Medicaid Archives - ��ϳԹ�� News

AI Is Being Used to Boost Medicaid Enrollment, but Not Without Concerns

Mark Kreidler — Tue, 04 Aug 2026 09:00:00 +0000

Vanessa Barahona received a call this past spring from Angelica at Kern Family Health Care in Bakersfield, California, telling her it was time to renew her coverage under Medi-Cal, the state’s version of Medicaid.

Angelica helped Barahona, 41, schedule an appointment to complete her paperwork in person at Kern Family’s offices before she submitted it to Kern County officials for approval. When Barahona had a conflict with her office-cleaning job, Angelica rescheduled the appointment. Barahona finished the process a little later than she’d planned but early enough to avoid an interruption in her coverage.

“It was easy. The fact that Angelica spoke Spanish when we were on the phone made it better,” Barahona, whom ��ϳԹ�� News met through Kern Family Health Care, said via a translator. “It felt like I was talking to a real person.”

She definitely wasn’t.

“Angelica” is the name assigned to an AI program deployed last year by Kern Family Health Care, the largest provider of Medi-Cal services in Kern County. An estimated 52% of residents there rely on the safety net program for health coverage, among the highest enrollment rates in the state.

Kern Family has spent about $370,000 on the software , a San Francisco startup, to facilitate rapid and repeated outreach to members when it’s time to renew their coverage — a process that is about to become more complex under new Medicaid eligibility rules established under Republicans’ One Big Beautiful Bill Act, signed into law last year by President Donald Trump. Mandatory work requirement documentation will take effect nationally beginning in 2027, and under the GOP’s new rules, most Medicaid patients will now have to renew their enrollment twice a year, rather than once a year.

Kern Family and other similar health plans have an interest in keeping people enrolled, since they’re paid through managed care contracts with Medi-Cal. They can also save money by using AI software to do what Kern says would otherwise require it to hire 40 full-time workers. Angelica does it at a fraction of the cost and without increasing payroll — or requiring Kern Family to navigate workers’ rights issues or government-mandated workplace protections.

Although Kern Family officials say no workers have lost jobs, the health plan, which is not unionized, estimated it would have had to spend $2.4 million in staffing costs to match the program’s more than 800,000 calls to its 387,000 members since Kern Family began using Angelica late last year.

As the federal government ended pandemic-era protections and states resumed screening people for Medicaid eligibility, health plans such as Kern Family began looking to technology to keep eligible people enrolled. Kern Family officials say that Angelica helps people, in their preferred language, set up appointments with the plan’s staffers, who make sure that applications are filled out correctly and delivered to county health officials for verification and processing.

Careforce CEO Huzaifa Sial said Kern Family is one of a few health insurers using his company’s software to help boost its Medi-Cal enrollment, and the company is also working with the Central California Alliance for Health in much the same way. “Most people don’t know what they need, and if they do, they have a hard time getting there,” Sial said. “That’s the hidden execution problem that nobody sees.”

“Angelica” is the name assigned to a conversational AI program deployed last year by California’s Kern Family Health Care, the largest provider of Medi-Cal services in Kern County. Kern Family has spent about $370,000 on the software by Careforce, a San Francisco startup, to facilitate rapid and repeated outreach to members when it’s time to renew their coverage. (Screengrab of Careforce.ai)

The rise of AI in the healthcare industry has prompted worries about who’s overseeing these tools and whether people are being improperly or . Unions have raised concerns about workplace surveillance and the . Polling shows over AI-driven job losses and growing income inequality, while health policy researchers have also about algorithmic biases, transparency, data privacy, and safety risks.

Mark Duggan, a Stanford University economics professor who has studied the Medicaid system for 30 years, said one long-standing fear is that insurers could use such software to cherry-pick patients for coverage.

“When you have a new technology like this, you need to police it,” Duggan said.

Complying With Regulations

California health plan regulators say they are tracking AI use closely, and the state attorney general’s office has to healthcare entities about their obligation to follow consumer protection rules.

Anthony Cava, a spokesperson for the state’s Department of Health Care Services, said Medi-Cal health plans have flexibility in how they handle member renewals, including with the use of AI tools. But plans are responsible for ensuring that technology complies with state and federal regulations, including patient privacy and data security, he said.

Last year, the agency, foreseeing the huge volume of reenrollments that were going to be required in the state, began allowing managed care plans to contact members about renewals. State rules still prohibit Medi-Cal health plans from soliciting new enrollees, and only county health officials determine eligibility.

Emily Duran, CEO of Kern Health Services (which administers Kern Family), said that the plan worked closely with the Kern County Department of Human Services to obtain some data, allowing Kern Family to know when a member’s Medi-Cal eligibility will expire.

The health plan, in turn, lets the county know anytime it receives updated demographic or contact information for its Medi-Cal members. And the county has stationed workers inside Kern Family Health Care’s main facility in Bakersfield to answer enrollment questions for people who walk in to finish their paperwork.

“They have a leadership group that is very innovative and forward-thinking,” Vanessa Frando, the chief deputy director of Kern County Human Services, said of Kern Family. The agency also works closely with other Medi-Cal providers in the county, Frando said.

Duran said the health plan was initially concerned about how Angelica would be received.

“We had to set the tone to really be open to the idea, because you hear ‘AI’ and you’re like, ‘Oh, yeah, Jeff Bezos laid off 100,000 people because of that,’” Duran said. “But we are already stretched thin. We need this functionality to be much more effective and augment our efforts.”

Duran said Kern Family’s leadership and staff bought in after seeing a demonstration.

Today, it would take 40 Kern Family employees, each working 40 hours a week, to match Angelica’s calls to remind people to reenroll and talk them through what is involved, according to Jackie Byrd, a spokesperson for the health plan. The AI program’s settings are constantly adjusted to match the capacity of Kern Family’s full-time staff.

Full Conversations With AI

Barahona said she received a Medi-Cal packet in the mail but didn’t think about it until Angelica called days later. That exchange highlights one of local and state health officials’ biggest concerns — that people who’ve grown accustomed to automatic renewals aren’t aware of the reenrollment requirements.

Angelica speaks more than 30 languages and can answer lengthy questions. In samples of actual conversations provided to a reporter, Angelica sounded lifelike at first, although more than once cross-talk with a patient caused the program to pause suddenly. Barahona said it took her a minute before she realized she wasn’t speaking with a human, but she ended up having a full conversation with Angelica.

Duran said Kern Family was able to redirect full-time staff to focus on the more complex parts of the Medi-Cal process, such as making sure the patients’ information is complete and up to date. The Angelica software also operates at all hours, making it easier for patients to call back at their convenience. Another version, David, is used internally to help staffers navigate the technology.

“This will always be, in my opinion, an AI-human combination,” said Careforce’s Sial. Working with AI solutions for more than a decade at UnitedHealthcare and Optum, Sial said, he saw an opportunity to improve the enrollment process by helping people organize their paperwork.

Kern Family’s Medi-Cal renewal rate in April was 94.9%, delighting the plan’s officials, who feared a significant drop-off from patients who’d gotten used to being automatically renewed over the past several years. By comparison, Duran said that about 80% of enrollments had automatically renewed under federal pandemic-era rules, but that figure was cut in half as those protections began to expire.

Kern Family officials say there could be other uses for Careforce’s software in the future; Angelica, like other generative-AI large language models, can learn and adapt to new situations and requests.

Cesar Delgado, Kern Family’s chief information officer, said Angelica is already being used to make general greeting calls to new members and can discuss plan benefits and answer basic questions. But Kern Family officials say the program’s primary purpose, for now, is limited to contacting patients whose Medi-Cal eligibility is coming up for review.

Duggan, the Stanford professor, said Angelica could help Kern Family minimize the number of Medi-Cal enrollees who lose coverage as federal requirements take effect.

“The best-case scenario is helping people to stay on when they don’t realize that things are changing,” Duggan said. “It’s not an easy program to navigate.”

This article was produced in collaboration with , an independent, California-based nonprofit investigative news publication that reports on inequality, climate change and other issues.

��ϳԹ�� News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

This article first appeared on ��ϳԹ�� News and is republished here under a .

Kennedy, Oz Contend Fraud Crackdown, Not Skyrocketing Prices, Led Millions To Leave Obamacare

Julie Appleby — Mon, 03 Aug 2026 09:00:00 +0000

The Trump administration credits its fraud control efforts for the disappearance of millions of people from Obamacare rolls rather than a sharp rise in premiums — a claim disputed by policy experts that glosses over the reality that many more Americans now find themselves without health insurance.

Enrollment in Affordable Care Act plans fell by nearly 3 million this year to about 19.2 million, following steep premium increases by insurers and the Republican-led Congress’ unwillingness to extend more generous premium subsidies. On average, ACA customers in premium payments this year, a 58% increase from 2025, according to KFF, while their deductibles — the amount consumers must pay annually before insurers pick up their share — have climbed 37% to nearly $3,800 a year.

“These are real people who are now forced to make impossible choices,” said Annalyse Keller, a spokesperson for a large coalition of lobby organizations for the healthcare industry, including insurers and patient advocacy groups.

But a released in June, written mostly by President Donald Trump’s political appointees and allies, asserts that 5.6 million people were fraudulently enrolled in ACA plans in 2025, and that the Trump administration removed 2.9 million of them — the same number as the 2026 drop in enrollment.

There’s little dispute that the ACA suffers from some fraud, as do most government programs. The administration said it has taken actions to tighten the enrollment process to thwart brokers who fraudulently enroll people without their knowledge.

For example, the administration in August 2025 halted a Biden-era initiative that allowed low-income people to sign up for coverage year-round. Regulators 1.5 million people since 2025 for reasons such as not meeting a requirement to file their taxes over two years or being concurrently enrolled in another health program, such as Medicaid, which is not allowed.

But health policy experts say that the administration is overstating the extent of ACA fraud and that the HHS report relies on debatable assumptions, such as that all sign-ups under the year-round enrollment program for low-income people were potentially fraudulent. ACA enrollment fell off a cliff because of escalating prices for insurance plans, policy analysts say, which the administration’s done nothing to stem.

“The top-level claim” that all the decline in enrollment since 2025 is because of improper or fraudulent enrollees leaving the market “is not remotely credible,” said , a senior fellow at the Brookings Institution. “We know that lots of people have seen higher premiums, and there’s really good evidence that when premiums go up, people drop coverage.”

Healthcare costs are a big concern for voters ahead of November’s midterm elections, and both Democrats and Republicans are trying to spin the issue to their advantage. Democrats argue more needs to be done to make insurance less expensive for consumers, while Republicans are trying to focus on the need to save taxpayer dollars from fraud.

found that voters trust Democrats over Republicans to address healthcare costs (37% vs. 26%). The poll also found, though, that 55% of Republican voters consider it extremely important for candidates to address healthcare fraud, more than any other issue, showing that the White House’s effort to shift focus from costs has had some success with its own supporters.

But Jonathan Oberlander, a professor of health policy and management at the University of North Carolina, questioned whether the fraud narrative will hold up as voters continue to struggle with rising costs.

“It will be cold comfort to the very real persons who could no longer afford coverage and dropped their plans,” he said in an email to ��ϳԹ�� News.

How We Got Here

Under President Joe Biden, Congress that included more generous tax subsidies for people enrolled in Obamacare, starting in 2021. Those enhanced subsidies lowered premium payments, for a large enough tax credit to reduce their monthly payment to zero. The Biden-era law also allowed wealthier households to get assistance.

ACA coverage essentially doubled, from just over 11 million Americans in 2021 to more than 22 million in 2025, according to the HHS report.

Republicans and conservative groups argue that the growth wasn’t driven only by people newly enrolling because of lower premiums. Instead, they say, the enhanced subsidies, along with other Biden-era policies — including easing income verification requirements for some enrollees — invited fraud. Unscrupulous, commission-seeking insurance brokers found it easier to sign people up for coverage, often without their knowledge, while ordinary consumers could more easily fudge their income and qualify for the largest subsidy possible.

The conservative Paragon Health Institute’s president, Brian Blase, wrote that the HHS report’s conclusion on the scope of improper enrollment is likely an undercount. He remains unconvinced by the arguments that rising premiums are to blame for the sharp drop in ACA enrollment, saying subsidies remain generous for many people.

The Administration’s Current Targets

The debate will continue as more enrollment data emerges from the federal marketplace and the exchanges run by states. Some policy experts — including the consulting group Wakely — expect the year to end with the number of ACA policyholders down by .

Trump’s regulators will likely connect further drops with anti-fraud efforts. The HHS report alleges there are potentially millions more who remain improperly enrolled. The report’s authors noted that some of the administration’s anti-fraud proposals have been blocked by court rulings.

HHS released June 27, HHS Secretary Robert F. Kennedy Jr. pats Mehmet Oz, the head of the Centers for Medicare & Medicaid Services, on the back for the number of canceled ACA plans so far. Oz threatens potential ACA hucksters: “Don’t walk away from us, run! Because we are going to find you.”

In an email responding to ��ϳԹ�� News’ questions, CMS spokesperson Christopher Krepich said his agency this summer will block ACA applications made by brokers that lack a Social Security number. By open enrollment this fall, CMS plans to require more identify-proofing when brokers enroll people and will limit a broker’s access to accounts until that person “has been authorized by the consumer to work on their behalf.”

How some suspicious enrollments will be removed is spelled out in emails sent in June to insurance carriers and obtained by ��ϳԹ�� News.

CMS told insurers that the agency will send them files for ACA accounts it believes are potentially unauthorized. Each flagged consumer account will have used a sales broker to enroll, be in a zero-premium plan, and lack a Social Security or an immigration documentation number — which Kennedy said in the video is a glaring sign of fraud.

Insurers must try to contact the enrollees to verify that they signed up for coverage. After 60 days, insurers must report policies they were unable to verify to CMS, which will cancel them.

Krepich wrote that carriers are cooperating with efforts to investigate accounts with missing or unverified information.

Policy experts, including Fiedler, note that the absence of a Social Security number doesn’t automatically prove fraud. While it could indicate a fake enrollee, a missing Social Security number might also be a simple oversight by the consumer or their broker, for example, or a newborn added to a parent’s account at birth, before they’ve received a number.

“That the administration put it in a report and did not summarily terminate these enrollments suggests they believe there is some mix of different circumstances,” Fiedler said.

The administration report singles out another segment of enrollments as suspicious: very low-income, subsidy-eligible people who shifted to plans that carry no monthly premium, suggesting “fraudulent agents and brokers are moving them to keep gaining commissions and avoid detection.” The report also cites ACA enrollees who file no medical claims as suspicious.

Policy experts question the assumptions behind those concerns.

Younger or lower-income people use healthcare less often, for example, which can explain why they may make no claims — particularly when they must first spend thousands of dollars out-of-pocket to meet high deductibles.

And very low-income people may switch to plans with higher deductibles in exchange for making no premium payment because they struggle to come up with the $50 or $80 monthly share that other plans might require.

“People are hurting for money,” said Florida insurance agent Jason Fine. “I literally have people who can’t afford to pay $15. I would not immediately assume that a person who went from a silver plan to a bronze plan, that it’s fraud,” referring to two types of ACA plans.

Fine said the administration needs to focus on better enforcement of existing rules, saying he has reported to regulators dozens of unscrupulous agents who have switched clients without authorization, yet none were barred from selling ACA policies.

He and other agents continue to push for adding multifactor identification, as banks and other financial institutions use, to the federal ACA marketplace. Some states that run their own exchanges have two-factor authentication or other types of ID verification and have not reported problems with unauthorized switching.

CMS — under both Biden and Trump — has not added two-factor authentication to the federal marketplace, healthcare.gov.

Rep. Glenn Grothman (R-Wis.) to require it in June, but its prospects are murky.

“It will help reduce fraud,” said Ronnell Nolan, who leads Health Agents for America, a lobbying group that has long urged CMS to add the feature. Grothman’s legislation, she said, might “encourage CMS to do it themselves.”

This article first appeared on ��ϳԹ�� News and is republished here under a .

People With Disabilities Fear Service Cuts as Trump’s DOJ Questions Legal Protections

Stephanie Armour — Mon, 03 Aug 2026 09:00:00 +0000

Amanda DeSimone-Shabrack relies on a home healthcare aide to help her high-needs autistic 12-year-old son. Virginia’s Medicaid program covers the assistance, enabling her to work as both an education technology specialist and a professor, run errands, and keep Mason in the home.

That could change. In June, the Department of Justice issued saying federal disability rights laws don’t require states to provide services that allow people with disabilities to remain in their homes rather than institutions.

It’s a sharp reversal from 1999, when a held that unjustified institutionalization constituted discrimination under the Americans with Disabilities Act. Previous administrations have relied on that ruling to enforce civil rights for disabled people, but the Trump administration says that long-held interpretation is wrong.

Advocacy groups say legal protections for about and 5 million children who have disabilities could be undermined, and they worry that the new interpretation may herald a return to forced institutionalization.

The stage is also now set for a legal fight between advocates, states, and the federal government. Some states with ongoing lawsuits challenging disability rights requirements are already citing the DOJ opinion in hopes it will help them prevail.

In a case in Texas, for example, that a rule instituting a 1973 civil rights law that led to community and home integration of people with disabilities is costly and infringes on states’ rights.

People like DeSimone-Shabrack are especially worried because, they say, the opinion follows a spate of White House and Republican-led initiatives that have already begun eroding hard-won protections for people with disabilities.

“I’m worried. Am I going to have to put him in an institution, and what’s that going to be like for him?” said DeSimone-Shabrack, whose personal home care help was recently reduced from 30 to 18 hours a week by the state. “As he gets older, am I going to be able to care for him without this support?”

The Department of Health and Human Services remains steadfast in enforcing federal civil rights laws, agency spokesperson Emily Hilliard said in an email.

“Our commitment to ensuring that individuals with disabilities are treated with dignity, afforded equal opportunity, and are able to meaningfully access community services remains unchanged,” she said.

But advocacy groups say the DOJ opinion could have sweeping repercussions. The opinion doesn’t change existing law, but advocates worry that HHS and the DOJ could begin that mandate integration for people with disabilities.

They’re concerned that agencies will stop enforcing disability laws that ensure people aren’t. HHS, for example, has historically investigated disability discrimination claims at hospitals and in states that get federal funding, enforcing compliance with home and community integration through . Disability rights experts say those agreements could now be imperiled.

And some states facing financial pressures may roll back Medicaid services that enable people with disabilities to stay in their homes and communities — a trend that’s already happening following last year’s passage of the One Big Beautiful Bill Act, which cuts a projected from the safety net program over a decade.

Democrats are seizing on the opinion, which was released in a DOJ memo, to portray President Donald Trump and Republicans as a threat to people with disabilities. Sen. Tammy Duckworth (D-Ill.) and other Senate Democrats led the calling on the DOJ to rescind the opinion.

“The Trump Administration’s memo is an outrageous attack on the rights and independence of the disability community,” Duckworth said in a statement.

The DOJ didn’t return emails seeking comment.

According to the DOJ’s interpretation, regulations that give disabled people the right to demand certain services for daily living — bathing, mental health counseling, and financial budgeting help, for instance — and that require states to extend to mentally disabled individuals are unlawful, a view the agency acknowledged “is out of step with the common understanding of that decision within the federal courts.”

States may have legitimate reason to treat mentally disabled people in institutions, “including resource constraints, capacity limitations in community-based facilities, and safety concerns for both the patient and the community,” the memo reads.

The Supreme Court case, Olmstead v. L.C., has long shaped federal policy. And while it remains to be seen how courts will respond to the DOJ, some states seeking to curtail disability protections see the opinion as significant.

Consider the in federal court in the Northern District of Texas by Republican-led states arguing that an HHS rule about the integration mandate is unlawful. The lawsuit began with broader claims and 17 state plaintiffs. Following significant advocacy from the disability community, only Texas, Alaska, and Florida remain.

Following the new DOJ interpretation, the states filed documentation to inform the court about the memo as a new and relevant development. Similar documentation citing the memo has been filed in disability rights cases in Florida and New Hampshire, according to The Arc of the United States, a disability advocacy group.

Advocates for people with disabilities say the speed at which plaintiffs are citing the opinion underscores how it may be used to justify the erosion of protections.

“The administration’s attempt to dismantle decades of progress in community integration is alarming and inconsistent with federal disability rights laws and Supreme Court precedent as well as the critical enforcement work of prior administrations,” said , senior executive officer of legal advocacy and general counsel at The Arc.

Forced institutionalization led to human rights violations, segregation, and a eugenics movement in the late 19th and early 20th centuries that included involuntary sterilization.

Exposure of the abuses, legal battles, and an caused a major shift toward integration. Fewer than 1% of people with intellectual or developmental disabilities lived in state-run facilities in 2021, down from almost 30% in 1967, from the University of Minnesota’s , which maintains metrics on such long-term services and supports.

The Trump administration has already taken steps to reverse that trend, advocates say.

Trump signed that addresses homelessness by expanding involuntary treatment and institutionalization, reversing a championed by the Biden administration.

Much of the special education program office is moving from the Department of Education to HHS, raising concerns among advocates that the administration is reverting to a view that disabilities are a medical issue to be fixed rather than differences that can be accommodated.

And cuts in federal funding for Medicaid, a federal-state insurance program for people with low incomes or disabilities, also portend fewer resources and services. States have responded by reducing some optional benefits such as home health aides and support. In addition, qualifying for an exemption from the program’s work requirements, which take effect Jan. 1 in most states, will pose significant hurdles for people with disabilities.

The June DOJ opinion, advocates say, could accelerate the shift and result in court rulings that chip away at disability rights.

“While it doesn’t overnight change the law, it’s very troubling and very dangerous,” said , director of the Disability Rights Program at the American Civil Liberties Union. “It reflects a really deeply held disrespect for disabled people from this administration and a total lack of awareness of the lived experiences of people with disabilities who are living in their homes.”

Data shows there can be benefits to involuntary institutionalization. Relative to those voluntarily admitted, people with psychiatric illness who were involuntarily admitted “experienced greater improvements in symptoms and function,” according to a in Psychiatry, Psychology and Law, a peer-reviewed academic journal.

Deinstitutionalization has created new challenges. More hospitals have been forced to board people with psychiatric illness in emergency rooms because of a dearth of available beds. And moving people into home- and community-based living was supposed to be accompanied by an increase in outpatient care and treatment that never materialized, creating gaps in support.

But advocates for the disabled community say involuntary institutionalization and poses a higher risk of neglect and abuse.

, 57, of Cleveland, spent two years in a nursing home. She has spinal muscular atrophy, a genetic disease that kills motor neurons, leaving her able to move only part of her left arm and her head.

At the institution, she said, she felt bored and trapped and developed intense itching from scabies, which is caused by microscopic mites.

For more than a decade, however, she has lived in an apartment with the help of caregivers who come in the morning to get her dressed and ready and return to put her to bed. She works at a disability rights group, and her care is covered by Medicaid.

“The two years I lived in the nursing home, it was the most horrible time in my life,” said Kucera, who worries about the DOJ opinion on Olmstead. “My future is a shaking floor beneath me. With the stroke of a pen, they could get rid of everything I’ve built for myself.”

This article first appeared on ��ϳԹ�� News and is republished here under a .

Medicaid Insurers’ Contracts on the Line in Tight Governor’s Race

Tony Leys — Thu, 30 Jul 2026 09:00:00 +0000

One of America’s most competitive gubernatorial races could settle a heated argument over whether private insurance companies should run Medicaid.

The race is in Iowa, whose Medicaid program has been plagued with controversy since 2016, when the state hired national insurance companies to manage billions of dollars’ worth of benefits.

That shift was made by then-Gov. Terry Branstad, a Republican. With his executive order, Iowa joined most other states in privatizing the management of Medicaid, which covers healthcare for more than 67 million Americans with low incomes or disabilities.

The arguments have resurfaced this year during the competition to replace Republican Gov. Kim Reynolds, who was Branstad’s protégé and continued contracting with private companies to manage Medicaid benefits. Zach Lahn, the Republican candidate to succeed the retiring governor, supports the practice. Rob Sand, the Democratic candidate, wants to end it.

“It’s been a disaster,” said Sand, Iowa’s state auditor. “The number of complaints has been catastrophic.”

Pros and Cons

Supporters of privatization say the insurers, known as managed-care organizations, make Medicaid more effective and efficient. Critics contend the companies pad their profits by denying payment for crucial health services and by shortchanging agencies and professionals who provide care.

Iowa is among 41 states, plus the District of Columbia, that contract with outside companies to run at least part of their Medicaid programs. Overall, private insurers manage the benefits of more than three-quarters of Medicaid patients. Connecticut is the only state that has fully reversed course after privatizing its Medicaid system.

Sand has criticized privatized Medicaid for years. As state auditor, he alleging that the national insurers systematically deny or delay payment for services to which Medicaid participants are entitled.

He has vowed not to renew state contracts with the three insurers managing care for more than 600,000 Iowans on Medicaid, which is jointly financed by the state and federal governments. He would rather have state employees or nonprofit agencies review and pay bills from clinics, hospitals, and other healthcare providers.

Lahn told ��ϳԹ�� News that Sand’s pledge to resume state administration of Medicaid “is the exact wrong idea.”

Lahn is a former activist for Americans for Prosperity, a national pro-business group affiliated with the Koch family. He contends that state governments and Medicaid participants benefit when insurers compete to serve them.

“There are very few things that government does more efficiently than the private sector,” he said.

Lahn, who is a businessman and farmer, emphasized that state officials should strictly enforce contract requirements, ensuring that the insurers treat Medicaid recipients fairly and make prompt payments to care providers. He also said he would bar insurers from using artificial intelligence systems to determine whether to pay for medical claims under Medicaid. “Iowans deserve to have a human looking at their case,” he said.

Sand said in a recent interview that he doesn’t want Iowa to fully return to a “fee-for-service” Medicaid system, in which hospitals, clinics, and other healthcare agencies would effectively be paid piecemeal for whatever services they provided. Instead, he said, state employees or nonprofit organizations could take over operation of a managed-care system, in which administrators review services to help ensure Medicaid participants receive what they need without wasting public money on ineffective services.

A few months ago, Republicans controlling the Iowa Legislature considered a bill to require the state to have a privately managed Medicaid system. That proposal would have blocked future governors from unilaterally shifting back to public management of the program. But the bill

Sand, a former assistant state attorney general, said he is confident he would have legal authority as governor to stop contracting with private Medicaid managers, although he cautioned that the transition would be complicated and could take time.

Republican candidate Zach Lahn says that if he were elected Iowa governor he would continue contracting with private insurance companies to manage the state’s Medicaid program because he believes they are more efficient than the government. (Erin Murphy/The Gazette via AP)

Democratic candidate Rob Sand says that if he were elected Iowa governor he would end private management of the state’s Medicaid program, which he says has been a disaster. (KC McGinnis/Bloomberg via Getty Images)

A Toss-Up Race

National political observers say the Iowa governor’s race

This June, Lahn won an underdog primary campaign to beat a sitting congressman backed by President Donald Trump. Lahn gained Trump’s endorsement after winning the Republican primary. He is a vocal supporter of the Make America Healthy Again movement, led by Health and Human Services Secretary Robert F. Kennedy Jr., which aims to improve Americans’ diets and reduce environmental poisons.

Sand noted that Lahn’s past political activism included a failed 2014 attempt to defeat a proposal to cover more people under Montana’s Medicaid program.

Lahn said that at the time he worried the federal government would reduce how much money it would contribute to such Medicaid expansions, leaving states to foot much of the bill. He said he also didn’t want to see public programs such as Medicaid giving benefits to adults capable of providing for themselves. But he said those concerns have been allayed, partly by the Trump administration’s moves to require millions of Medicaid recipients to prove they are working, volunteering, or going to school.

If elected governor, he said, he would not try to reverse Iowa’s expansion of Medicaid, which happened in 2014 under Branstad.

Branstad also is the governor who decided in 2016 to hire private insurers to manage Medicaid.

Branstad, who declined to comment for this article, did not need the legislature to approve his momentous decision. He weathered controversy over the change, including allegations that the companies systematically denied payment for care that people with disabilities needed to remain in their homes.

Andy Schneider, a who studies health policy issues, said it’s understandable that many government leaders see an advantage in hiring private Medicaid management companies. Each state’s Medicaid program pays claims for hundreds of thousands or even millions of members, and administrators must scrutinize bills from thousands of hospitals, clinics, and other healthcare organizations. “That’s a heavy lift,” said Schneider, who worked in federal Medicaid administration when Barack Obama was president.

Schneider noted that Medicaid expenses are among the biggest parts of any state’s budget. The costs can vary dramatically year to year, he said, which is hard for legislators and governors to plan for. Management companies sign contracts for set amounts of money per enrollee, depending on people’s ages and health conditions. Managed-care companies say they can improve Medicaid members’ health and reduce expenses. But Schneider said have been unable to confirm or disprove those claims.

Federal law gives states flexibility in how they run their Medicaid programs, including whether they hire private insurers to manage the programs. “Unwinding those arrangements might take a little time, but there’s no question they can do it,” Schneider said.

Connecticut of private insurers to run Medicaid in 2012. to contract only with nonprofit insurers, starting in 2025, and that state’s governor doing away with private management altogether.

Gary Jessee, a former Texas Medicaid director who helped transition that state’s program into managed care, noted that most Americans’ health coverage is managed by some kind of insurance company, whether they obtain it on their own or get it through a government or employer plan.

Jessee now helps run a whose clients include Medicaid managed-care companies. He said states rarely talk about totally scrapping contracts with such companies. Instead, he said, states have options to change the contracts, including to increase oversight or limit profits.

Overall, Jessee said, managed-care companies help Medicaid enrollees obtain the services they need to stay healthy. But it’s hard to calculate how much money the companies save states, he said, because all healthcare costs have been rising, and new members of managed-care plans may at first use more services as the insurance companies encourage them to get regular checkups instead of waiting for emergencies.

Iowa’s Medicaid program is managed by three insurers: Molina Healthcare, Elevance Health subsidiary Wellpoint, and Centene subsidiary Iowa Total Care.

None responded to requests for comment for this article.

Catherine Gray of Des Moines helps run a Facebook page for families who use Iowa’s Medicaid system. Her adult son, John, is on Medicaid because of a disability. Gray said the managed-care companies have made it much harder for people to obtain services, including mental healthcare, dental care, and transportation to health appointments. Iowa’s shift to the private system was abrupt and chaotic, she said. “We know people have died,” she said.

Gray said she probably will vote for Sand for governor, even though she doesn’t agree with every nuance of his stance on Medicaid. She suspects many other Iowans who use the program will do the same. “They’ve really been put through the wringer for 10 years, and they’re exhausted.”

This article first appeared on ��ϳԹ�� News and is republished here under a .

A Shrinking Safety Net

Thu, 23 Jul 2026 17:45:00 +0000

The Host

Julie Rovner ��ϳԹ�� News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of ��ϳԹ�� News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Enrollment in the federal food stamp program — the Supplemental Nutrition Assistance Program, known as SNAP — is down by more than 10% nationally, according to a new report, and in some states by as much as half. Those numbers are falling as states enact changes ordered by the GOP budget bill passed in 2025. The drop is much steeper than was predicted and could portend a similar fate for those on Medicaid, as states prepare to implement many of the same changes ordered for SNAP.

Meanwhile, amid a rise in reported cases of the gastrointestinal ailment caused by the parasite cyclospora, federal public health officials once again struggle to explain to a confused populace how to stay safe.

This week’s panelists are Julie Rovner of ��ϳԹ�� News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Alice Miranda Ollstein of Politico, and Margot Sanger-Katz of The New York Times.

Panelists

Joanne Kenen Johns Hopkins University and Politico

Alice Miranda Ollstein Politico

Margot Sanger-Katz The New York Times

Among the takeaways from this week’s episode:

Participation in the nation’s food stamp program is down, with children representing nearly half of those losing benefits, according to a recent analysis. Some states are showing much larger drops than others. The GOP-passed budget law imposes penalties for errors, leaving states spooked about the possibility of losing funding — and suggesting problems ahead for the full rollout of Medicaid work requirements next year.
President Donald Trump’s immigration crackdown is increasing pressure on the health system, in particular on the availability of home-based and long-term care workers — including those who fill critical roles such as serving food and driving patients to medical appointments. Research has shown that the presence of immigrant workers has a protective effect on the health of their charges.
Responding to revelations that doctors are reaping large payouts from the surprise-billing arbitration process, the Trump administration this week released information showing a spike in such payments and noted the need for changes to the law — without specifying what kind of changes. That law, the No Surprises Act, took effect in 2022 with the primary intention of shielding patients from big bills when they unknowingly receive out-of-network medical care.
In other news, the Pentagon is imposing testosterone tests for many service members. The cyclospora outbreak continues. And the Trump administration announced plans to withhold Medicaid funding from California and Minnesota over accusations of fraud.

Also this week, Rovner interviews Sen. Bill Cassidy (R-La.), chairman of the Senate Health, Education, Labor, and Pensions Committee, as part of the “How Would You Fix It?” series.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The New York Times’ “,” by Arijeta Lajka, Isabelle Niu, Mark Boyer, James Surdam, and Dan T. Peters.

Joanne Kenen: Stat’s “,” by Adam Feuerstein.

Margot Sanger-Katz: NPR’s “,” by Andrea Hsu.

Alice Miranda Ollstein: Roll Call’s “,” by Ariel Cohen.

Also mentioned in this week’s podcast:

��ϳԹ�� News’ “Doctors ‘Cringe’ at Possibility of Documenting Which Medicaid Enrollees Too Sick To Work,” by Sam Whitehead.
��ϳԹ�� News’ “A Deloitte-Run System Denied Medicaid Benefits for Michigan’s Disabled. Now Trump’s Law Piles On,” by Rachana Pradhan, Samantha Liss, and Kate Wells.
The New York Times’ “,” by Miriam Jordan.
The Wall Street Journal’s “” by Anna Wilde Mathews and Tom McGinty.

click to open the transcript Transcript: A Shrinking Safety Net

A Deloitte-Run System Denied Medicaid Benefits for Michigan’s Disabled. Now Trump’s Law Piles On.

Rachana Pradhan, Samantha Liss and Kate Wells — Tue, 21 Jul 2026 09:00:00 +0000

Marie Noon takes eight medications a day. One keeps her heart rate from spiking to avoid a stroke. One prevents debilitating headaches. Another ensures she doesn’t retain excess fluid.

More than a decade ago, Noon said, she was diagnosed with adult-onset Still’s disease, a rare type of inflammatory arthritis that can cause rashes, debilitating pain, and fevers. The disease upended her life.

She had been living a typical suburban life in Michigan, shuttling her two kids to activities like cheerleading, choir practice, and track. She was active in the PTA. She managed a bank.

She went from that to crawling to the bathroom because she was in so much pain, “just crying all day long” from being so sick.

Noon, who is disabled, said she couldn’t work for eight years — a time marked by hospital stays that stretched for weeks.

“I honestly thought I was going to die,” Noon said.

So it was a shock when Michigan denied her application for Medicaid benefits last year after she lost private insurance. Worse yet, it came down to an IT error, according to an attorney who helped Noon overturn the denial.

“I can’t afford my medical care. I have to have insurance,” said Noon, who has returned to working.

Deloitte, a multibillion-dollar global consulting firm, has operated Michigan’s Medicaid eligibility system under contracts worth roughly $768 million since 2006, according to contracts reviewed by ��ϳԹ�� News. Nationwide, Deloitte dominates this important slice of government business: At least 25 states have awarded the company contracts to build or run computer systems that control access to safety net benefits such as Medicaid.

Michigan’s system has incorrectly directed people with disabilities into skimpier benefits that cover limited care or has denied coverage completely, a ��ϳԹ�� News investigation found. Similar problems were at the center of a class-action suit in Tennessee, , and have occurred in Texas, according to interviews and state records.

The ��ϳԹ�� News investigations are based on statements from state officials, allegations and declarations in court documents, emails obtained through public records requests, state government information provided to Medicaid enrollees and applicants, and interviews with attorneys and patients or their caregivers.

In an emailed statement, Deloitte spokesperson Karen Walsh said it found “no system anomalies causing routine denials of Medicaid for people with disabilities.”

“There are many reasons why someone may no longer be eligible for a benefit they once received or believe they deserve,” Walsh said. “All of the eligibility systems we support are owned by the states and built to their unique specifications. We will continue to work at the direction of our state clients.”

Lynn Sutfin, a spokesperson for Michigan’s Department of Health and Human Services, said it “is not aware of any widespread or systemic issues” within Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits, “related to disability‑based eligibility pathways.”

Since 2006, Deloitte’s contracts with the state have said the company is responsible for development, implementation, maintenance, operations, and enhancements to the Michigan system.

Computer system problems foreshadow trouble as states prepare to roll out the most significant and complicated changes to their Medicaid programs in years. Those changes, dictated by President Donald Trump’s landmark One Big Beautiful Bill Act, have states rushing to update their Medicaid computer systems.

Nationwide, on Medicaid have a disability, according to KFF.

“When these administrative systems get overloaded, everyone gets impacted,” said Pamela Herd, a University of Michigan professor who researches bureaucratic obstacles to accessing government benefits. “The systems are going to be really, really strained.”

In Michigan, Noon was eligible for Medicaid through a program that provides coverage to disabled adults who work. But the state’s computer system didn’t register that she is disabled and said she earned too much to qualify, according to documents reviewed by ��ϳԹ�� News and interviews with Noon and Anastassia Kolosova, a disability rights attorney who helped her.

Without Medicaid coverage, Noon paid hundreds of dollars out-of-pocket for prescriptions, after scrounging for discount coupons. She takes some of the drugs twice a day.

Without them, “I’m toast,” she said. It was stressful “not knowing if my medicine’s going to be $50 or $500 this month, because it changes constantly.”

Noon said her doctor agreed to fewer visits to avoid medical bills.

“It was kind of a nightmare,” Noon said.

‘I Just Wanted To Give Up’

Medicaid, a safety net health program jointly run by the federal government and states, people with low incomes or disabilities. State governments rely on companies like Deloitte to design and operate computer systems that assess whether people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly known as food stamps.

That technology has a history of errors that deprive eligible people of benefits, earlier ��ϳԹ�� News investigations have shown. As reported previously, Kenneth Smith, a Deloitte executive who leads its national human services division, said Medicaid eligibility technology is state-owned and agencies “direct their operation” and “make decisions about the policies and processes that they implement.”

“They’re not Deloitte systems,” he said, noting Deloitte is one player among many who together administer Medicaid benefits.

States are under immense pressure to update their eligibility systems on a tight schedule to adhere to requirements in the Republicans’ sweeping 2025 tax and spending law. Companies including Deloitte, Accenture, and Optum are being paid millions in taxpayer funds to make the changes, which are projected to strip Medicaid from roughly 7.5 million people and SNAP from 2.4 million people by 2034.

Many coverage restrictions in the new federal law don’t apply to seniors, children, or people who are disabled, such as Noon. Nonetheless, the law’s demands on state agencies and the computer systems they oversee will disrupt benefits, advocates for Medicaid enrollees and other healthcare experts said in interviews.

The same systems also need to correctly classify why someone is eligible for Medicaid — and therefore which rules and restrictions apply.

The law’s SNAP restrictions began to take effect in 2025, and major Medicaid provisions begin later this year, generally after the midterm elections.

Kolosova is a supervising attorney with Disability Rights Michigan, a legal advocacy organization for people with disabilities. She said she has been unable to get a meeting with Michigan officials to understand the underlying problem that deprived Noon of health coverage.

Anastassia Kolosova, a supervising attorney with Disability Rights Michigan, helped Noon navigate the complicated process to obtain safety net health insurance through Medicaid. Kolosova says she has seen multiple wrongful coverage denials and fears problems will soon get worse because of changes required by federal law. (Kate Wells/��ϳԹ�� News)

State records show Deloitte has held contracts for at least 14 years for Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits. In its attempts to secure more business, the company often cites its nationwide footprint in Medicaid operations.

“Deloitte understands Bridges,” and its history in Michigan makes the company “the ideal vendor,” the firm said in its . Given Deloitte’s work on similar systems in 31 other states, , “Michigan benefits from our technical expertise drawn from across the nation.”

But advocates who work with people with disabilities say Michigan’s computer system has failed to recognize when certain adults should receive Medicaid benefits.

Problems aren’t unique to the Great Lakes State. Medicaid beneficiaries who brought a against Tennessee in 2020 said the state’s Deloitte-built system “does not reliably test for eligibility” for several categories of people with disabilities. The firm’s is worth $1.12 billion over a decade.

A federal judge in 2024 , ruling that Tennessee violated federal law and the U.S. Constitution. The lawsuit does not name Deloitte as a defendant.

In Michigan, a from the state’s Office of the Auditor General said government agencies “did not provide effective project administration” and failed to ensure that the state could “independently maintain and operate Bridges” because “the contractor did not transfer knowledge and skills” to state officials, according to the audit.

The auditor’s report said that, as a result, Deloitte’s original contract — valued at roughly $70 million — ballooned by $50 million over the initial cost, a 71% increase. State records show Michigan would go on to add millions more, bumping the cost of Deloitte’s initial contract to $124.1 million.

The audit said maintaining the contract would result “in significant additional costs.”

Sutfin said that “the state is now fully capable of operating and maintaining Bridges independently.”

Deloitte’s in Michigan — worth $197.4 million — is set to expire in 2030.

Noon applied for Medicaid in August, she and Kolosova said. In September, the Michigan Department of Health and Human Services sent a notice denying her coverage, citing incorrect income information and stating she wasn’t disabled, according to Kolosova and state documents reviewed by ��ϳԹ�� News.

Noon said that when she called the state for help, state workers “didn’t know anything about” the Medicaid program she had applied to, Freedom to Work.

“I can’t tell you how many times I just wanted to give up,” she said.

For some people with disabilities, Medicaid is supposed to count only half their earnings when assessing whether they should receive benefits. That didn’t happen. Kolosova said she thinks Michigan’s eligibility system didn’t identify Noon as disabled, even though the state “already had all the information they needed” to show she was.

By failing to recognize her disability, the state used the wrong income formula and said Noon earned too much to qualify for Medicaid, she added. Deloitte and Michigan declined to respond to a detailed list of questions about Noon’s experience.

Kolosova said Disability Rights Michigan has seen a growing number of calls from people about Freedom to Work benefit denials. “Maybe two or three a month,” she said.

“There’s something wrong with the system if they’re relying on individual caseworkers to catch this,” Kolosova said. “The system needs to work.”

Noon at home with her dog, Ziggy. Despite being eligible for Medicaid, she was denied coverage in 2025 because of an error with the state’s benefits system. It took months of pushback before the state reversed its mistake. Even as a “tech-savvy” former bank manager, she says, she wanted to give up several times along the way. (Kate Wells/��ϳԹ�� News)

Enrolled in the Wrong Coverage

Noon’s experience isn’t the first time in recent years that people with disabilities have been denied benefits by Deloitte-run eligibility systems.

In Texas in 2023, Lilly Livingston, who has Down syndrome and is now 22, was abruptly cut off from Medicaid benefits, according to Livingston’s mother, Marie. She has undergone numerous surgeries to reconstruct her severely misaligned jaw, which caused sleep apnea and impaired her speech and chewing ability. She relied on an array of Medicaid services, including speech and occupational therapy.

When Livingston lost benefits, she was wrongly enrolled in Healthy Texas Women, a limited program that provides breast and cervical cancer screenings and family planning services.

“Trying to fix that was a nightmare,” Marie Livingston said.

Terry Anstee, an attorney with Disability Rights Texas, intervened.

In a September 2023 email with the subject line “URGENT,” Anstee begged a Texas Medicaid eligibility worker for help.

Some unknown “error” had occurred and stripped Livingston of her benefits, Anstee said in an email he sent to a state Medicaid staffer. “Lilly has had 2 major surgeries, and her recovery is contingent on Medicaid.”

It was clear that Livingston qualified for Medicaid through multiple paths, Anstee said: “It never made any sense.”

Deloitte declined to respond to a detailed list of questions about Livingston’s case. Jennifer Ruffcorn, a spokesperson for Texas Health and Human Services, confirmed that Livingston was erroneously enrolled in Healthy Texas Women. However, Ruffcorn said, Livingston did not experience a lapse in Medicaid coverage in 2023.

Anstee disputed the state’s characterization: “A glance in the system by a Texas HHS press officer or other staff 3 years after the fact may not tell the full story or show the issues that Ms. Livingston endured in August and September 2023. Ms. Livingston experienced lapses in coverage.”

The problem Livingston encountered in Texas was also reported in Michigan.

In 2024, mental health services advocates in Michigan raised red flags about a similar error: People with disabilities were being enrolled in a limited Medicaid program covering sexual health and family planning services. Plan First covers only services and treatment for sexually transmitted infections. It doesn’t provide the comprehensive coverage that people with disabilities require.

But some enrollees were “being automatically enrolled in Plan First,” Malcolm Kletke, a lobbyist representing the Community Mental Health Association of Michigan and other mental health providers, wrote to a Michigan health official, according to emails obtained by ��ϳԹ�� News through a public records request.

These enrollees had “long received Medicaid due to their disability,” and getting enrolled in the wrong plan meant losing access to “services essential to their recovery and quality of life,” Kletke wrote in September 2024 to Amy Epkey, a senior deputy director of the Michigan Department of Health and Human Services.

In fact, the state’s own records show that Medicaid enrollment for those with disabilities did decline.

Over roughly four years, enrollment in the Medicaid category that includes people with disabilities , according to the Michigan House Fiscal Agency, which provides nonpartisan analysis to lawmakers. The drop was unusual given people generally leave the program because of death or having recovered from a temporary disability, and it’s unlikely those numbers would balloon, said Robert Sheehan, who was the mental health association’s CEO at the time.

Sutfin said the state examined the decline in enrollment and found “several contributing factors, including post‑covid renewal patterns, changes in beneficiary circumstances and movement to other coverage categories.”

After inquiries from ��ϳԹ�� News, the Michigan health department acknowledged in April that it had made changes to “address concerns raised by advocates.”

Michigan’s computer system now prevents approval of Plan First benefits until all other coverage options are evaluated, Sutfin told ��ϳԹ�� News. Sutfin said the changes were implemented but “not to correct system errors.”

Sutfin said the state submitted a change request to Deloitte to address this problem. The fix was implemented in January 2025.

Until presented with Kletke’s email, the state had denied there were problems related to Plan First.

Even after the state addressed that issue, other problems persisted.

Noon’s coverage denial notice arrived in September. She fought with the state for months to reverse its decision, “paying cash for all of the medicines through these appeals over and over and over again.”

It was only in January that she was approved.

“I literally cried,” Noon said. “It was a really big deal.”

This article first appeared on ��ϳԹ�� News and is republished here under a .

Doctors ‘Cringe’ at Possibility of Documenting Which Medicaid Enrollees Too Sick To Work

Sam Whitehead — Mon, 20 Jul 2026 09:00:00 +0000

Alice Thornton has spent more than two decades treating people living with HIV in Lexington, Kentucky.

Her team tends to “cringe” anytime they hear about patients having to fill out lots of paperwork, like when applying for Social Security Disability payments, because it can be a difficult, burdensome process.

Thornton tries to support her patients, she said, but understands the limits of her training.

“A lot of times the forms are so complex that I don’t really know what’s the true definition of what this form is asking me,” she said. “We refer them to a disability provider.”

Doctors including Thornton worry they’ll see more of those kinds of requests because of coming changes to Medicaid, the government health insurance program for people with low incomes or disabilities. Starting Jan. 1 in most of the country, some enrollees — mainly adults without dependents — must prove they’re working or performing other qualifying activities 80 hours a month.

issued in June say people can obtain an exemption if they’re “medically frail,” or too sick or disabled to work, which may require them to submit documentation from a medical professional. That standard prompted a lawsuit at the end of June from dozens of mostly Democratic-led states and has Thornton worried it could force her and her staff to assess things like how much a patient can lift or how far they can walk.

“If I’m asked, ‘Is this person medically frail?’ What does that even mean?” Thornton said. “I don’t know, and I’ve been doing this for 25 years.”

Last year’s GOP tax-and-spending law known as the One Big Beautiful Bill Act established the work rule, which will affect an estimated when more states start enforcing it. The mandate is expected to cause a larger increase in the number of people without health insurance than any other part of the law, a health information nonprofit that includes ��ϳԹ�� News.

Doctors say they aren’t trained to accurately assess whether someone’s health keeps them from working. Many don’t have time to handle another administrative task that takes them away from patient care. And being involved in whether someone gains access to a public benefit undermines the doctor-patient relationship, several doctor groups and physicians said.

“When you introduce unnecessary, non-evidence-based, confusing, and bureaucratic policies like this into clinical care, it just raises the level of moral distress for providers,” said Christopher Chen, a senior healthcare adviser at the consulting firm Manatt.

The Centers for Medicare & Medicaid Services declined to respond on the record about doctors’ concerns. But the agency confirmed that enrollees may need to get documentation from a clinician to prove they’re too sick to work and said states would make final determinations.

The Trump administration has previously said states should use available data sources — such as medical claims and payment data — before making patients submit proof of medical frailty from a provider.

“Documentation should be relatively easy to provide,” Mehmet Oz, the CMS administrator, said during a June 1 press call.

But deciding whether a patient is too sick to work is a subjective, high-stakes decision, said Chen, who also practices as a hospitalist at Valley Medical Center in Renton, Washington.

“We’re trained to take care of people,” he said. “We’re trained to learn about someone’s symptoms, make diagnoses, treat them. We’re not trained to make these kinds of work determinations.”

When they apply and every six months after, Medicaid enrollees subject to the rule will have to prove that they’re performing the minimum monthly hours of qualifying activities — or will likely have to prove as frequently that they qualify for an exemption.

If states can’t find sufficient evidence that someone is too sick to work, that person will be able to self-attest to it under penalty of perjury — but only for a short time. States may take someone’s word that they’re medically frail twice in 2027 and only once in 2028.

Last month, 25 mostly Democratic-led states over the final regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess.

The standard, they argue, requires state Medicaid agencies to “take on the role of occupational medicine experts” or adds that burden to physicians who are not necessarily trained in occupational medicine.

CMS declined to comment on the litigation.

The Trump administration has crusaded against fraud in government health programs including Medicaid. It recently — including medical professionals — over more than $6.5 billion in alleged fraud schemes.

CMS has said it will keep a close watch on how states administer the work requirements and may take corrective action if states step out of line.

That has doctors concerned about the potential repercussions if they incorrectly assess whether someone is too sick to work, as farfetched as those worries might be, said Rahul Vanjani, a primary care and addiction medicine physician and researcher at Brown University.

“We, using our imaginations, wonder if someone is auditing these forms in the background and if they’re going to reach out to the licensing board.”

The country is short of primary care providers, and it could be hard for people seeking an exemption to find a clinician to help them document that they’re too sick to work, doctors said.

It will be even more challenging for someone without insurance, said Jennifer Wagner, who researches Medicaid eligibility at the left-leaning Center on Budget and Policy Priorities.

“How could an applicant who doesn’t have health coverage get a doctor’s note?” she asked.

The American Medical Association, the nation’s largest professional association of doctors and medical students, lobbied federal officials to change the standard for documenting medical frailty in the days before the final regulations were made public.

In May, the AMA sent to Oz, the CMS administrator, arguing that forcing doctors to attest to their patients’ ability to work wouldn’t just be an administrative headache but would affect the way they interact with those in their care.

In a statement, the association’s president, Willie Underwood III, said the work rule “transforms the clinical encounter into an eligibility gatekeeping process.”

“Patients will likely sense that shift,” he said. “And if they begin to suspect that what they share with their physician could affect their coverage, the conditions for open and honest communication will start to break down.”

Doctors have a fixed amount of time to spend with patients and would rather focus on treating medical conditions than filling out forms, especially ones that put them in a position to “represent the state,” said John Ayanian, an internal medicine physician and researcher at the University of Michigan.

“Their first obligation is to serve the best interest of their patients,” Ayanian said.

Lauren Davis, an attorney with Community Legal Services of Philadelphia, helps clients navigate other public benefit programs, such as the Supplemental Nutrition Assistance Program, which has a similar work rule. Enrollees can get an exemption from it if they’re too sick to work.

She recalled a client with a cognitive condition that affected her memory. The client’s doctor wasn’t comfortable filling out an exemption form without seeing her in person, but she kept forgetting to make an appointment and eventually gave up, said Davis, who worries Medicaid enrollees could face similar barriers to getting exemptions.

“This person is eligible,” Davis said. “The reason that they’re not able to get what they need to show that they’re eligible is because of their medical condition.”

This article first appeared on ��ϳԹ�� News and is republished here under a .

States Start Their Medicaid Cuts

Thu, 16 Jul 2026 18:40:00 +0000

The Host

When Republicans passed their big budget bill in 2025, they scheduled many of the Medicaid reductions to take effect in 2027, after the 2026 midterm elections. But in anticipation of getting less money from Washington come January, many states are already cutting their Medicaid programs, making the issue more relevant for voters in November.

This week’s panelists are Julie Rovner of ��ϳԹ�� News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico, and Sandhya Raman of Bloomberg Law.

Panelists

Anna Edney Bloomberg News

Alice Miranda Ollstein Politico

Sandhya Raman Bloomberg Law

Among the takeaways from this week’s episode:

Congress has no clear path to passing its annual spending bills, with the issue of Medicaid funding for Planned Parenthood again threatening to gum up the works. Meanwhile, senators this week screened President Donald Trump’s newest health nominees: Erica Schwartz to lead the Centers for Disease Control and Prevention and Sean Kaufman to lead the Administration for Strategic Preparedness and Response. But Schwartz undermined some senators’ confidence by claiming ignorance about a number of Trump administration funding cuts, and Kaufman faced fiery questions over a deleted social media post about the hepatitis B vaccine.
The confirmation hearing for Todd Blanche as attorney general also trod into health territory, with Blanche saying he would review potentially using the 19th-century Comstock Act to block distribution of medication abortion drugs by mail. Such a move could block not only mifepristone but also misoprostol, which is the second abortion medication in the two-drug regimen — and is also used for non-abortion purposes. Trump promised on the campaign trail not to invoke the Comstock Act.
In politics, Maine Democrats are cautiously eying the abortion stances of a replacement Senate candidate, hoping to pin the rollback of abortion rights on Sen. Susan Collins, the Republican incumbent. And Sen. Ron Wyden (D-Ore.) is calling for an investigation into whether Health and Human Services Secretary Robert F. Kennedy Jr. violated a federal law aimed at preventing electioneering by officials when he made recent calls to persuade some candidates to drop out of congressional races.
And the gastrointestinal infection cyclosporiasis is sickening more Americans and drawing attention to the Trump administration’s actions undermining food safety surveillance programs. The cyclospora parasite was once subject to mandatory reporting but has since been made voluntary, challenging efforts to track the source and contain the outbreak.

Also this week, Rovner interviews Elizabeth Mitchell of the Purchaser Business Group on Health as part of the “How Would You Fix It?” series.

Plus, for “extra credit” the panelists this week suggest health policy stories they read (or wrote) that they think you should read, too:

Julie Rovner: Mississippi Today’s “,” by Sophia Paffenroth and Joanne Kenen.

Anna Edney: Bloomberg News’ “,” by Anna Edney.

Alice Miranda Ollstein: Politico’s “,” by Amanda Chu and Robert King.

Sandhya Raman: Bloomberg Law’s “,” by Nyah Phengsitthy and Skye Witley.

Also mentioned in this week’s podcast:

Stat’s “,” by O. Rose Broderick.
NPR’s “,” by Selina Simmons-Duffin.
Stat’s “” by Anil Oza and J. Emory Parker.
Politico’s “,” by Alice Miranda Ollstein.

Click to open the transcript Transcript: States Start Their Medicaid Cuts

A Sales Tax on Doctor Visits and Medicine? In Missouri, Some Worry

Bram Sable-Smith — Thu, 16 Jul 2026 09:00:00 +0000

ST. LOUIS — Missouri healthcare advocate Leslie Ortbals and her husband want to start a family, but she worries they can’t afford it. The 27-year-old said she takes 10 medications daily to manage multiple chronic illnesses.

Now she worries the cost of those drugs could rise — not because of price increases, but because of a tax system revamp put on the ballot by the state’s Republican-dominated legislature and backed by the Republican governor.

Prescription drugs and doctor visits are currently exempt from taxes in the state. But in August, Missouri voters will weigh in on a proposed constitutional amendment to give the legislature the power to replace the state’s income tax with expanded sales taxes, including on goods and services currently exempt.

“Politicians want Missourians to trust them when they say not to worry about our medications and healthcare being up for grabs,” Ortbals said at a June press event organized by Progress MO, a progressive advocacy group.

“I have spent enough time in Jefferson City to know better,” said Ortbals, who works for a Democratic state legislator but was speaking in her personal capacity. “I have watched them speak about protecting life while making lifesaving healthcare less accessible.”

Taxes on healthcare are unusual in the United States but not unprecedented. Most states over-the-counter drugs. Illinois, Missouri’s neighbor, prescription drugs. Delaware, Hawai‘i, New Mexico, and Washington all on services by physicians, dentists, out-of-hospital nursing providers, and medical laboratories.

Critics of the amendment to eliminate income tax in Missouri say it’d be difficult to make up the lost revenue without also imposing taxes on healthcare. Nearly two-thirds of the state’s general revenue budget comes from income taxes, about $8.7 billion in 2026. Failing to make up that revenue could lead to steep cuts in state services.

The proposed tax cut comes at an already precarious time for the state budget. Missouri Gov. Mike Kehoe in spending in this year’s budget over concerns of lagging revenues. The state legislature has passed a since 2022, including . Federal covid aid has propped up the budget in recent years, but the that the surplus is dwindling. And the state is projected to in federal Medicaid funding over 10 years due to cuts from President Donald Trump’s signature One Big Beautiful Bill Act.

Proponents of the Missouri income tax proposal, such as of the Show-Me Institute, a conservative think tank, say the cut would in the state, both of which have been flat in recent years. He doubts healthcare would be among the things subject to sales tax. But even if it were, he said, it could be done in ways that wouldn’t target lower-income residents. New Jersey, for example, (excluding reconstructive surgeries), which tend to be performed on wealthier people.

In a statement to ��ϳԹ�� News, Kehoe spokesperson Gabby Picard said the governor “will never support extending sales taxes on agriculture, healthcare, or real estate,” noting that the legislature would have to decide what to exempt if the ballot measure passes.

Federal law already prohibits states from imposing taxes on many healthcare services covered by government programs such as Medicare, the federal health insurance program for seniors, and Medicaid, the joint state-federal health insurance program for people with low incomes or disabilities, Picard wrote. More than were insured through those two programs in 2024.

But Jay Hardenbrook, advocacy director for AARP Missouri, argued that raising taxes on healthcare, real estate, and agriculture is the for the amendment, considering the legislature doesn’t need special permission to cut income taxes. He cautioned that because the amendment opens the door to new taxes on anything, it could unleash a “weird feeding frenzy” with special-interest groups lobbying for exemptions.

“Let’s say we do protect prescription drugs from a tax increase; does that mean that the cost of food goes up?” Hardenbrook said.

And if the Missouri measure passes and the legislature exempts healthcare and real estate from new taxes, Hardenbrook worries about cuts to state-funded services like home and community-based care.

“When I talk about taxes going up, and the price of every good and services going up, that’s the best-case scenario,” Hardenbrook said. “The worst-case scenario is that the income tax just goes away, and we just don’t have the money to do the things that we need to do.”

have no income tax, and Washington taxes only capital gains, but of the Institute on Taxation and Economic Policy, a progressive think tank, said the way Missouri is going about its elimination is nearly unprecedented. Only Alaska has repealed a broad-based personal income tax that had previously accounted for a significant portion of the state budget, Davis said.

“The situation in Alaska was they struck oil, and they had this gusher of economic activity and tax revenue that resulted from that,” Davis said. “Missouri has not struck oil.”

A 2012 tax cut in Kansas that reduced income taxes for individuals and eliminated them for some types of businesses created a large budget hole, prompting lawmakers there to the cuts five years later.

Tsapelas of the Show-Me Institute said Missouri’s income tax elimination wouldn’t happen overnight but would instead be more akin to in the state: phased in and tied to revenue targets that would shield the state from massive budget gaps.

“It’s not as doom and gloom as some people are worried about,” Tsapelas said.

But Ortbals, the healthcare advocate, said too many Missourians are already delaying medical care because of costs.

“I want a Missouri where young people can afford to stay, where families can afford to grow, where chronic illness does not become financial ruin,” Ortbals said.

This article first appeared on ��ϳԹ�� News and is republished here under a .

Facing Funding Losses, States Call Out Big Businesses With Employees on Medicaid

Jazmin Orozco Rodriguez — Wed, 15 Jul 2026 09:00:00 +0000

As the Trump administration’s January deadline looms for states to enforce new Medicaid work requirements, some state lawmakers are turning the tables by pushing to publicly name the largest companies that have employees enrolled in the government program covering low-income and disabled people.

California lawmakers an expired law that would require the state to identify companies that employ 100 or more people and have employees enrolled in Medi-Cal, the state’s Medicaid program. Nevada has had a similar law in place since 2017, though a proposal for one in Oregon stalled when its legislative session ended in March.

The California bill author, Democratic state Sen. Lola Smallwood-Cuevas, said she is deeply troubled by what is going to happen when work requirements kick in. According to the state, out of more than on Medi-Cal will be subject to the rule.

“We think this is a bill that’s about fairness,” Smallwood-Cuevas said. “It’s a basic principle that taxpayers deserve transparency about which large employers are shifting their healthcare costs onto the public.”

Large employers that regularly top Nevada’s list, such as Walmart and Amazon, have said that the state included part-time and seasonal workers in their counts and that their full-time hourly employees to qualify for Medicaid.

Walmart spokesperson Katrina Proffitt said that the company offers affordable medical coverage to most employees, including eligible part-time workers, and that most of its plans include no-cost virtual care options.

“Healthcare affordability and access to quality care remain real barriers for many Americans, and Walmart continues to be committed to being part of the solution,” Proffitt said.

The push to name and shame companies reflects dueling narratives about the biggest abusers of the joint state-federal Medicaid program, which reached nearly in government spending in 2024. The Trump administration, led by Centers for Medicare & Medicaid Services Administrator Mehmet Oz, has called out blue states for not doing enough to fight insurer fraud and abuse. State Democratic leaders, meanwhile, are pushing back by calling attention to big employers that don’t offer affordable health benefits, which leaves taxpayers subsidizing healthcare costs for the low-wage workforce.

Some states have considered financial penalties. Democratic New Jersey Gov. Mikie Sherrill signed a bill in June that have at least 50 Medicaid-enrolled employees. Companies with 50 to 249 workers on Medicaid per person, and those with at least 500 will pay $725.

Bills that would have penalized companies with workers enrolled in Medicaid failed in this year.

In Sacramento, California, Democrats want to figure out a way to make large businesses pay for their employees’ health coverage. State lawmakers struck a deal with Democratic Gov. Gavin Newsom, who is contemplating a presidential bid as he wraps up his final year in the governor’s office, to explore tax options. Any tax hike would be up to the new governor.

States face of dollars under HR 1, the GOP tax-and-spending law known as the One Big Beautiful Bill Act, notably through that requires nondisabled Medicaid enrollees ages 19 to 64 in most states to prove they are working, volunteering, or going to school at least 80 hours a month to keep their coverage.

Yet federal work requirements are projected to increase the number of uninsured people nationwide by more than 5 million by 2034, according to the . Nebraska and Montana have begun enforcing the rule.

One health policy researcher said employer Medicaid reports highlight the lack of affordable healthcare options available to low-wage workers. More than half of adults enrolled in Medicaid who don’t have dependent children already meet the 80-hour-a-month requirement or face challenges that would likely qualify them for an exemption, .

“There’s a whole set of people who are working — they may not satisfy the work requirement provisions, they may not get the exemption that they’re qualified for, and they don’t have access to that employer-sponsored insurance either,” said Edwin Park, a research professor at the Center for Children and Families at Georgetown University.

Employers Push Back

While employer lists haven’t succeeded in bringing down Medicaid costs, supporters say measuring the burden can be the first step and help lawmakers make the case for further action.

In Nevada, Amazon has employed more Medicaid enrollees than any other company since 2020, according to the state’s report . For state fiscal year 2025, Walmart, the Clark County School District, the state government, and Tesla rounded out the top five.

Employers that the reports are misleading because they have included part-time and seasonal employees. The state’s includes only full-time employees, plus those who could not be confirmed as either full- or part-time employees.

That came to 4,914 Amazon employees and 3,503 Walmart workers in Nevada on Medicaid in 2025.

There are no penalties for companies on the list.

Amazon said it pays its workers more than double the $7.25-an-hour federal minimum wage and noted that Medicaid eligibility is based on household income and size rather than an individual’s wage. That means two employees who earn the same pay may have different eligibility depending on whether they have children or live with parents.

“Pointing fingers at Amazon over Medicaid is a red herring,” said spokesperson Alisa Carroll. “What really needs to happen is a significant and large increase in the federal minimum wage — that would be a big boost for American families.”

Nevada Medicaid spent nearly $950 million on healthcare for more than 133,000 full-time employees and more than 140,000 of their dependents. While the total amount spent dipped in fiscal year 2025, the average cost per member per year increased by nearly 17%.

Yvanna Cancela, a former Nevada lawmaker who sponsored the legislation on Medicaid work reports, said the annual reports force an important conversation “about whether or not this is the kind of economy we want and whether or not it is right or just that people who work full-time don’t make enough to have health insurance.”

A Fraying Safety Net

Health researchers say that uninsured people delay or skip and that their children may end up losing coverage, too.

One analysis found that more than were enrolled in Medicaid and the Children’s Health Insurance Program this April than in January 2025. California is among the states with the among children.

The loss in healthcare coverage among residents will be compounded by the loss of public food assistance benefits, Smallwood-Cuevas said. is pending in the legislature.

She compared Medi-Cal to a trampoline that has become a “very tattered kind of fishnet” overwhelmed by people falling into it. President Donald Trump’s spending-and-tax law pulls and rips at the safety net, she said.

When people lose food assistance and health benefits, they must choose between paying for medicine and paying for rent, Smallwood-Cuevas said.

“We’re going to see more people in their cars, more people on the street, and a lot more people in the emergency room,” she said. “That is dangerous for all of California.”

This article first appeared on ��ϳԹ�� News and is republished here under a .

Medicaid Archives - ���ϳԹ��� News

AI Is Being Used to Boost Medicaid Enrollment, but Not Without Concerns

Kennedy, Oz Contend Fraud Crackdown, Not Skyrocketing Prices, Led Millions To Leave Obamacare

People With Disabilities Fear Service Cuts as Trump’s DOJ Questions Legal Protections

Medicaid Insurers’ Contracts on the Line in Tight Governor’s Race

A Shrinking Safety Net

Panelists

A Deloitte-Run System Denied Medicaid Benefits for Michigan’s Disabled. Now Trump’s Law Piles On.

Doctors ‘Cringe’ at Possibility of Documenting Which Medicaid Enrollees Too Sick To Work

States Start Their Medicaid Cuts

Panelists

A Sales Tax on Doctor Visits and Medicine? In Missouri, Some Worry

Facing Funding Losses, States Call Out Big Businesses With Employees on Medicaid

Medicaid Archives - ��ϳԹ�� News