LISTEN: Quashing innovation or risking a patient’s health? Lauren Sausser told WAMU’s Health Hub on April 15 why the White House and some states are at odds over how to regulate AI in health care.

Speed, efficiency, and lower costs. Those are the traits artificial intelligence supporters celebrate. But the same qualities worry physicians who fear the technology could lead to insurance denials with humans left out of the loop.

With scant federal regulation, states are left to shape the rules on AI in health care. For residents in the Washington, D.C., metropolitan area, a divide is playing out on opposite sides of the Potomac River. Maryland and Virginia have taken very different approaches to regulating AI in health insurance.

ºÚÁϳԹÏÍø News correspondent Lauren Sausser joined WAMU’s Health Hub on April 15 to explain why where you live may determine how much of a role AI plays in your coverage.

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The federal government doesn’t track how many children have entered foster care because of immigration enforcement actions, leaving it unclear how often it happens. In Oregon, as of February two children had been placed in foster care after being separated from their parents in immigration detention cases, according to Jake Sunderland, a spokesperson for the Oregon Department of Human Services.

“Before fall 2025, this simply had never happened before,” Sunderland said.

As of mid-February, nearly by Immigration and Customs Enforcement. The record 73,000 people in detention in January represented an compared with one year before. According to , parents of 11,000 children who are U.S. citizens were detained from the beginning of Trump’s term through August.

The news outlet NOTUS that at least 32 children of detained or deported parents had been placed in foster care in seven states.

Sandy Santana, executive director of Children’s Rights, a legal advocacy organization, said he thinks the actual number is much higher.

“That, to us, seems really, really low,” he said.

Separation from a parent is deeply traumatic for children and can lead to , including post-traumatic stress disorder. Prolonged, intense stress can lead to more-frequent infections in children and developmental issues. That “toxic stress” is also associated with responsible for learning and memory, according to KFF.

, and amended existing laws during Trump’s first term to allow guardians to be granted temporary parental rights for immigration enforcement reasons. Now the enforcement surge that began after Trump returned to office last year has prompted a new wave of state responses.

In New Jersey, lawmakers are considering to amend a state law that allows parents to nominate standby, or temporary, guardians in the cases of death, incapacity, or debilitation. The bill would add separation due to federal immigration enforcement as another allowable reason.

Nevada and California passed laws last year to protect families separated by immigration enforcement actions. California’s law, called the , allows parents to nominate guardians and share custodial rights, instead of having them suspended, while they’re detained. They regain their full parental rights if they are released and are able to reunite with their children.

There are significant legal barriers to reunification once a child is placed in state custody, said Juan Guzman, director of children’s court and guardianship at the Alliance for Children’s Rights, a legal advocacy organization in Los Angeles.

If a parent’s child is placed in foster care and the parent cannot participate in required court proceedings because they are in detention or have been deported, it’s less likely they will be able to reunite with their child, Guzman said.

are U.S. citizens who live with a parent or family member who does not have legal immigration status, according to research from the Brookings Institution, a Washington, D.C.-based think tank. Within that group, 2.6 million children have two parents lacking legal status.

Santana said he expects the number of family separation cases to grow as the Trump administration continues its immigration enforcement campaign, putting more children at risk of being placed in foster care.

the agency to make efforts to facilitate detained parents’ participation in family court, child welfare, or guardianship proceedings, but Santana said it’s uncertain whether ICE is complying with those rules.

ICE officials did not respond to requests for comment for this report.

Before the change in California’s law, the only way a parent could share custodial rights with another guardian was if the parent was terminally ill, Guzman said.

If parents create a preparedness plan and identify an individual to assume guardianship of their children, the state child welfare agency can begin the process of placing the children with that individual without opening a formal foster care case, he added.

While Nevada lawmakers expanded an existing guardianship law last year to include immigration enforcement, the measure requires the parents to take the additional step of filing notarized paperwork with the secretary of state’s office, said Cristian Gonzalez-Perez, an attorney at Make the Road Nevada, a nonprofit that provides resources to immigrant communities.

Gonzalez-Perez said some immigrants are still hesitant to fill out government forms, out of fear that ICE might access their information and target them. He reassures community members that the state forms are secure and can be accessed only by hospitals and courts.

The Trump administration has taken through the Centers for Medicare & Medicaid Services, the IRS, the Supplemental Nutrition Assistance Program, the Department of Housing and Urban Development, and other entities.

Gonzalez-Perez and Guzman said that not enough immigrant parents know their rights. Nominating a temporary guardian and creating a plan for their families is one way they can prevent feelings of helplessness, Gonzalez-Perez said.

“Folks don’t want to talk about it, right?” Guzman said. “The parent having to speak to a child about the possibility of separation, it’s scary. It’s not something anybody wants to do.”

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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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But seven months later, findings from five states shared with ºÚÁϳԹÏÍø News show that the reviews have uncovered little evidence of a widespread problem.

Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, which covers health care costs for people with low incomes and disabilities, and the closely related Children’s Health Insurance Program. Both programs are administered by states.

Spokespeople from Pennsylvania’s and Colorado’s Medicaid agencies said, as of March, the states had found no one who needed to be terminated from Medicaid. That was after checking a combined 79,000 names.

Texas has reviewed records of more than 28,000 Medicaid enrollees at the Trump administration’s request and terminated coverage for 77 of them, according to Jennifer Ruffcorn, a spokesperson for the Texas Department of Human Services.

Ohio has checked 65,000 Medicaid enrollees, of which 260 people were disenrolled from the program, said Stephanie O’Grady, a spokesperson for the Ohio Department of Medicaid.

In Utah, 42 of the 8,000 enrollees identified by the Trump administration had their Medicaid coverage terminated, said Becky Wickstrom, a spokesperson for the state’s Department of Workforce Services.

In announcing the reviews, Health and Human Services Secretary Robert F. Kennedy Jr. said: “We are tightening oversight of enrollment to safeguard taxpayer dollars and guarantee that these vital programs serve only those who are truly eligible under the law.”

Leonardo Cuello, a research professor at Georgetown University’s Center for Children and Families, said the reviews ordered by the federal Centers for Medicare & Medicaid Services were unneeded because states check immigration status when people sign up.

“It is entirely predictable that all of these burdensome reviews that the federal government is forcing upon states would yield no pay dirt,” Cuello said. “The states had already done the reviews once, and CMS was just making them reverify the same information they had already checked. Making states go through the same bureaucratic process twice is incredibly wasteful and inefficient.”

CMS spokesperson Chris Krepich said in a statement to ºÚÁϳԹÏÍø News that the ongoing checks are verifying eligibility “for certain enrollees whose status could not be confirmed through federal data sources.”

“CMS provides states with regular reports for follow-up review, and states are responsible for independently verifying eligibility and taking appropriate action consistent with federal requirements,” he said.

But the findings shared with ºÚÁϳԹÏÍø News also suggest that many of the enrollees whose eligibility the Trump administration said it could not confirm are indeed U.S. citizens. O’Grady said Ohio found that, of the 65,000 names referred by the federal government, the state already had information on 53,000 confirming them as citizens and an additional 11,000 showing appropriate immigration status for Medicaid.

Caseworkers then worked on the remaining 1,000 names to review their information or reach out for more details, she said.

CMS did not answer questions about the findings from the states sampled by ºÚÁϳԹÏÍø News or provide information about responses it received from all 50 states and the District of Columbia, which were instructed to perform verification checks.

The agency also did not respond to a question about whether it’s forwarding the names of those whose Medicaid coverage was terminated to federal immigration officials.

In June, advisers to Kennedy ordered CMS to share information about Medicaid enrollees with the Department of Homeland Security, prompting a lawsuit by some states alarmed that the administration would use the information for its deportation campaign against residents living in the U.S. without authorization.

A federal judge that Immigration and Customs Enforcement workers could access information only about people in the country unlawfully in the Medicaid databases of the states that sued.

CMS continues to send states lists of names at least every few months, though state officials say the numbers have declined since the first batch last summer.

People without legal status are ineligible for federally funded health coverage, including Medicaid, Medicare, and plans through the Affordable Care Act marketplaces. Medicaid does reimburse hospitals for providing emergency care to people without legal status if they meet income and other program requirements.

Seven states and the District of Columbia provide health coverage regardless of immigration status, funding the programs with their own money.

In March 2025, CMS began financial reviews of those programs. “CMS has identified over $1.8 billion in federal funds that are being recouped through voluntary returns and deferrals of future federal Medicaid payments,” Krepich said. He did not answer how much has been collected so far or from which states.

Medicaid’s overall spending topped $900 billion in fiscal year 2024.

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“I have these conversations with children starting at 8, 10, 12 years old: What do you want to be when you grow up?” Duane said. If you’re a child who wants to be a doctor, for instance, “there are things you need to put in place. If you hope to have children one day, there are things that you need to consider and have the conversation early.”

The proposal from Duane, a specialist in who is affiliated with the anti-abortion Charlotte Lozier Institute, got a warm reception from the audience gathered for the Trump administration’s inaugural .

The three-day event hosted by the Department of Health and Human Services last week was designed to “explore breakthroughs in research, prevention, diagnosis, and treatment of health conditions that affect women across the lifespan.” Government officials hosted an eclectic mix of wealthy philanthropists, alternative medicine influencers, health tech executives, and medical researchers to discuss a wide range of issues, from Lyme disease to gut health.

Seeking to reach women at a moment when President Donald Trump’s among a key voting bloc, the Make America Healthy Again movement, the administration-sponsored event elevated perspectives outside conventional standards of medical care and counter to many women’s health choices.

For example, during a 40-minute panel hosted by Alexis Joel, the wife of musician Billy Joel, several doctors raised concerns about how frequently hormonal birth control is used to treat women’s health symptoms. Two female physicians on the panel said they were uncomfortable with the idea of using birth control pills for their own treatment, noting that their “values” or “cultural perspective” did not align with use of the medication.

Nearly a third of U.S. women ages 18 to 49 report having used birth control pills in the previous 12 months, according to a . In addition to their use as a contraceptive, the pills are prescribed for , including preventing anemia from heavy periods and treating uterine fibroids.

Joel, who has about her experience with endometriosis, brought her own doctor, Tamer Seckin, to discuss the common, painful condition, in which thick tissue develops outside of the uterus. Seckin said women’s concerns about menstrual pain are often dismissed by doctors, leading to missed diagnoses.

Asima Ahmad, a doctor who specializes in fertility and co-founded Carrot, a company that offers job-based fertility benefits, offered another explanation for why the disease is overlooked.

“As providers, we should learn how to treat it, rather than covering it up with birth control pills or progesterone,” she said.

Hormonal birth control pills, which help slow the growth of new tissue, are for treating endometriosis, according to the American College of Obstetricians and Gynecologists.

Andrea Salcedo, a California OB-GYN on the panel who said she has endometriosis as well, said she declined birth control as a treatment. She noted her decision aligned with her “values,” in particular her desire to have more children.

“Is this all that we can do?” Salcedo said of being offered birth control.

Salcedo said she prescribes alternative treatments to her patients because she believes the root cause of infertility is directly related to gut health. Cod liver oil and vitamin A top her list, she said.

whether there is an association between vitamin deficiencies and endometriosis. Taking too much vitamin A can cause health problems, including if taken while pregnant.

Those supplements have been touted by HHS Secretary Robert F. Kennedy Jr. — including, falsely, as during an outbreak in Texas last year.

About a quarter of U.S. adults wrongly believe vitamin A can prevent measles infections, according to a .

The panel also coalesced around the idea that a lack of knowledge is the root problem: Girls do not receive enough education on how to become pregnant or identify the warning signs of infertility, the doctors suggested.

Education has become too hyperfocused on preventing pregnancy, Ahmad said.

“I was in junior high, and I was learning about trying not to get pregnant, and I was scared that if I sit in a room with a guy alone, I will,” she said. “They put all of this fear into it, but family planning isn’t just about preventing pregnancy. It’s about learning about how to build your family.”

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It’s all part of a drama that roiled the ACA’s 2026 open enrollment period. Congressional debate over whether to extend more generous subsidies made available under the Biden administration led to and focused public attention on rising health care costs and the affordability issue.

The enhanced subsidies, which expanded eligibility both by lowering the percentage of household income people had to pay toward their care and removing an income cap, expired at the end of last year. As a result, just about everyone buying ACA coverage saw their costs increase. For some, what they paid toward premiums doubled or more, even though less generous subsidies remain in place.

Many experts expected ACA enrollment, which hit a record 24 million in 2025, to fall this time around.

“If you raise the price of something a whole lot, economics tell us that a lot of people will buy less of it or not buy at all,” said Katherine Hempstead, a senior policy officer with the Robert Wood Johnson Foundation.

Here are things to watch now:

Initial Numbers Aren’t Final

The in December 2024 that not extending the enhanced subsidies would cause 2.2 million people to lose insurance in 2026, with further increases in following years. Analysts with the Wakely Consulting Group would opt out of insurance for this year.

Data released Jan. 28 by federal officials showed a year-over-year enrollments across the federal healthcare.gov marketplace and those run by states. Overall, there were 23 million enrollees, including 3.4 million new to ACA coverage.

At about the same time last year, there were , with 3.9 million new to the marketplaces.

But there’s more to it than those initial numbers.

For one thing, both years’ data was pegged to Jan. 15 for the federal marketplace, which closed its open enrollment period that day. But, the data for the states that run their own marketplaces included sign-ups in most cases only through Jan. 10 or 11, even though some held open enrollment until the . Thus, the numbers don’t reflect what might have happened in those last days. Was there a surge in state sign-ups? Or, conversely, did the marketplaces see more enrollees cancel their coverage?

Additionally, those initial numbers are a mix of newly minted ACA enrollees and existing customers, many of whom were auto-reenrolled for 2026 — which raises other issues.

For existing, reenrolled policyholders, the real figures won’t be known for weeks or months, when it becomes clear how many actually pay their premiums. Some consumers may not have focused on their reenrollment costs or may have hoped Congress would extend the subsidies.

That’s an important factor to keep in mind because the CBO and Wakely estimates of millions losing insurance were based on projections for full-year coverage, not initial sign-ups.

In the coming weeks, “consumers may find they really can’t afford the premiums and cancel their plans, while carriers may also cancel coverage for nonpayment,” said Pat Kelly, executive director of Your Health Idaho, a state-based ACA marketplace, during a Jan. 22 call with reporters.

Sharp Differences in State Enrollment Patterns

Changes are also afoot in the 19 other states (and the District of Columbia) that , some of which have issued more detailed data about enrollment than the federal marketplace.

Most states saw lower enrollment for 2026 than the prior year, with the biggest drop in North Carolina, where sign-ups fell by nearly 22%, federal data shows.

In a few states — including New Mexico, Texas, California, and Maryland, as well as the District of Columbia — the number of people selecting ACA plans increased.

The jump was largest in New Mexico, with its initial number of people selecting plans up by nearly 14%. Increases were in the single digits in the other states and Washington, D.C.

New Mexico — uniquely — used its own tax dollars to fully offset the loss of the more generous federal tax subsidies for all consumers. , including California, Colorado, Maryland, and Washington, used state money to help some enrollees.

The , a collective of 22 state marketplaces supported by the National Academy for State Health Policy, said initial enrollment figures . Compared with the same time last year, outright plan cancellations are up 83% in Colorado, disenrollments are four times what they were in Idaho, and Virginia has seen cancellations double.

New enrollments are from the same period last year, according to data from the state. In Pennsylvania, people ages 55 to 64, the group with the highest premiums, and young people 26 to 34 in higher numbers than other age groups, state data shows.

“We have drastically higher rates of people dropping their coverage,” said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority. “We had 70,000 drop in the last two months, from early retirees to small-business owners to farmers not knowing how to make ends meet.”

On Feb. 9, Pennsylvania released , showing enrollment dropped by about 2% from last year, although that figure masks some of the effects. The state says nearly 18% of enrollees dropped coverage altogether, with older and rural residents being the most likely to fall out.

Some Republicans credited Trump-administration-backed anti-fraud measures, which included a range of , for tightening the system. Although some of those actions were paused by a federal court and have not taken effect, those ACA critics, some of whom have produced that millions may have been improperly enrolled, say that’s behind the decline. They have previously for unauthorized enrollments or ACA plan-switching by commission-seeking brokers.

States that run their own ACA marketplaces, however, reported little or no such unauthorized switching. Relative to the federal marketplace, the state-based ACA platforms employ additional safeguards to prevent brokers from accessing consumers’ coverage without authorization.

Among consumers not returning to the marketplace, the main reason is cost, said Mila Kofman, executive director of the DC Health Benefit Exchange Authority, which runs the district’s ACA marketplace.

“When we looked at who these folks are, half are small-business owners,” Kofman said. “They are not folks committing fraud.”

Lower Premiums, Higher Deductibles

Rather than sticking with automatic reenrollment, existing customers in many states shifted sharply into lower-priced “bronze” plans that come with higher deductibles than silver, gold, and platinum plans.

California saw 73% of renewing members who switched plans move to a bronze plan, up from 27% at the same time last year, the State Marketplace Network reported. In Maine, bronze enrollment now represents almost 60% of all plans purchased.

People are “looking at what works in their monthly budget, looking for that lower premium,” said Stacey Pogue, a senior research fellow at the Center on Health Insurance Reforms at Georgetown University. “Some might be crossing their fingers that they won’t need to meet their deductible.”

On average, bronze plans have an . All ACA plans are required to cover certain preventive services — such as some vaccinations, cancer screenings, and other tests — without a copayment or deductible, but most everything else is covered only after an annual deductible is met.

High deductibles can lead some patients to avoid seeking medical care, Hempstead said.

“People are terrified to use their care,” she said. “They may delay something until it’s more serious.”

She added that medical providers, including hospitals and doctors, are bracing for an increase in the number of insured patients who can’t afford to pay their deductibles.

“Everyone is anticipating that hospitals will have to give out more charity care, which will hurt their bottom lines and might lead them to have to lay off people or close or reduce services,” she said.

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

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

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

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

“Police want us out of the way,” he said, dressed in a gray jacket and carrying none of his possessions. “Out of sight, out of mind.”

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

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

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

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

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

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

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

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

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

The Homeless Shuffle

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Worsening Health Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Centers for Medicare & Medicaid Services is scouring payments covering health care for immigrants without legal status to ensure there isn’t any waste, fraud, or abuse, according to public records obtained by ºÚÁϳԹÏÍø News and The Associated Press. While acknowledging that states can bill the federal government for Medicaid emergency and pregnancy care for immigrants without legal status, federal officials have sent letters notifying state health agencies in California, Colorado, Illinois, Minnesota, Oregon, and Washington that they are reviewing federal and state payments for medical services such as prescription drugs and specialty care.

The federal agency told the states it is reviewing claims as part of its commitment to maintain Medicaid’s fiscal integrity. California is the biggest target after the state self-reported overcharging the federal government for health care services delivered to immigrants without legal status, determined to be at least $500 million, spurring the threat of a lawsuit.

“If CMS determines that California is using federal money to pay for or subsidize healthcare for individuals without a satisfactory immigration status for which federal funding is prohibited by law,” according to a letter dated March 18, “CMS will diligently pursue all available enforcement strategies, including, consistent with applicable law, reductions in federal financial participation and possible referrals to the Attorney General of the United States for possible lawsuit against California.”

The investigations come as the White House and a Republican-controlled Congress slashed taxpayer spending on immigrant health care in President Donald Trump’s spending-and-tax law passed this summer. The administration is also living in the U.S. without authorization off Medicaid rolls. Health policy experts say these moves could hamper care and leave safety net hospitals, clinics, and other providers . Some Democratic-led states — — have already had to end or slim down their Medicaid programs for immigrants due to ballooning costs. Colorado is also considering cuts due to cost overruns.

At the same time, 20 states are pushing back on Trump’s immigration crackdown the administration for on millions of enrollees to deportation officials. A federal judge the move. California’s attorney general, Rob Bonta, who led that challenge, says the Trump administration is launching a political attack on states that embrace immigrants in Medicaid programs.

“The whole idea that there’s waste, fraud, and abuse is contrived,” Bonta said. “It’s manufactured. It’s invented. It’s a catchall phrase that they use to justify their predetermined anti-immigrant agenda.”

Trump Targets Immigrants

Immigrants lacking permanent legal status are not eligible to enroll in comprehensive Medicaid coverage. However, states bill the federal government for emergency and pregnancy care provided to anyone.

Fourteen states and Washington, D.C., expanded their Medicaid programs with their own funds to cover low-income children without legal status. Seven of those states, plus Washington, D.C., have also provided full-scope coverage to some adult immigrants living in the country without authorization.

The Trump administration appears to be targeting only states with full Medicaid coverage for both kids and adults without legal status. Utah, Massachusetts, and Connecticut, which provide Medicaid coverage , have not received letters, for instance. CMS declined to provide a full list of states it is targeting.

Federal officials say it is their legal right and responsibility to scrutinize states for misspending on immigrant health coverage and are taking “decisive action to stop that.”

“It is a matter of national concern that some states have pushed the boundaries of Medicaid law to offer extensive benefits to individuals unlawfully present in the United States,” CMS spokesperson Catherine Howden said about the agency’s probe of selected states. The oversight is intended to “ensure federal funds are reserved for legally eligible individuals, not for political experiments that violate the law,” she said.

Health policy researchers and economists say providing Medicaid coverage to immigrants for preventive services and treatment of chronic health conditions staves off more costly care for patients down the road. It also tamps down insurance premium increases and the amount of uncompensated care for hospitals and clinics.

Francisco Silva, president and CEO of the , said the Trump administration is threatening to drive up health care costs and make it more difficult to access care.

“The impact is emergency rooms would get so crowded that ambulances have to be diverted away and people in a real emergency can’t get into the hospital, and public health threats like disease outbreaks,” Silva said.

California has taken a approach, providing coverage to 1.6 million immigrants without legal status. The expansion, which was rolled out from 2016 to 2024, is estimated to cost $12.4 billion this year. Of that, $1.3 billion is paid by the federal government for emergency and pregnancy-related care.

As California rolled out its expansion, the state erroneously billed the federal government for care provided to immigrants without legal status — details that have not previously been reported and that former state officials shared with ºÚÁϳԹÏÍø News and the AP. The state improperly billed for services such as mental health and addiction services, prescription drugs, and dental care.

Jacey Cooper, who served as California’s Medicaid director from 2020 to 2023, said she discovered the error and reported it to federal regulators. Cooper said the state had been working to pay back at least $500 million identified by the federal government.

“Once I identified the problem, I thought it was really important to report it and we did,” Cooper said. “We take waste, fraud, and abuse very seriously.”

It’s not clear whether that money has been repaid. The state’s Medicaid agency says it does not know how CMS calculated the overpayments or “what is included in that amount, what time period it covers, and if or when it was collected,” said spokesperson Tony Cava.

California has an enormously complicated Medicaid program: It serves the largest population in the nation — nearly — with a budget of nearly this fiscal year.

Matt Salo, a national Medicaid expert, said these types of mistakes happen in states throughout the country because the program is rife with overlapping federal and state rules. Salo and other policy analysts agreed that states have the authority to administer their Medicaid programs as they see fit and root out misuse of federal funds.

And Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Trump administration’s actions “persecute a minority that’s unpopular with the powers that be.”

“The Trump administration cannot maintain that this effort has anything to do with maintaining the fiscal integrity of the Medicaid program,” Cannon said. “There are so much bigger threats to Medicaid’s fiscal integrity, that that argument just doesn’t wash.”

Immigrants’ Medicaid Under Attack

National Republicans have targeted health spending on immigrants in different ways. The GOP spending law, which Trump calls the “One Big Beautiful Bill,” will lower reimbursement to states in October 2026. In California, for example, federal reimbursement for immigrants without legal status will go to 50% for emergency services, down from 90% for the Medicaid expansion population, according to Cava.

The Trump administration is also scaling back Medicaid coverage to immigrants with temporary legal status who were previously covered and that it would provide states with monthly reports pointing out enrollees whose legal status could not be confirmed by the Department of Homeland Security.

“Every dollar misspent is a dollar taken away from an eligible, vulnerable individual in need of Medicaid,” CMS Administrator Mehmet Oz said in a statement. “This action underscores our unwavering commitment to program integrity, safeguarding taxpayer dollars, and ensuring benefits are strictly reserved for those eligible under the law.”

States under review say they are following the law.

“Spending money on a congressionally authorized medical benefit program that helps people get emergency treatments for cancer, dialysis, and anti-rejection medications for organ transplants is decidedly not waste, fraud and abuse,” said Mike Faulk, deputy communications director for Washington state Attorney General Nick Brown.

Records show Washington Medicaid officials have been inundated with questions from CMS about federal payments covering emergency and pregnancy care for immigrants without legal status.

Emails show Illinois officials met with CMS and sought an extension to share its data. CMS denied that request and federal regulators told the state that its funding could be withheld.

“Thousands of Illinois residents rely on these programs to lawfully seek critical health care without fear of deportation,” said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services, noting that any federal cut would be “impossible” for the state to backfill.

Shastri reported from Milwaukee.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

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The Department of Health and Human Services in late March canceled nearly 700 Centers for Disease Control and Prevention grants nationwide — together worth about $11 billion. Awarded during the covid-19 pandemic, they supported efforts to vaccinate people, reduce health disparities among demographic groups, upgrade antiquated systems for detecting infectious disease outbreaks, and hire community health workers.

Initially, grant cancellations hit blue and red states roughly evenly. Four of the five jurisdictions with the largest number of terminated grants were led by Democrats: California, the District of Columbia, Illinois, and Massachusetts.

But after attorneys general and governors from about two dozen blue states sued in federal court and won an injunction, the balance flipped. Of the five states with the most canceled grants, four are led by Republicans: Texas, Georgia, Oklahoma, and Ohio.

In blue states, nearly 80% of the CDC grant cuts have been restored, compared with fewer than 5% in red states, according to the ºÚÁϳԹÏÍø News analysis. Grant amounts reported in an HHS database known as the Tracking Accountability in Government Grants System, or TAGGS, often don’t match what states confirmed. Instead, this analysis focused on the number of grants.

The divide is an example of the polarization that permeates health care issues, in which access to safety-net health programs, abortion rights, and the ability of public health officials to respond to disease threats diverge significantly depending on the political party in power.

In an emailed statement, HHS spokesperson Andrew Nixon said the agency “is committed to protecting the health of every American, regardless of politics or geography. These funds were provided in response to the COVID pandemic, which is long over. We will continue working with states to strengthen public health infrastructure and ensure communities have the tools they need to respond to outbreaks and keep people safe.”

The money in question wasn’t spent solely on covid-related activities, public health experts say; it was also used to bolster public health infrastructure and help contain many types of viruses and diseases, including the flu, measles, and RSV, or respiratory syncytial virus.

“It really supported infrastructure across the board, particularly in how states respond to public health threats,” said Susan Kansagra, chief medical officer of the Association of State and Territorial Health Officials.

The Trump cutbacks came as the U.S. recorded its largest measles outbreak in over three decades and 266 pediatric deaths during the most recent flu season — the outside of a pandemic since 2004. Public health departments canceled vaccine clinics, laid off staff, and put contracts on hold, health officials said in interviews.

After its funding cuts were blocked in court, California retained every grant the Trump administration attempted to claw back, while Texas remains the state with the most grants terminated, with at least 30. As the CDC slashed grants in Texas, its measles outbreak spread across the U.S. and Mexico, sickening at least 4,500 people and killing at least 16.

Colorado, which joined the lawsuit, had 11 grant terminations at first, but then 10 were retained. Meanwhile, its neighboring states that didn’t sue — Wyoming, Utah, Kansas, Nebraska, and Oklahoma — collectively lost 55 grants, with none retained.

In Jackson, Ohio, a half-dozen community health workers came to work one day in March to find the Trump administration had canceled their grant five months early, leaving the Jackson County Health Department half a million dollars short — and them without jobs.

“I had to lay off three employees in a single day, and I haven’t had to do that before. We don’t have those people doing outreach in Jackson County anymore,” Health Commissioner Kevin Aston said.

At one point, he said, the funding helped 11 Appalachian Ohio counties. Now it supports one.

Marsha Radabaugh, one employee who was reassigned, has scaled back her community health efforts: She’d been helping serve hot meals to homeless people and realized that many clients couldn’t read or write, so she brought forms for services such as Medicaid and the Supplemental Nutrition Assistance Program to their encampment in a local park and helped fill them out.

“We would find them rehab places. We’d get out hygiene kits, blankets, tents, zero-degree sleeping bags, things like that,” she said. As a counselor, she’d also remind people “that they’re cared for, that they’re worthy of being a human — because, a lot of the time, they’re not treated that way.”

Sasha Johnson, who led the community health worker program, said people like Radabaugh “were basically a walking human 411,” offering aid to those in need.

Radabaugh also partnered with a food bank to deliver meals to homebound residents.

Aston said the abrupt way they lost the funds — which meant the county unexpectedly had to pay unemployment for more people — could have ruined the health district financially. Canceling funding midcycle, he said, “was really scary.”

HHS Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist and promoter of vaccine misinformation, a “cesspool of corruption.” At HHS, he has taken steps to undermine vaccination in the U.S. and abroad.

Federal CDC funding accounts for of state and local health department budgets, according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. States that President Donald Trump won in the 2024 election received a higher share of the in fiscal 2023 than those that Democrat Kamala Harris won, according to KFF.

The Trump administration’s nationwide CDC grant terminations reflect this. More than half were in states that Trump won in 2024, totaling at least 370 terminations before the court action, according to ºÚÁϳԹÏÍø News’ analysis.

The Columbus, Ohio, health department had received $6.2 million in CDC grants, but roughly half of it — $3 million — disappeared with the Trump cuts. The city laid off 11 people who worked on investigating infectious disease outbreaks in such places as schools and nursing homes, Columbus Health Commissioner Mysheika Roberts said.

She also said the city had planned to buy a new electronic health record system for easier access to patients’ hospital records — which could improve disease detection and provide better treatment for those infected — but that was put on ice.

“We’ve never had a grant midcycle just get pulled from us for no reason,” Roberts said. “This sense of uncertainty is stressful.”

Columbus did not receive its money directly from the CDC. Rather, the state gave the city some funds it received from the federal government. Ohio, led by Republican Gov. Mike DeWine and a Republican attorney general, did not sue to block the funding cuts.

Columbus to keep its money, along with other Democratic-led municipalities in Republican-governed states: Harris County, Texas, home to Houston; the Metropolitan Government of Nashville and Davidson County in Tennessee; and Kansas City, Missouri. A federal judge in June blocked those cuts.

As of mid-August, Columbus was awaiting the funds. Roberts said the city won’t rehire staff because the federal funding was expected to end in December.

Joe Grogan, a senior scholar at the University of Southern California’s Schaeffer Institute and former director of the White House Domestic Policy Council in Trump’s first term, said state and local agencies “are not entitled” to the federal money, which was awarded “to deal with an emergency” that has ended.

“We were throwing money out the door the last five years,” Grogan said of the federal government. “I don’t understand why there would ever be a controversy in unspent covid money coming back.”

Ken Gordon, Ohio Department of Health spokesperson, wrote in an email that the $250 million in grants lost had helped with, among other things, upgrading the disease reporting system and boosting public health laboratory testing.

Some of the canceled HHS funding wasn’t slated to end for years, including four grants to strengthen public health in Indian Country, a grant to a Minnesota nonprofit focused on reducing substance use disorders, and a few to universities about occupational safety, HIV, tuberculosis, and more.

Brent Ewig, chief policy and government relations officer for the Association of Immunization Managers, said the cuts were “the predictable result of ‘boom, bust, panic, neglect’ funding” for public health.

The association represents 64 state, local, and territorial immunization programs, which Ewig said will be less prepared to respond to disease outbreaks, including measles.

“The system is blinking red,” Ewig said.

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Now, as Congress steamrolls toward passing historic Medicaid cuts of about through Trump’s tax and spending legislation, red-state governors are saying little publicly about what it does to health care — even as they face reductions that will punch multibillion-dollar holes in their states’ budgets.

Medicaid, a program jointly run by states and the federal government, covers more than 70 million low-income or disabled people, including nearly half of the nation’s children. Republicans say the $900 billion-a-year program was allowed to grow too large under Democrats Barack Obama and Joe Biden by adding nondisabled adults they say , and they have long sought to scale it back.

Some of the biggest health cuts in the legislation Trump calls the “One Big Beautiful Bill” are achieved through new policies that would reduce enrollment by imposing more paperwork demands on enrollees, including a requirement that many prove they’re working. Those policies would affect only states that expanded Medicaid to more low-income people under the Affordable Care Act.

Nineteen of those states are . Their silence on the bill’s health measures is giving political cover to GOP lawmakers from their states as they seek to cut Medicaid coverage for millions of people who gained it within the last decade.

ºÚÁϳԹÏÍø News contacted all 19 governors for comment on the legislation’s Medicaid cuts. Only six responded. Most said they backed imposing a work requirement on adult Medicaid enrollees.

“Implementing work requirements for able-bodied adults is a good and necessary reform so that Medicaid is being used for temporary assistance and not a permanent entitlement,” said Drew Galang, a spokesperson for Gov. Patrick Morrisey of West Virginia.

“Governor Rhoden supports workforce participation as a requirement of Medicaid expansion eligibility,” said Josie Harms, a spokesperson for South Dakota Gov. Larry Rhoden, adding that congressional lawmakers have the governor’s support: “South Dakota has an excellent federal delegation, and Governor Rhoden trusts them to fight for South Dakota’s priorities while delivering on President Trump’s promises.”

In a sign of how the political winds have changed, none of the governors said anything about another of the legislation’s significant cuts, to provider taxes — a tool that nearly all of their states use to help pay their share of Medicaid and gain additional funds from the federal government. That change is expected to cost states billions.

No Longer a Bipartisan Issue

In contrast to the radio silence from GOP governors, Democratic governors have campaigned against the megabill for weeks.

Pennsylvania Gov. Josh Shapiro posted that Trump and congressional Republicans were misleading Americans by saying they were cutting only waste, fraud, and abuse in Medicaid.

“They’re rushing to kick hundreds of thousands of Pennsylvanians off their healthcare — and lying about it,” he posted. “The damage this will do here in Pennsylvania and across America is staggering and will be felt for years to come.”

In New York, Gov. Kathy Hochul on July 1 charged that Trump’s legislation would devastate hospitals and could lead to more than 34,000 job cuts in her state.

“The collective impact of the GOP reconciliation bill in Washington, D.C., could force hospitals to curtail critically needed services such as maternity care and psychiatric treatment, not to mention to downsize operations, and even close entirely,” she said .

In 2017, the chorus was bipartisan, as Republican governors in , , and spoke out against cutting Medicaid. Trump’s bill to repeal much of the Affordable Care Act and roll back its Medicaid expansion narrowly failed in the Senate.

“It’s been surprising that red-state governors, particularly those in Medicaid expansion states, haven’t spoken out against Medicaid cuts,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. “Republican governors were a potent political force in the failed 2017 effort to repeal and replace the ACA, including Medicaid expansion.”

What’s changed since 2017, policy experts say, is that there are fewer moderate Republican governors, and GOP state executives who advocated for Medicaid expansion over a decade ago are no longer in office.

Additionally, seven of the then-red states that expanded Medicaid , mostly over opposition from their governors.

In fact, the Medicaid work requirement is backed by many Republican governors, even if it means less federal Medicaid money and leads to fewer people covered.

Several states, including Arkansas and Ohio, have already passed state laws to implement a requirement that adults enrolled under the ACA’s Medicaid expansion work, volunteer, go to school, or participate in job training. Most states have yet to bring work requirement programs to fruition because they are waiting for federal government approval.

Charles “Chip” Kahn, president of the Federation of American Hospitals, a trade group of investor-owned hospitals, said that while fewer governors have engaged publicly in trying to block Medicaid cuts under the bill, federal lawmakers are hearing from legislators in their states.

A political dilemma for Republican governors is that, unlike in 2017, the bill before Congress is not legislation aimed expressly at repealing Obamacare. With a scope broader than health care, it would extend many of Trump’s tax cuts and direct billions in new spending toward border security, immigration enforcement, and the military, while also cutting health care spending.

“It’s like playing multidimensional chess rather than focusing on one issue,” Kahn said.

, director of the Center for the Study of Politics and Governance at the University of Minnesota, said some Republican governors may have expressed concerns privately to their states’ GOP senators but are not speaking out publicly for fear of drawing Trump’s wrath.

“Why are they being cagey? Trump and not wanting to be ‘Liz Cheney’d,’” Jacobs said, referring to the Republican former Wyoming lawmaker whom Trump helped oust after she served as vice chair of an inquiry into his attempts to overturn the results of the 2020 election.

Walking Political Tightropes

The political peril Republican lawmakers face in publicly challenging Trump remains explicit. On June 29, Sen. Thom Tillis (R-N.C.) announced he would not run for reelection after he voiced concerns about the bill and the president threatened to back a primary challenger. Tillis was one of three GOP senators to vote against it on July 1, though it still narrowly passed.

In addition to the work requirement, the biggest Medicaid cuts in the bill stem from its restrictions on provider taxes — levies that states impose on hospitals, nursing homes, and other health care institutions to help increase their federal reimbursement. Much of the additional money is then returned to the health care providers in the form of higher payments for their Medicaid patients.

The practice, which has been adopted in every state but Alaska, has been criticized by some Beltway Republicans as “money laundering” — even though the taxes are approved by state lawmakers and the federal Centers for Medicare & Medicaid Services and have been allowed under federal law for decades.

The Senate bill would limit the money states could raise — a move that would mean billions in funding cuts to states and their hospitals.

The states with Republican governors that expanded Medicaid are Alaska, Arkansas, Idaho, Indiana, Iowa, Louisiana, Missouri, Montana, Nebraska, New Hampshire, Nevada, North Dakota, Ohio, Oklahoma, South Dakota, Vermont, Virginia, West Virginia, and Utah.

One of the governors who expressed concerns about repealing the Obamacare Medicaid expansion in 2017 was Jim Justice of West Virginia, a Democrat at the time.

In a to West Virginia Sen. Shelley Moore Capito, a Republican, Justice wrote: “Since so many of our people count on Medicaid, any cut to Medicaid would destroy families in West Virginia.” He added that “the consequences would be beyond catastrophic.”

On July 1, Justice — elected to the Senate as a Republican last year — voted for Trump’s megabill, including its Medicaid cuts.

“The Senator believes this bill strikes a good balance between protecting the most vulnerable and those who rely on the program while rooting out waste, fraud, and abuse to ensure the program is run efficiently for those deserving,” William O’Grady, a Justice spokesperson, said in an email July 2.

ºÚÁϳԹÏÍø News correspondent Arielle Zionts contributed to this report.

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