, , una organización de investigación y defensa del sector.

Así y todo, , el país necesitará unos 740.000 trabajadores adicionales de cuidado en el hogar en los próximos diez años, y reclutarlos no será tarea fácil. El costo para los consumidores es alto: en promedio, $34 por hora por uno de estos asistentes el año pasado, según la , con grandes diferencias según la región.

Pero los trabajadores reciben, en promedio, menos de $17 por hora.

Siguen siendo empleos inestables y mal remunerados. De una fuerza laboral compuesta en su mayoría por mujeres, aproximadamente un tercio inmigrantes, el 40% vive en hogares de bajos ingresos y la mayoría recibe algún tipo de asistencia pública.

Incluso cuando las agencias que los contratan ofrecen seguro médico y los trabajadores reúnen los requisitos para tenerlo, muchos no pueden pagar las primas.

No es sorprendente que el índice de rotación de personal alcance el 80% anual, , una organización sin fines de lucro que promueve cooperativas.

Pero no en todos lados. Una innovación que aún es pequeña pero está en expansión son las cooperativas de cuidado en el hogar que pertenecen a los propios trabajadores. La primera y más grande, Cooperative Home Care Associates en el Bronx, comenzó en 1985 y actualmente emplea a unos 1.600 cuidadores. The ICA Group contabiliza ahora 26 negocios de cuidado en el hogar propiedad de trabajadores en todo el país.

“Estas cooperativas están logrando resultados excepcionales”, dijo el doctor Geoffrey Gusoff, médico de familia e investigador en servicios de salud en la Universidad de California en Los Ángeles. “Tienen la mitad de la rotación que las agencias tradicionales, mantienen a los clientes el doble de tiempo y pagan $2 más por hora” a sus copropietarios.

Cuando Gusoff y sus colegas entrevistaron a miembros de cooperativas para publicado en JAMA Network Open, “esperábamos escuchar más sobre la compensación”, comentó. “Pero la respuesta más común fue: ‘tengo más voz’” en cuanto a las condiciones laborales, la atención a los pacientes y la gestión de la cooperativa.

“Los trabajadores dicen que se sienten más respetados”, señaló Gusoff.

A través de una iniciativa que ofrece financiamiento, asesoramiento empresarial y asistencia técnica, The ICA Group planea aumentar el número de cooperativas a 50 en los próximos cinco años, y a 100 para 2040.

Otra alternativa que está ganando terreno son los registros que permiten que trabajadores de cuidado en el hogar y personas que necesitan asistencia se conecten directamente, a menudo sin involucrar a agencias que supervisan y hacen verificación de antecedentes, pero que también se quedan con aproximadamente la mitad del pago que hacen los consumidores.

Uno de los registros más grandes, , conecta a trabajadores y clientes en Oregon y Washington. Establecido a través de acuerdos con el Service Employees International Union, el sindicato de salud más grande del país, Carina atiende a 40.000 proveedores y 25.000 clientes. (Según PHI, solo alrededor del 10% de los trabajadores de cuidado en el hogar están sindicalizados).

Carina funciona como una especie de “bolsa de trabajo digital” gratuita, explicó Nidhi Mirani, su directora ejecutiva. Salvo en el área de Seattle, solo atiende a personas que reciben cuidado a través de Medicaid, el principal financiador de atención en el hogar. Las agencias estatales se encargan del papeleo y de supervisar las verificaciones de antecedentes.

Las tarifas por hora que se pagan a proveedores independientes encontrados a través de Carina, establecidas por contratos sindicales, suelen ser más bajas que las que cobran las agencias. Pero los trabajadores ganan desde $20 por hora, además de recibir seguro médico, días de licencia paga y, en algunos casos, beneficios de jubilación.

pueden ser gestionados por los estados, como ocurre en Massachusetts y Wisconsin, o por plataformas como , que está disponible en cuatro estados. “La gente busca tener afinidad con la persona que entra a su casa”, dijo Mirani. “Y los proveedores individuales también pueden elegir a sus clientes. Funciona en ambas direcciones”.

Por último, estudios recientes indican que una mejor capacitación para los trabajadores de atención en el hogar puede tener un impacto positivo.

“Estos pacientes tienen afecciones complejas”, dijo la doctora Sterling. Los trabajadores, al tomar la presión arterial, preparar alimentos y ayudar a que sus clientes se mantengan activos, pueden detectar síntomas preocupantes apenas surgen.

Su equipo llevó a cabo un ensayo clínico con —“la principal causa de hospitalización entre los beneficiarios de Medicare”, señaló— en el que se midieron los efectos de un módulo virtual de capacitación de 90 minutos sobre los síntomas y el manejo de esta enfermedad.

“Hinchazón en las piernas. Falta de aire. Son las primeras señales de que la enfermedad no está bajo control”, explicó Sterling.

En el estudio, que incluyó a 102 trabajadores de VNS Health, una gran organización sin fines de lucro en Nueva York, la capacitación demostró mejorar tanto el conocimiento como la confianza del personal para atender a pacientes con insuficiencia cardíaca.

Además, cuando los asistentes recibieron una aplicación móvil para comunicarse con sus supervisores, hicieron menos llamadas al 911 y los pacientes tuvieron menos visitas a salas de emergencia.

Iniciativas a pequeña escala como los registros, cooperativas y programas de capacitación no resuelven el principal problema del cuidado en el hogar: el costo.

Medicaid cubre los cuidados en el hogar para adultos mayores de bajos ingresos con escasos recursos, aunque el nuevo presupuesto del gobierno de Trump en más de $900.000 millones durante la próxima década. En teoría, las personas con más recursos pueden pagar de su bolsillo.

Pero “las familias jubiladas de clase media terminan usando todos sus recursos y básicamente se empobrecen para poder calificar para Medicaid, o simplemente no reciben cuidados”, dijo el doctor Landers. Opciones como la residencia asistida o las residencias de mayores son aún más costosas.

Estados Unidos nunca ha asumido el compromiso de financiar el cuidado a largo plazo para las personas de clase media, y parece poco probable que lo haga esta administración.

Aun así, los ahorros derivados de estas innovaciones podrían reducir costos y ayudar a ampliar el acceso a esta atención a través de programas federales o estatales. Hay varias pruebas y programas piloto en curso.

Los trabajadores de cuidado en el hogar “tienen una comprensión muy profunda de las afecciones de los pacientes”, expresó la doctora Sterling. “Capacitarlos y darles herramientas tecnológicas demuestra que, si queremos que los pacientes se queden en casa, esta es una forma de lograrlo con la fuerza laboral que ya tenemos”.

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Health officials are recommending diet and exercise as alternatives to heavily advertised weight loss drugs like Wegovy and Zepbound, advice experts say is unrealistic.

“Of course he tried eating well and everything, but now with the medications, it’s better — a 100% change,” said Wilmer Cardenas of Santa Clara, who said his husband lost about 100 pounds over about two years using GLP-1s covered by Medi-Cal, California’s version of Medicaid.

California joined several other states in restricting an option they say is no longer affordable as they confront soaring pharmaceutical costs and steep Medicaid cuts under the Trump administration, among . Despite negotiated price reductions announced in November that would make the drugs available at a “dramatically lower cost to taxpayers” and enable Medicaid to cover them, states are going ahead with the cuts, which providers say may undermine patients’ health.

“It will be quite negative for our patients” because data shows people typically regain weight after stopping the drugs, said , medical director of the University of California-San Francisco Weight Management Program.

While California, , , and stopped covering adult GLP-1 prescriptions for obesity on Jan. 1, they continue to cover the drugs for other health issues, such as Type 2 diabetes, cardiovascular disease, and chronic kidney disease.

, , and Wisconsin are planning or considering restrictions, according to KFF’s .

That reverses a trend that saw 16 states covering the medications for obesity as of Oct. 1. Interest in providing the coverage “appears to be waning,” the survey found, likely due to the drugs’ cost and other state budget pressures. North Carolina pulled back GLP-1 coverage in October, but reinstated it in December, bowing to court orders despite a lingering budget shortfall.

Catherine Ferguson, vice president of federal advocacy for the American Diabetes Association and its affiliated Obesity Association, said it’s not clear how states will adjust to the White House plan to lower the cost of several of the most popular GLP-1s through TrumpRx, an online portal for discounted prescription drugs. The price of Wegovy, for example, will be $350 per month for consumers, versus the current list price of nearly $1,350, and Medicare and Medicaid programs will pay $245, according to the plan.

“Many states are facing budgetary challenges, such as deficits, and are working to address the impacts of the changes to Medicaid and SNAP,” Ferguson wrote, referring to the Supplemental Nutrition Assistance Program. “As more details become available for the Administration’s agreements, we will see how state Medicaid responds.”

The Department of Health and Human Services referred questions to the White House, which did not respond to requests for comment on states’ termination of Medicaid coverage for the weight loss drugs.

California projected its costs to cover GLP-1s for weight loss would have more than quadrupled over four years to if it didn’t end Medi-Cal coverage for that use. Medi-Cal has covered weight loss drugs since 2006, but use of GLP-1s soared only in recent years. By 2024, more than 645,000 prescriptions were covered by Medi-Cal across all uses of the medications. The California Department of Health Care Services could not readily provide a breakdown of whether the drugs were for weight loss or other conditions.

When asked whether the state would reconsider its plans in light of the announced price cuts, Department of Finance spokesperson H.D. Palmer said it had no plans to do so. California’s cut is written into .

California officials would not say how much it could save under the TrumpRx plan, citing federal and state restrictions on disclosing rebate information.

Health providers don’t expect the Trump administration’s negotiated price cuts to make much difference to consumers, because pharmaceutical companies already offer some discounts.

“The out-of-pocket costs will still be very cost-prohibitive for most, especially individuals with Medicaid insurance,” Thiara said.

is among the other states that ended their coverage Jan. 1. Officials with the New Hampshire Department of Health and Human Services did not respond to requests for comment.

About 1 in 8 adults are now taking a GLP-1 drug for obesity, disease, or both, up 6 percentage points from May 2024, according to released in November. Over half of users said their GLP-1s were difficult to afford, and many who had stopped the treatment cited the cost.

Public and private payers have been trying to wean patients off to save costs. California health officials said Medi-Cal members and their health care providers “other treatment options that can support weight loss, such as diet changes, increased activity or exercise, and counseling.” That echoes advice from the New Hampshire Medicaid program.

California Department of Health Care Services spokesperson Tessa Outhyse said in an email that the official advice to try those other approaches now “is not meant to dismiss any past efforts, but to encourage Medi-Cal members to take a renewed, proactive, and medically supported approach with their healthcare provider that may appropriately include these additional options.”

But that may be unrealistic, said , founding director of the Center for Clinical Nutrition at Keck School of Medicine of the University of Southern California.

“We definitely want patients to do their part with the diet and exercise, but unfortunately, and from a practical standpoint, that itself frequently is not enough,” Hong said, adding that usually by the time patients see doctors they have already failed at achieving results through those means.

Hong understands why Medicaid programs, as well as private providers, want to cut back on covering the drugs, which can cost per patient per year. However, they can produce twice the weight loss as the medications typically used previously, he said.

A school of medical thought supports patients’ gradually ending their use, but Hong said obesity is generally considered a chronic condition that requires indefinite treatment.

“Once they reach their target weight, a lot of people will try to see whether or not they can wean off,” Hong said. “We do see a lot of patients — when they try to get off, unfortunately, then the weight comes back.”

Medi-Cal members under age 21 for purposes including weight loss, California officials said, citing a federal requirement.

Medi-Cal members are able to keep their GLP-1 coverage if they can demonstrate it is medically necessary for purposes other than weight loss, the department said. Members who are denied coverage can seek a hearing, the department said in to members.

Members will still be able to pay for the prescriptions and may be able to use various discounts to lower costs. Another option is new pills to treat obesity, which will be cheaper than their injectable counterparts. The a pill version of Wegovy on Dec. 22, which will likely run $149 per month for the lowest dosage, and similar weight loss pills are expected to be available in the first half of the year.

While Cardenas said his husband, Jeffer Jimenez, 37, uses GLP-1s primarily for weight loss, Jimenez’s prescription is for his diabetes, so the couple hoped to continue receiving coverage through Medi-Cal.

“He tried a thousand medications, pills, natural teas, exercise program, but it doesn’t work like the injections,” Cardenas said. “You need both.”

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Or, you’ve completed a couple of weeks in rehab. Can you handle your complicated medication regimen, along with shopping and cooking?

Perhaps you fell in the shower, and now your family wants you to arrange help with bathing and getting dressed.

There are facilities that provide such help, of course, but most older people don’t want to go there. They want to stay at home; that’s the problem.

When older people struggle with daily activities because they have grown frail, because their chronic illnesses have mounted, or because they have lost a spouse or companion, most don’t want to move. For decades, surveys have shown that for as long as possible.

That means they need home care, either from family and friends, paid caregivers, or both. But paid home care represents an especially strained sector of the long-term care system, which is experiencing an intensifying labor shortage even as an aging population creates surging demand.

“It’s a crisis,” said Madeline Sterling, a primary care doctor at Weill Cornell Medicine and the director of Cornell University’s . “It’s not really working for the people involved,” whether they are patients (who can also be younger people with disabilities), family members, or home care workers.

“This is not about what’s going to happen a decade from now,” said Steven Landers, chief executive of the National Alliance for Care at Home, an industry organization. “Do an Indeed.com search in Anytown, USA, for home care aides, and you’ll see so many listings for aides that your eyes will pop out.”

Against this grim backdrop, however, some alternatives show promise in upgrading home care jobs and in improving patient care. And they’re growing.

Some background: Researchers and elder care administrators have warned about this approaching calamity for years. Home care is already among the nation’s fastest-growing occupations, with 3.2 million home health aides and personal care aides on the job in 2024, up from 1.4 million a decade earlier, , a research and advocacy group.

But the nation will need about 740,000 additional home care workers over the next decade, , and recruiting them won’t be easy. Costs to consumers are high — the median hourly rate for a home health aide in 2024 was $34, shows, with big geographic variations. But an aide’s median hourly wage .

These remain unstable, low-paying jobs. Of the largely female workforce, about a third of whom are immigrants, 40% live in low-income households and most receive some sort of public assistance.

Even if the agencies that employ them offer health insurance and they work enough hours to qualify, many cannot afford their premium payments.

Unsurprisingly, the turnover rate approaches 80% annually, according to , a nonprofit organization that promotes co-ops.

But not everywhere. One innovation, still small but expanding: home care cooperatives owned by the workers themselves. The first and largest, Cooperative Home Care Associates in the Bronx borough of New York City, began in 1985 and now employs about 1,600 home care aides. The ICA Group now counts 26 such worker-owned home care businesses nationwide.

“These co-ops are getting exceptional results,” said Geoffrey Gusoff, a family medicine doctor and health services researcher at UCLA. “They have half the turnover of traditional agencies, they hold onto clients twice as long, and they’re paying $2 more an hour” to their owner-employees.

When Gusoff and his co-authors interviewed co-op members for in JAMA Network Open, “we were expecting to hear more about compensation,” he said. “But the biggest single response was, ‘I have more say’” over working conditions, patient care, and the administration of the co-op itself.

“Workers say they feel more respected,” Gusoff said.

Through an initiative to provide financing, business coaching, and technical assistance, the ICA Group intends to boost the national total to 50 co-ops within five years and to 100 by 2040.

Another approach gaining ground: registries that allow home care workers and clients who need care to connect directly, often without involving agencies that provide supervision and background checks but also absorb roughly half the fee consumers pay.

One of the largest registries, . Established through agreements with the Service Employees International Union, the nation’s largest health care union, it serves 40,000 providers and 25,000 clients. (About 10% of home care workers are unionized, according to PHI’s analysis.)

Carina functions as a free, “digital hiring hall,” said Nidhi Mirani, its chief executive. Except in the Seattle area, it serves only clients who receive care through Medicaid, the largest funder of care at home. State agencies handle the paperwork and oversee background checks.

Hourly rates paid to independent providers found on Carina, which are set by union contracts, are usually lower than what agencies charge, while workers’ wages start at $20, and they receive health insurance, paid time off, and, in some cases, retirement benefits.

may be operated by states, as in Massachusetts and Wisconsin, or by platforms like , available in four states. “People are seeking a fit in who’s coming into their homes,” Mirani said. “And individual providers can choose their clients. It’s a two-way street.”

Finally, recent studies indicate ways that additional training for home care workers can pay off.

“These patients have complex conditions,” Sterling said of the aides. Home care workers, who take blood pressure readings, prepare meals, and help clients stay mobile, can spot troubling symptoms as they emerge.

Her team’s recent clinical trial of home health — “the No. 1 cause of hospitalization among Medicare beneficiaries,” Sterling pointed out — measured the effects of a 90-minute virtual training module about its symptoms and management.

“Leg swelling. Shortness of breath. They’re the first signs that the disease is not being controlled,” Sterling said.

In the study, involving 102 aides working for VNS Health, a large nonprofit agency in New York, the training was shown to enhance their knowledge and confidence in caring for clients with heart failure.

Moreover, when aides were given a mobile health app that allowed them to message their supervisors, they made fewer 911 calls and their patients made fewer emergency room visits.

Small-scale efforts like registries, co-ops, and training programs do not directly address home care’s most central problem: cost.

Medicaid underwrites home care for low-income older adults who have few assets, though the Trump administration’s new budget by more than $900 billion over the next decade. The well-off theoretically can pay out-of-pocket.

But “middle-class retired families either spend all their resources and essentially bankrupt themselves to become eligible for Medicaid, or they go without,” Landers said. Options like assisted living and nursing homes are even more expensive.

The United States has never committed to paying for long-term care for the middle class, and it seems unlikely to do so under this administration. Still, savings from innovations like these can reduce costs and might help expand home care through federal or state programs. Several tests and pilots are underway.

Home care workers “have a lot of insight into patients’ conditions,” Sterling said. “Training them and giving them technological tools shows that if we’re trying to keep patients at home, here’s a way to do that with the workforce that’s already there.”

The New Old Age is produced through a partnership with .

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This story can be republished for free (details).