The Host Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health 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.

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 KFF Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico, and Sandhya Raman of Bloomberg Law.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories. Sandhya Raman Bloomberg Law @SandhyaWrites @sandhyawrites.bsky.social Read Sandhya's stories.

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 “Mississippi Is Getting Hotter. Experts Say It’s Hurting Moms and Babies,” by Sophia Paffenroth and Joanne Kenen.

Anna Edney: Bloomberg News’ “Almost $1 Billion Later, the US Still Can’t Make a Medical Glove,” by Anna Edney.

Alice Miranda Ollstein: Politico’s “Fraud Investigations Are Crumbling This State’s Medicaid System,” by Amanda Chu and Robert King.

Sandhya Raman: Bloomberg Law’s “Unverified GLP-1-Related Claims Flood Food, Supplement Markets,” by Nyah Phengsitthy and Skye Witley.

Also mentioned in this week’s podcast:

• Stat’s “As States Absorb Medicaid Funding Cuts, Family Caregivers Face Financial Ruin,” by O. Rose Broderick.
• NPR’s “Trump’s HHS Shelves Threat To Withhold Medicare and Medicaid Funding Over Trans Care,” by Selina Simmons-Duffin.
• Stat’s “Flood of Comments on White House Grantmaking Overhaul Is Largely Negative, Analysis Shows,” by Anil Oza and J. Emory Parker.
• Politico’s “Trump Admin Asks Appeals Court To Roll Back Obamacare’s Contraception Coverage,” by Alice Miranda Ollstein.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

Click here to find all our podcasts.

And subscribe to “What the Health? From KFF Health News” on Apple Podcasts, Spotify, the NPR app, YouTube, Pocket Casts, or wherever you listen to podcasts.

KFF Health 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 KFF.

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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 already tax over-the-counter drugs. Illinois, Missouri’s neighbor, is the only state to also tax prescription drugs. Delaware, Hawai‘i, New Mexico, and Washington all have taxes 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 restricted about $440 million in spending in this year’s budget over concerns of lagging revenues. The state legislature has passed a series of tax cuts since 2022, including repealing capital gains taxes. Federal covid aid has propped up the budget in recent years, but the state’s auditor recently warned that the surplus is dwindling. And the state is projected to lose about $14 billion 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 Elias Tsapelas of the Show-Me Institute, a conservative think tank, say the cut would spur economic and population growth 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, taxes cosmetic procedures (excluding reconstructive surgeries), which tend to be performed on wealthier people.

In a statement to KFF Health 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 a third of Americans 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 real reason 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.”

Eight states have no income tax, and Washington taxes only capital gains, but Carl Davis 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 largely repeal 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 recent income tax reductions 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.

KFF Health 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 KFF.

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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

A Tragic, Deadly Denial

I read your article in The Washington Post about the woman whose Humana policy required prior authorization for a drug she’d been taking (Bill of the Month: “She Struggled To Get a Lifesaving Drug Even After Insurers Vowed To Help,” June 29).

My husband, Kenney, had chronic obstructive pulmonary disease. On June 7, he fatally shot himself after a COPD exacerbation event.

His pulmonologist had prescribed two new nebulizer prescriptions on June 2. One was a specialty medication that would come directly from the drug company. A couple of days later, we called Walgreens to see why the other one hadn’t been filled. Turns out it required prior authorization.

Why the doctor who prescribed it needed to tell his health insurer that he really did think his patient needed it, I will never understand. The pharmacist said she would send the request to the doctor. And why she hadn’t already done that, again, I do not understand. By June 7, of course, it still wasn’t filled.

That day, a Sunday, Kenney experienced the flare-up when I was out mowing the yard. How terrifying it must have been for him to be unable to breathe and me not being there at least to hold his hand. That night he killed himself, leaving a note saying that he hated to leave me but that he couldn’t keep living like that — with the constant anxiety of not knowing when he wouldn’t be able to draw a breath.

Not long ago, a “welcome” packet came in the mail about the other nebulizer treatment — 25 days after it had been prescribed.

Admittedly, my husband’s health was not great. He did have COPD, but we still went out to eat once in a while, and he didn’t have to take his oxygen on those trips. He rarely used it just walking around the house.

He did make a serious suicide attempt six years ago (our daughter and granddaughter had died), but after seeing what it did to me and our son, he promised he’d never do it again. It was only when these exacerbation/flare-up events started this year that he indicated life was getting bad.

Perhaps, just perhaps, if he had received both medications in a timely manner, he would be here today, and we would have had many more years together. We met when we were 16 and had been together ever since. He was 78 when he died.

— Cindy Clements Blewett; Kyle, Texas

Navigating GLP-1 Coverage

Sydney Lupkin’s thoughtful article about the obstacles in obtaining weight loss drugs was interesting (Healthcare Helpline: “Trouble Getting Weight Loss Drugs Covered by Insurance? Here’s What To Know,” June 26). It would have been more helpful had it included a discussion of Medicare’s decision to cover these drugs as of July 1, 2026, and how to navigate the rocky shores of obtaining a prescription that won’t be denied.

— Sharie Hartman; Manteca, California

Beyond the Veil of Pregnancy Centers

I would like to address the article about a pregnancy resource center providing prenatal care in Sandpoint, Idaho (“Religious Anti-Abortion Center Finds Opportunity in Town Without OB-GYNs,” May 20). It is unfortunate that many still do not understand what pregnancy resource centers do, nor the high-quality care they provide. While there are some “crisis pregnancy centers” that provide limited offerings, most centers are aligned with a national organization like the National Institute of Family and Life Advocates, the Heartbeat Pregnancy Center, or Care Net. All these organizations require centers to have a medical director (a licensed healthcare practitioner) and require that the nurses who perform the ultrasounds have appropriate training. While I am not affiliated with 7B Care Clinic, I am concerned that the article may not have accurately reflected what is provided in such clinics. I offer my experiences to bring further clarity.

I work at a life-affirming women’s clinic. I am a board-certified family physician. I have delivered approximately 1,000 babies in my career. I have been performing ultrasounds for my patients for over a decade, and fought for this ability under the scrutiny of maternal-fetal medicine specialists, spending time alongside their registered diagnostic medical sonographer technicians, and having my scans reviewed by maternal-fetal medicine physicians. I have practiced medicine in three states over three decades.

Second, while I am life-affirming, I am not “anti-abortion.” I happen to believe that there are better choices, and I know that some women will still choose abortion, even after hearing all their options. I will gladly see those women for follow-up to answer questions and evaluate for complications — something that the abortion clinics in my area apparently will not do. I say this because that is what the women I see tell me. The clinic that performed the procedure or gave them the pills will not see a patient after the abortion for any follow-up. I have always willingly seen patients for any reason, whether I was working at a private clinic or hospital-owned clinic. That is no different now that I work for a life-affirming women’s clinic.

We provide a variety of services — free of charge. We are also stepping up to provide prenatal care up to 20 weeks because there is a shortage of obstetrical clinicians in our county. We encourage women to see a clinic where they can be followed throughout the entire pregnancy, if possible, and we are in no way marketing ourselves as competition. We are stepping in to fill the large gap that exists.

Just because the clinic in Sandpoint chooses to respect life does not make it a fake clinic. This clinic seeks to bring in physicians to provide prenatal care. They are bringing in OB-GYNs from Washington state, which has no restrictions on abortion. With this information taken into consideration, I ask you to reconsider any concerns about a clinic bringing board-certified OB-GYNs into an area where there is a shortage.

— James Heid, Vancouver, Washington

The Root of All Good

The article Claudia Boyd-Barrett wrote about how immigrant parents’ arrests are creating a mental health crisis for children was moving and brought awareness to the mental health challenges faced by them (Growing Up Scared: “Arrests of Immigrant Parents Create Mental Health Crisis for Children,” June 18). It was important to note how every story was different but focused on how much children missed and yearned for their parents to come back home. You also wrote about how it affected them by not having a parental figure in the home. That really touched me. Specifically, Jacob’s story and when he listed all the things he missed about his mom but especially being close to her.

I am currently a master’s student in social work working to become a better ally to the Hispanic immigrant community. I’ve seen how being afraid and sad over the immigration policies has affected my friends in this community. Losing a close parent and not being able to have that security with them anymore is hard to go through, and trauma affects children as they grow.

In this article, you have recognized the worth of a person, which is a core principle in social work. These children are worthy and have the right to feel taken care of and secure.

I would love to see more mental health services accessible to immigrant communities and their families. This would benefit children as they learn to cope with their feelings and how to make sense of a new world.

— Stacy Xiong, Athens, Georgia

Bagging a Bargain

Author Susan Jaffe mentioned GoodRx in the article “Thousands of Medicare Beneficiaries Thought Their Drug Plan Was Free. Then They Lost It” (July 7), but she failed to mention a much better discount drug site, Mark Cuban’s costplusdrugs.com, where a 90-day supply of 2.5 milligrams of rivaroxaban, a generic for Xarelto, is available for under $50. This could help the thousands of people who lost coverage through unpaid premiums from Wellcare Value Script obtain their medications. The problem of yearly increasing penalties for losing Part D coverage is something that has to be addressed by the Centers for Medicare & Medicaid Services.

Thanks to KFF Health News for the relevant coverage.

— Jackie Button; Miami

Fleshing Out the Details

Your report identifying alpha-gal syndrome as a red meat allergy is accurate in that respect but inadequate in its breadth (“Would Hunters Take a Lyme Disease Vaccine? We Asked,” June 30). Alpha-gal is an allergic reaction to virtually all mammalian products. If you explore that, you’ll find an interesting story, as mammalian products are everywhere, including in pharmaceuticals, cosmetics, and other non-meat products. Alpha-gal is growing rapidly, and too many people, including doctors, do not realize that AGS is far worse than just a red meat allergy.

I suggest you help build understanding of the threat by describing the allergy in the future as an allergy to mammalian products. If you do not think your audience will understand that term, perhaps you can explain that it includes pork and anything derived from animals with hooves. As a former and now retired reporter, I encourage you to cover this allergy because its implications are surprising and scary.

— John Varner, Surry, Virginia

KFF Health 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 KFF.

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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 seek to revive 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, nearly 5 million out of more than 14 million residents 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 make too much 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 $932 billion 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 to fine businesses that have at least 50 Medicaid-enrolled employees. Companies with 50 to 249 workers on Medicaid will pay $325 a year per person, and those with at least 500 will pay $725.

Bills that would have penalized companies with workers enrolled in Medicaid failed in Washington state and Colorado 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 losing billions of dollars under HR 1, the GOP tax-and-spending law known as the One Big Beautiful Bill Act, notably through a provision 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 Congressional Budget Office. 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, according to KFF.

“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 published in January. For state fiscal year 2025, Walmart, the Clark County School District, the state government, and Tesla rounded out the top five.

Employers have argued that the reports are misleading because they have included part-time and seasonal employees. The state’s latest report 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 using healthcare and that their children may end up losing coverage, too.

One analysis found that more than 2 million fewer children were enrolled in Medicaid and the Children’s Health Insurance Program this April than in January 2025. California is among the states with the steepest enrollment losses among children.

The loss in healthcare coverage among residents will be compounded by the loss of public food assistance benefits, Smallwood-Cuevas said. Her bill 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.”

KFF Health 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 KFF.

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Thousands of Americans who undergo a common knee surgery might be making their problems worse rather than better.

Researchers who followed patients for 10 years after they received either the actual procedure, arthroscopic knee surgery to trim degenerative cartilage tears, or merely “sham surgery” — a skin incision — for knee pain, found that the surgery provided little or no benefit and was, in fact, associated with accelerated osteoarthritis and higher rates of reoperation. That generally meant a total knee replacement.

“I don’t know how I would defend this procedure at all,” said one of the study’s authors, Teppo Järvinen, an orthopedist and the head of the Finnish Centre for Evidence-Based Orthopaedics. “What has been shown dramatically is that patients who have this procedure have more pain — they do worse. All the scores pointed in the same direction.”

Järvinen said the Finnish study, published in April in the New England Journal of Medicine, was the first to show the surgery left many patients worse off. Though the study was small, the results were compelling, he said, because his team picked the patients “most likely to benefit.”

The study does not apply to cartilage tears incurred from an acute pain-causing injury. It included subjects middle-aged or older who were experiencing knee pain and whose MRIs showed cartilage tears.

Evidence has been accumulating steadily for over a decade that arthroscopic knee surgery to shave torn, degenerative cartilage does not help more than physical therapy. Arthroscopic rates in Finland have dropped 90%, Järvinen said. They have been falling in the U.S., too, but at a far slower rate.

One study of commercial claims in the U.S., which counted over 2 million meniscus surgeries from 2010 to 2020, found the number decreased by about 4% each year. Most procedures were performed on women and patients in their 50s.

In the traditional Medicare fee-for-service program, the number of procedures has declined steadily in recent years, from about 169,000 in 2014 to 91,000 in 2024, federal data shows. These figures do not include beneficiaries in Medicare Advantage, private insurance plans that cover more than half of Medicare enrollees.

Prior studies of scans have found that such tears are common in people over 50, the result of wear and tear and often not painful.

“Nothing supports the idea that a patient’s pain comes from the meniscus,” Järvinen said.

Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, said that “evidence is growing for judicious use of this surgery in this population.” But, he noted, “many patients do benefit.”

All the same, he acknowledged that current practice among his peers is “all over the map.” For example, data shows that surgery for meniscus tears in the Medicare population is far more common in the South than in the Northeast.

A massive study committee of orthopedic societies in Europe and the U.S. last June released a consensus statement noting that “degenerative meniscus lesions can be treated with comparable results with either non-operative (including physical therapy) or surgical approach.” It recommended a trial of physical therapy before surgery but still endorsed the operation.

A concerted campaign by orthopedic specialty societies called the Save the Meniscus Society has been ongoing for years. The group advocates for protecting and maintaining long-term knee health through nonsurgical treatments, surgical repair, and other therapies.

One inherent issue in all medical specialties is that appropriate treatment is often in the eye of the physician beholder, meaning that specialists create the guidelines for when a treatment is in order. And financial considerations may influence that decision, Järvinen said.  

In the U.S., physician payments are decided by the Relative Value Scale Update Committee, or RUC, a committee of the American Medical Association composed largely of specialists. Department of Health and Human Services Secretary Robert F. Kennedy Jr. and his advisers have reportedly looked into wresting control of that committee from the association, though it’s not clear how that could be done, since the AMA owns the billing codes used to calculate patients’ charges.

Arthroscopic knee surgery takes 30 to 60 minutes in the operating room, and the patients spend a few hours recovering in a surgery center or in a hospital outpatient department. Medicare allots on average $2,159 to $3,875 for the procedure, depending on where it is performed; patients pay 20% of the fee as coinsurance. There may be additional costs, for example, if more than one doctor is involved in the procedure. Commercial insurers average well more than twice that, said Marcus Dorstel, a senior vice president at the data analytics firm Turquoise Health, adding that the amount providers charge for the procedure varies widely. Those charges do not include the fees of the surgeons and the anesthesiologist.

Treating chronic knee pain has a variegated history.

Fifty years ago, the treatment for cartilage tears, from acute injury or from wear and tear, was to remove the entire piece of cartilage. At that time, doctors did not consider it a shock absorber but a useless, vestigial piece of tissue like the appendix.

Today, the first-line therapy for a painful knee with degenerative tears is physical therapy and, for some people, weight loss. Then there is arthroscopic surgery, depending on the view of the surgeon about its utility.

There is also a menu of injections: Steroids have proved scientifically valuable in the short term. And injections of stem cells and plasma-rich protein are widely offered but are controversial — and not covered by most insurance — because studies have been at best inconclusive about their benefit.

And as orthopedists are backing away from shaving off meniscus tears, they are highlighting a newer procedure — sewing the torn cartilage back into a whole. But that is typically an option for patients under 50 with acute injuries and clean tears, and it is unclear exactly which patients might benefit.

When all else fails, there’s a different surgery that’s also a big moneymaker for hospitals and doctors: knee replacement.

KFF Health 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 KFF.

This <a target="_blank" href="https://kffhealthnews.org/health-industry/knee-surgery-arthroscopic-cartilage-meniscus-finnish-study-osteoarthritis/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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HHS and the U.S. Department of Veterans Affairs entered into a Memorandum of Understanding to strengthen collaboration on the research, clinical development, and responsible deployment to veterans suffering from serious mental health conditions.

SACRAMENTO, Calif. — Sen. John Kennedy of Louisiana is taking aim at California’s Medicaid program for providing housing assistance, food, and other social services to high-need, low-income patients who tend to rack up big healthcare costs and, he argued, strain taxpayer funds.

The Republican blasted California during back-to-back political attacks in May, saying the heavily Democratic state is committing “outrageous fraud” and “stealing” by spending state and federal Medicaid money meant for basic medical treatment on unconventional services such as housing and nutrition assistance, gym memberships, and even tribal prayers and, he claimed, exorcisms.

“The California Medicaid program will pay for herbal medicines, meal deliveries. They’ll pay for housing,” Kennedy said. “I don’t know what housing has to do with healthcare.”

“California, they’re just setting all kind of records,” he added. “They’re wild people.”

Despite criticism from congressional Republicans and growing scrutiny from the Trump administration, Gov. Gavin Newsom, a Democrat considering a presidential run, said he’s proud of California’s spending on social services in Medi-Cal, the state’s Medicaid program. It’s a multibillion-dollar experiment to help medically frail patients meet their housing, food, and other social needs that Newsom says is not only legal but also a more cost-effective and evidence-backed approach to providing healthcare for Californians with complex health conditions. He counters that investing in services outside clinical settings can help people avoid emergency rooms and hospital admissions, improve their long-term health, and ultimately save taxpayers money.

“It’s about whole-person care,” Newsom said, adding that he hopes President Donald Trump’s administration sees California’s leadership and agrees with the “reforms we’re advancing as national best practices.”

Now one of the governor’s marquee health initiatives is at the center of an intensifying partisan battle with Republicans in Washington, D.C., who have moved to rein in billions in healthcare spending on low-income and disabled people across red and blue states. It’s a philosophical divide: Conservatives say social services are a financial strain on Medicaid and shouldn’t be considered healthcare, while liberals argue that investing in prevention ultimately saves money. While experiments proliferated across the country under President Joe Biden, the Trump administration has rescinded federal policy encouraging state Medicaid programs to address health-related social needs.

The Medicaid fight is putting patients in limbo.

Lucy Rodriguez teaches Mexican folk dancing in the town of Hollister, in California’s Central Coast region. She said her life turned around this year once an intensive case manager with Titanium Healthcare, which contracts with health insurers to provide services, began helping her manage her chronic diseases and stay on top of her medical appointments and prescriptions, even picking up free food boxes for her. The 73-year-old is on Medicare and Medi-Cal, which offers more extensive benefits. The low-income health program has helped pay her utility bills, and she was recently approved for home-delivered meals.

“This has been a godsend,” said Rodriguez, who has diabetes, high blood pressure, and kidney disease. “I was getting so stressed out and depressed. It’s really hard when you’re on a fixed income. Groceries are so expensive, and with summer, electricity gets even more expensive. But this is really improving my life.”

She worries the Trump administration will cut benefits to low-income older people.

Lucy Rodriguez, an enrollee in California’s Medicaid program, known as Medi-Cal, has benefited from social services the program covers, including a care manager who helps her manage her diabetes and kidney disease. (Angela Hart/KFF Health News)

Last year, the Centers for Medicare & Medicaid Services warned states that federal funding for social services would be determined on a case-by-case basis. CMS spokesperson Christopher Krepich said the agency is not ending current agreements, known as waivers, that grant states temporary permission to provide social services, which are paid for with state and federal dollars. But future applications, for new services or to extend existing initiatives, could be at risk if they veer too far from traditional healthcare.

“Moving forward, CMS will work with states on innovative waivers that address core healthcare needs, as consistent with evidence-based approaches tied to clinical diagnoses and services, to the goal of ultimately improving health outcomes in the Medicaid population,” Krepich said in a statement.

In a further escalation, the Justice Department put out a recent memo allowing states to institutionalize people with disabilities and severe mental illness instead of providing community-based care. Republicans have also targeted states, mostly blue ones, for what they say is a failure to go after waste, fraud, and abuse in Medicaid. In May, CMS Administrator Mehmet Oz stood alongside JD Vance as the vice president announced the deferral of $1.3 billion in Medicaid money to California over suspicions of fraud.

California Attorney General Rob Bonta said Republicans are simply trying to score political points while ignoring the healthcare needs of poor people. “The federal government wants to politicize fraud,” Bonta said, “and use it, unfortunately, as a bludgeon and a cajole to beat up on blue states.”

Social Healthcare

Health policy researchers say roughly 80% of health outcomes are linked to socioeconomic, environmental, and behavioral factors, such as housing instability, homelessness, food insecurity, and exposure to violence, whereas 20% is associated with medical care delivered in hospitals and clinics. That evidence fueled the Biden administration’s efforts to tackle social services.

At least 24 states use their own money while drawing federal Medicaid funds for social healthcare experiments. Colorado, Massachusetts, New York, North Carolina, Oregon, and Pennsylvania are among those that provide housing and nutrition assistance.

As the Trump administration pulls back on social services, states are rethinking how to fund benefits that have improved preventive care for low-income people. Some have launched new benefits under what’s known as a state plan amendment, a mechanism states use to modify their Medicaid programs that doesn’t need federal waiver approval. Michigan and Minnesota, for example, use this to add recuperative care for homeless patients after hospitalization. These short-term care facilities offer people the opportunity to recover, bridging the gap between hospital discharge and independent living.

This approach “has the advantage of establishing a permanent, statewide benefit that does not require ongoing federal renewals, offering greater stability and predictability,” said Lynn Sutfin, a spokesperson for the Michigan Department of Health and Human Services.

Other states, meanwhile, rely on federal waivers, which require renewal every five years, to provide social services. Arizona officials said the state intends to submit a request by the end of September to continue its program to provide housing and other services to homeless patients, or those at risk of homelessness, with a serious mental illness and a chronic health condition or recent incarceration.

“When members have access to stable housing and supportive services, they are more likely to engage in ongoing care and less likely to experience avoidable emergency department visits and inpatient admissions,” said Roberta Harrison, interim director of the Arizona Health Care Cost Containment System.

California, which has been the most aggressive state in adopting social services, has taken a two-pronged approach to keep its vast offerings funded past this year. The state is using its authority to make most of its existing social services and benefits permanent in Medi-Cal managed-care coverage. That regulatory maneuver bypasses federal waiver approval — a move that could attract further Republican scrutiny.

But not everything the state offers can be funded without permission from the federal government. As some services are made permanent, the Newsom administration is seeking new waivers to continue other social services, while also adding more.

It’s an ambitious approach that would expand California’s social healthcare experiment. Newsom said he’s worried that the federal government will decline the latest waiver request. “How could you not be with this administration?” he said. “I’m always concerned.”

Rodriguez tests her blood sugar to help manage her diabetes. Conservatives say that spending healthcare funds on nontraditional services such as housing and nutrition assistance is inappropriate, but liberals say it saves money in the long run. (Angela Hart/KFF Health News) Through Medi-Cal, Rodriguez has received help managing medical appointments after arm surgery. State officials say social healthcare provides a more cost-effective approach for people with complex health conditions. (Angela Hart/KFF Health News)

New Front in Healthcare

California offers most of its health-related social services under Biden-era waivers within Medi-Cal, which has a proposed budget of $217 billion. Although there are more than 14 million residents on Medi-Cal, the state has been selective about who gets help from 15 types of social services in its program, called California Advancing and Innovating Medi-Cal, or CalAIM. Patients with complex needs can also receive help navigating their health and social needs from specialized social workers under a benefit known as enhanced care management.

Since 2022, California has been offering social services, spending nearly $12 billion in joint state and federal money, with the hope of reducing long-term Medi-Cal spending by keeping enrollees out of costly institutions including emergency rooms, jails, nursing homes, and mental health crisis centers.

CalAIM had provided social services to more than 528,000 patients as of September 2025, the most recent state data available. And nearly 453,000 low-income Californians have received intensive case management. Some patients receive both services.

Among the services California is making permanent: Homeless patients can get help finding an apartment, with Medi-Cal paying rental security deposits and six months of rent. Patients with chronic conditions such as diabetes and heart disease are eligible for home-delivered meals. Asthmatic patients can get mold removed from their homes to control flare-ups. Low-income seniors with disabilities can get a wheelchair ramp installed free of charge. And inmates leaving jail or prison can be connected immediately with primary care, mental health, and substance use treatment.

The social services — especially housing, food assistance, and home modifications — are already demonstrating success in stabilizing the health of the most complex patients, while achieving savings for Medi-Cal through reductions in emergency room visits and hospitalizations and less reliance on institutional care such as nursing homes, according to the state Department of Health Care Services.

In the Central Valley, for instance, Health Plan of San Joaquin CEO Lizeth Granados said CalAIM has helped place homeless patients who were routinely hospitalized into housing. And patients with uncontrolled diabetes saw their blood sugar drop after receiving nutrition counseling and home-delivered meals.

Overall, Granados said, the health plan has seen major improvements in chronic disease management and reductions in hospital stays, dropping to 44 inpatient hospitalizations per 1,000 members since it launched in 2022, down from 61 per 1,000 before CalAIM.

In Orange County, officials with CalOptima Health credited CalAIM housing services for contributing to a nearly 27% drop in unsheltered homelessness. “We’ve been able to expand our street medicine programs, too,” said Yunkyung Kim, the insurer’s chief operating officer.

Around the state, Medi-Cal health insurers said they’re optimistic that CalAIM will continue to save money and improve patient health. Yet, the fate of some services will be decided by the Trump administration.

California has asked CMS to continue enrolling jail and prison inmates in Medi-Cal 90 days before their release to maintain consistent treatment for substance use, mental disorders, or physical conditions, a CalAIM service still in its early stages.

The state has also proposed a new job assistance benefit that counties could opt into to help patients find and retain work in response to upcoming federal work requirements imposed by congressional Republicans’ One Big Beautiful Bill Act, signed by Trump last summer.

And the state wants to continue its array of traditional healers and natural helpers for Californians with tribal affiliations, including music therapy, dancing, drumming, and referrals to sweat lodges for mental health treatment and substance use recovery. While it covers spiritual services, such as ceremonies, rituals, and herbal remedies, state officials said Medi-Cal does not cover exorcisms.

Already, the Trump administration’s positioning has forced the state to eliminate room-and-board benefits, which is threatening local efforts to provide recovery beds.

The state is cutting short-term post-hospitalization housing, which was meant to prevent hospitals from dumping homeless patients or those at risk of homelessness onto the streets. The CalAIM service providing up to six months of temporary housing and ongoing care is ending at the close of this year. And the state is cutting recuperative care benefits, no longer paying for beds for patients to recover from illness or injury, instead offering only wraparound services.

In San Francisco, these beds have been crucial in reducing overdose deaths, helping transition homeless people off the streets and into housing, and reducing hospital bed usage, said Neal Sheran, a medical director with the city’s Department of Public Health. The city’s health plan operates a sobering center, and recuperative care facilities where patients can recover from hospitalizations.

“We’re concerned,” Sheran said. “Funding for the overnight piece of these programs is really crucial to their success.”

Cuts on the Horizon

Even without federal threats, state budget pressures have strained CalAIM financing. Newsom has proposed reducing funding for social services by $68.3 million this fiscal year. The cut will deepen next year and remain at $150.2 million per year beginning in 2028.

Providers worry that Medi-Cal patients will lose access. And services, such as home-delivered meals and housing assistance, will be further restricted.

“It’s moving us back to the old days where our healthcare system is more expensive and reactive, instead of investing in prevention,” said Anwar Zoueihid, a vice president and the chief strategy officer at the Los Angeles-based Partners in Care Foundation, a CalAIM provider. “It’s contradictory to Make America Healthy Again.”

To save money, the state is tightening eligibility to limit services and reduce inappropriate use. For instance, Medi-Cal patients with food insecurity would no longer be eligible for home-delivered healthy meals without a qualifying condition like diabetes. And a homeless patient would get capped at six months for help finding an apartment.

Some of the biggest providers of CalAIM say services should be continuously evaluated and curtailed if health plans were too permissive. In some cases, food and housing services were given to low-income patients who didn’t necessarily qualify as the highest-need.

“It’s important everybody takes a look with a very sober view at whether we’re truly benefiting people so we’re spending money in the right places,” said Charlie Robinson, the chief health equity officer at L.A. Care, one of the state’s largest Medi-Cal health insurers.

Dorothy Seleski, the Medi-Cal president for Health Net, said the health insurer isn’t deterred by state and federal cuts.

“Regardless of what happens at the federal level, we are committed,” she said. “This is a significant transformation of the healthcare system, and we are already seeing major reductions in avoidable emergency room trips, avoidable hospital admissions, and we’ve closed gaps in preventive care.”

KFF Health 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 KFF.

This <a target="_blank" href="https://kffhealthnews.org/medicaid/medicaid-social-services-gavin-newsom-california-republican-criticism/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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Kelly Haggett figures that a mandatory surcharge added to Washington state’s payroll tax cost her about $500 last year. But she doesn’t really mind.

“On a scale of 1 to 10 of my annoyance with taxes in general, this one is about a 2,” she said. “I see the benefits.”

The small surcharge on wages provides the funding for Washington Cares, the nation’s first state-operated program for long-term care insurance. It was set to begin distributing benefits July 1.

If Haggett, 67, a systems administrator who lives in Auburn, Washington, needs help with daily activities as she ages — bathing, dressing, grocery shopping, managing medications — she’ll be able to use the benefit she has accrued through WA Cares, as the program is known.

About 3.7 million workers participated last year, paying an additional 0.58% in payroll taxes. Those who contribute for 10 years will qualify for a lifetime benefit of $36,500. The amount will rise with inflation: A 36-year-old now earning about $50,000 a year who contributes $291 a year for a decade will have a projected $98,000 benefit if she needs assistance at age 75.

Both the WA Cares mandatory premiums and eventual benefits are modest. But for older adults and people with disabilities, they can help pay for a variety of services: home care, transportation, adult day programs, home modifications like ramps and grab bars, compensation for family members who assist them, or assisted living facilities and nursing homes.

Haggett had looked into private long-term care insurance to cover those needs, but she balked. “It’s crazy expensive,” she said. And since premiums can rise, and frequently have, “you’re basically saying, I’ll pay whatever, whenever.”

Haggett knows that WA Cares can’t cover all her long-term care costs. In fact, because she was already in her 60s when payroll deductions began in 2023, and because she is planning to retire in two years, she’ll receive only half the lifetime benefit.

But “if I required care and it would protect my wife from having to spend our savings, $18,250 is not meaningless,” she said.

Washington has been working toward implementing WA Cares for a decade; the program has survived two statewide votes aimed at overturning or weakening it. Now, other states will be paying attention.

‘Most People Have Nothing’

An estimated 70% of Americans will need long-term care at some point in their lives, but “they haven’t planned for it or saved for it,” said Cathleen MacCaul, advocacy director for AARP Washington State, which supported the legislation that created WA Cares.

“People are under the misconception that Medicare will pay for this,” MacCaul said. In fact, while Medicare pays for healthcare, it rarely covers long-term care, either at home or in facilities.

Medicaid does cover long-term care, but it involves such strict limits on income and assets that “most middle-class people are left out, or they have to impoverish themselves” by spending nearly all their assets to qualify, said Richard Frank, director of the Center on Health Policy at the Brookings Institution. Those who are eligible often face lengthy waiting lists for care at home.

“Long-term care is the largest area of unprotected health risk in the United States,” Frank said. “Most people have nothing.”

Previous efforts to establish public long-term care protections have foundered. In 2010, the Affordable Care Act included the CLASS Act, a legacy of Sen. Ted Kennedy that would have created a voluntary long-term care insurance program. The Obama administration eventually deemed it unworkable, and “it never saw the light of day,” Frank said.

The private market has also contracted. Most of the largest companies selling long-term care insurance — Genworth, John Hancock, MetLife — have exited the market. The return on their investments plummeted when interest rates fell after the Great Recession, and the number of insured people who abandoned their policies — a profitable development for insurers — was far below projections.

“The psychology of the industry was: Holy smokes, we’re losing money! We’re getting out,” said Claude Thau, who directs the annual Milliman Long-Term Care Insurance Survey. As the losses mounted and premiums spiked, consumers such as Haggett stopped buying policies. Moreover, Thau estimated, 1 in 6 applicants are unable to get coverage for health reasons.

Thus, fewer than 35,000 Americans bought stand-alone policies in 2024, compared with about 235,000 in 2010, according to a report from LIMRA, a trade association. The average 60-year-old purchaser would, at age 80, receive a projected maximum benefit of $369 a day, Milliman reported. But the average annual premium on new stand-alone policies in 2024 — $3,265 — can seem daunting to someone close to retirement.

As the purchase of stand-alone policies has dropped, insurance companies have turned to policies bundling some long-term care benefits with life insurance or annuities. Those sales figures are climbing. Still, the association notes, only 3% of Americans age 50 or older have any long-term care insurance.

‘A Five-Alarm Fire’

That has prompted a recent spate of proposals to find public ways to protect Americans from ruinous costs that can continue for years. “This is a five-alarm fire,” said a letter sent in May by U.S. Sen. Ron Wyden of Oregon and 16 fellow Senate Democrats to their colleagues.

The letter, more a statement of purpose than a specific legislative plan, proposed a “home care guarantee” for Medicare beneficiaries, among other efforts. Proponents expect to issue a more detailed report in the fall and to introduce a bill early next year.

A Brookings report also proposed providing subsidized long-term care at home through Medicare, with beneficiaries making contributions according to their ability to pay. Like most of these programs, it would kick in when people need help with activities related to daily living or require supervision because of cognitive decline. The authors estimate that 8.2 million Americans will be eligible, far more than those who qualify for home-based care under Medicaid.

In the House, Rep. Tom Suozzi, a Democrat from New York, and Rep. John Moolenaar, a Republican from Michigan, have introduced legislation to create a catastrophic-insurance program for older people with disabilities. It would require them to pay for care out-of-pocket or with private insurance for the first several years before they would receive a monthly federal benefit.

Enacting federal initiatives in the current political climate seems unlikely, proponents acknowledge. The Trump administration’s plan to cut billions of dollars from Medicaid “has moved the needle backward on the accessibility of long-term care,” said Taylor Harvey, a spokesperson for the Senate Finance Committee.

So other states “are looking at what Washington is doing with a lot of interest,” said Norma Coe, who is an economist at the University of Pennsylvania and is tracking long-term care programs. Legislators have introduced bills in Illinois, Hawai‘i, and West Virginia; other states have task forces studying the issue.

“Long-term care is one of those conversations around every dinner table,” said Bea Rector, assistant secretary for the Department of Social and Health Services’ Home and Community Living Administration.

“Families step in,” she explained. Sometimes they can continue providing care, “but sometimes more formal care has to be put in place. That’s when people see the value of programs like this.”

Steven Russakoff knows the challenges of elder care, having provided years of support for his father, who died two years ago, and for his mother, who is now living in a nursing facility. “It’s brutal, it’s exhausting, and it’s extraordinarily expensive,” he said. The family has liquidated virtually all his parents’ assets to pay for their care.

Russakoff, who is 56 and lives in Shoreline, Washington, initially disliked WA Cares. He could handle the additional deductions (about $250 a year) from his paycheck as a director of university dining services, but he felt forced into a program he couldn’t use if he left the state to retire.

But WA Cares has already been amended several times and has become portable for many participants who move away, making him a convert. “It’s a good idea,” Russakoff concluded. “A necessary evil.”

KFF Health 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 KFF.

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Seasonal work. Inconsistent hours. Frequent moves. Cash payments and informal jobs. For farmworkers who rely on Medicaid, these common employment patterns could put their health coverage at risk.

It’s a heightened concern for the estimated million-plus farmworkers who are U.S. citizens or legal permanent residents, as new work requirements kick in for the federal-state healthcare program that serves low-income and disabled Americans.

Starting next year in most states, many adults enrolled in Medicaid will have to prove they work, are enrolled in college or vocational courses, volunteer, or do unpaid work for at least 80 hours a month.

Advocates say this could pose a significant challenge to Medicaid-eligible farmworkers, who frequently work more than 80 hours a month during harvest season but less in other months. What’s more, outside the harvest season, many workers take on informal jobs in construction, landscaping, or home repair for which they don’t receive formal paychecks that would prove their continuing Medicaid eligibility. Still, they can establish eligibility if they prove their average monthly income over six months is equivalent to at least 80 hours of work at the federal minimum wage.

“Having a work requirement — having to create more paperwork and more proof — is certainly extremely challenging for farmworkers and others who are low-income and who may especially have seasonal jobs, not year-round, and do have periods” when there is no work available, said Alexis Guild, vice president of strategy and programs at Farmworker Justice.

New Requirements, Additional Hurdles

Agriculture is a trillion-dollar industry, and Americans depend on an estimated 2.9 million farmworkers to put food on their tables. Nearly 60% of those workers are U.S. citizens or green-card holders, according to the U.S. Department of Agriculture. The remaining 40% lack legal status or are otherwise ineligible for Medicaid.

Even among farmworkers with citizenship or legal status, the uninsured rate is three times that of the general population, and most farmworkers with insurance are Medicaid beneficiaries, although participation rates vary by state. According to a new analysis, 71%-79% of eligible farmworker households report participation in Medicaid.

The new Medicaid work requirements were a key provision of the One Big Beautiful Bill Act signed last July by President Donald Trump. Under the federal law, 43 states and the District of Columbia must implement the requirements by Jan. 1. A few states have moved to implement the work rule early.

The 80-hour rule applies in states that expanded Medicaid, a process that began in 2014 and was tied to the Affordable Care Act. Following the initial expansions, agricultural workers with legal documentation became 24% more likely to have health insurance, according to a 2021 article in the American Journal of Agricultural Economics.

Immigration Anxieties

The work requirements are the latest in a long list of obstacles placed between workers and the healthcare they’re legally entitled to, Guild said. “Medicaid certainly helps because it alleviates the cost issue,” she said. “But there are still other barriers, such as transportation, taking sick leave, and finding time to visit a health center. All these factors can prevent them from actually receiving medical care.”

For farmworkers with green cards and naturalized U.S. citizens, there is another source of stress: the fear that signing up for Medicaid could put personal information in the hands of immigration authorities.

That’s what worries Luis, a 45-year-old green-card holder and Medicaid recipient who dreams of becoming a U.S. citizen. Luis — who asked to be identified by only his middle name — lives with his wife and daughter in North Carolina, where he has worked in agriculture for nearly a decade.

Speaking in Spanish, he said that when he learned about the work requirements, he knew it would be challenging for him to prove that he works 80 hours a month. “I only work on farms for six or seven months; the rest of the year I work in whatever I can find,” he said.

Republicans in Congress argue that work requirements will reduce federal healthcare spending, encourage nondisabled adults to enter the workforce, and preserve safety net resources for the most vulnerable populations.

Among Hispanic adults enrolled in Medicaid, 67% are already working, according to a 2025 KFF report.

The Centers for Medicare & Medicaid Services did not respond to requests for comment for this article. But in June, when CMS announced its “nationwide framework” to implement the Medicaid work requirements, Administrator Mehmet Oz said it would help beneficiaries “build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families.” Federal officials say the new requirements “could reduce poverty by as much as 2.9 million people.”

Chronic Illness

Agricultural work is one of the nation’s most dangerous occupations, and it is associated with long-term health impacts and high rates of chronic illness, including respiratory conditions. A 2021-22 California survey found that 37% of male farmworkers and 47% of female farmworkers in the state had at least one chronic health condition. The new work requirements present one more barrier for those seeking care, advocates said.

“People skip checkups and screenings, and conditions that could be caught early and treated cost-effectively” aren’t, said Adriana Cadena, executive director of Protecting Immigrant Families.

Emergency rooms often become the “natural” place to go for healthcare, Cadena added. “This drives up waiting times and costs for all of us. … And when people are sick enough that they miss work, it starts a vicious cycle of lost productivity and family economic instability that again threatens all of us.”

A Loss for Families and Children

The new federal rules also require beneficiaries to verify their eligibility at least twice a year, twice as often as previously, creating another potential obstacle.

“Letters can easily be missed, and forms may go unfilled. If people get caught up in the paperwork, they could lose coverage,” said Akeiisa Coleman, an assistant vice president at The Commonwealth Fund, a nonprofit that promotes an equitable healthcare system.

For farmworkers who travel from state to state, the process can be especially difficult.

“You have to find the time to transfer your coverage and probably find a person or organization that can help you — and that can be really hard when you’re constantly moving,” Cadena said.

The situation highlights the difficulties of navigating a complex system for individuals and families already struggling to make ends meet.

“The result,” Cadena said, “could be the loss of coverage not only for workers, but also for their families and children.”

KFF Health 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 KFF.

This <a target="_blank" href="https://kffhealthnews.org/insurance/agricultural-workers-medicaid-eligibility-immigration-food-harvest/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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The Host Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health 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.

As health costs rise and insurance coverage falls, Democrats appear to be doubling down on the healthcare issue as they press their case to take control of Congress in November’s midterm elections.

Meanwhile, on Capitol Hill, Republicans — and some Democrats — are taking aim at nonprofit hospitals and whether they are delivering enough “community benefit” to justify not having to pay taxes.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Victoria Knight of Bloomberg Government, and Rachel Roubein of The Washington Post.

Panelists Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Victoria Knight Bloomberg Government @victoriaregisk Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories.

Among the takeaways from this week’s episode:

• Insurers say they’re expecting to hike premiums even more next year as Affordable Care Act plan enrollment continues to drop. The current decline comes after Congress allowed enhanced ACA subsidies to expire, with many Americans publicly saying they can no longer afford coverage — even as the Trump administration attributes the enrollment drop to a crackdown on fraud.
• Meanwhile, President Donald Trump has seized on the idea that medical providers should have end-of-life conversations with patients, even suggesting penalizing hospitals for not doing so. In 2009, a similar proposal in the ACA debate prompted the GOP to coin the term “death panels.”
• As the midterms approach, a top Senate Democrat has teed up a proposal to cap out-of-pocket costs in traditional Medicare, an idea that could gain even more traction should Democrats reclaim the Senate. Plus, lawmakers are proposing closer scrutiny of nonprofit hospitals, with a new bill proposing the collection of more information on their finances.
• Also, the GOP’s one-year ban on Medicaid funding for Planned Parenthood ended over the weekend, with little appetite in Congress for renewal. And separate pilot programs in Utah and traditional Medicare are testing the use of artificial intelligence in meting out healthcare.

Also this week, Rovner interviews KFF Health News’ Samantha Liss, who wrote the latest “Bill of the Month” report, about a Medicare Advantage patient who changed plans and got a lot of trouble in return. If you have a medical bill that’s confusing, infuriating, or inscrutable, you can share it with us here.

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

Julie Rovner: Axios’ “Chinese Fentanyl Makers Find New U.S. Market in Peptides,” by Tina Reed.  

Shefali Luthra: Stat’s “Online GLP-1 Prescriptions Are Often Fast, Easy — And Low on Clinical Oversight,” by Katie Palmer.  

Rachel Roubein: The New York Times’ “Efforts To Help Smokers Quit Stall Under Trump,” by Chistina Jewett.  

Victoria Knight: Stat’s “Booze Schmooze: The Alcohol Industry, Frazzled by Headwinds, Wields Its Power Behind the Scenes,” by Isabella Cueto and Lev Facher.  

Also mentioned in this week’s podcast:

• Stat’s “America’s Small Businesses Are Giving Up on Health Insurance,” by Bob Herman.
• KFF Health News’ “Medicare’s AI Push Snarls Patients and Doctors in Errors and Delays,” by Darius Tahir.  

Credits Francis Ying Audio producer Taylor Cook Audio producer Emmarie Huetteman Editor

Click here to find all our podcasts.

And subscribe to “What the Health? From KFF Health News” on Apple Podcasts, Spotify, the NPR app, YouTube, Pocket Casts, or wherever you listen to podcasts.

KFF Health 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 KFF.

This <a target="_blank" href="https://kffhealthnews.org/podcast/what-the-health-454-democrats-midterms-nonprofit-hospitals-july-9-2026/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Eight days before my 33rd birthday in April, a social worker at a crisis clinic near Denver determined I was an imminent danger to myself. She placed me on an involuntary 72-hour mental health hold.

What came next wasn’t treatment, but a search for a bed. Clinic staffers called area hospitals with inpatient psychiatric units, asking if they had available beds. They didn’t. So, I was told I had to spend the night at the clinic, which is open 24/7. I settled into a recliner, trying to make myself comfortable as my mind drifted in a blank, disassociated haze. Sleep came in brief bursts.

Since the 1950s, the United States has seen a dramatic decline in the number of psychiatric beds nationwide due in part to deinstitutionalization and the rise of antipsychotics. But that has created a critical shortage for those needing help. From 2011 to 2023, the number of hospitals with inpatient psychiatric units dropped significantly, according to a 2025 study. Another study from that year found that this country has 28.4 inpatient psychiatric beds per 100,000 people — not even half the 60-bed ratio researchers frequently refer to as the optimal level.

The shortage has created what the American Psychiatric Association calls a crisis: emergency rooms overwhelmed with people suffering from severe mental health illnesses, inpatient stays prematurely shortened to speed up bed turnover, and acutely ill individuals left without critical care.

(Oona Zenda/KFF Health News)

“Where are these people going?” said Zoe Lindenfeld, an assistant health policy professor at Rutgers University, who co-authored those 2025 studies. “For people who don’t receive this care, they don’t just go away. How is it affecting them? Society? Their families?”

Meanwhile, the White House shut down the part of the national suicide hotline catering to LGBTQ+ youth, President Donald Trump’s 2027 budget proposal calls for cuts to agencies engaged in mental health work, and Health and Human Services Secretary Robert F. Kennedy Jr. recently announced a plan to reduce the “overuse of psychiatric medications.”

A Fractured System

I was already intimately familiar with the country’s fractured mental healthcare system before I was involuntarily committed. What I had yet to experience myself, I saw through my wife: waitlists, outpatient programs stretched beyond capacity, and inpatient psychiatric care so scarce that access often depends on surviving a crisis severe enough to justify it.

She died by suicide after we had separated.

As the years passed, grief and anxiety pushed me from observer to patient.

At the crisis clinic, I woke up the following morning disoriented and groggy. In the bathroom — its door deliberately unable to latch, swinging both ways so staffers could enter in case of an emergency — I stood at the sink and watched the faucet run, trying to piece together how I had ended up here.

(Oona Zenda/KFF Health News)

America’s history of treating mental illness is long and complicated.

The 19th and 20th centuries saw the removal of people with severe mental disorders from jails and poorhouses — squalid facilities designed to house the poor — to state asylums that promised “moral treatment” (though they ultimately became overcrowded hospitals for the impoverished). From the 1860s to the 1930s, the number of psychiatric hospitals increased dramatically, according to the American Psychiatric Association, and by 1955, the number of psychiatric beds in the U.S. peaked at more than half a million.

However, owing to the development of antipsychotics, the belief that psychiatric institutions were inhumane, and President John F. Kennedy’s 1963 Community Mental Health Act to free thousands of Americans from a life in institutions, many state hospitals shut down. An estimated 61,000 inpatient psychiatric beds for adults and kids are left in a country where more than 14 million experience severe mental illness each year.

Two years after JFK’s legislation passed, a new policy prohibited federal Medicaid funds from covering inpatient psychiatric care in facilities with more than 16 beds. The goal was to encourage states to move patients out of large, often substandard psychiatric institutions into community-based care settings.

The consequences of these changes, however, have been far-ranging. People with severe mental illnesses are often forced to board in emergency departments as they wait for a bed to open. The length of stay in state psychiatric hospitals is shrinking while readmission rates rise, according to research by the Treatment Advocacy Center, a national organization focused on eliminating barriers to the treatment of severe mental illness. And some people with mental illness languish for months, or even years, in jail.

From 1986 to 2014, as the behavioral health crisis intensified, mental health expenditures in the U.S. rose from $32 billion to $186 billion — though the proportion of that spending allocated to inpatient care fell from 42% to 27%.

This period also recorded major policy shifts affecting inpatient hospitalization rates, notably the 1999 U.S. Supreme Court decision in Olmstead v. L.C. The ruling shifted care away from psychiatric facilities by mandating states provide home and community-based services to people with developmental and mental disabilities.

“The road to hell is paved with good intentions,” said Leslie Carpenter, legislative advocacy manager at the Treatment Advocacy Center. “A lot of these bills, including the Community Mental Health Act, were really well intended and ended up with adverse consequences.”

For me, that next day at the clinic passed both painfully slowly and in a blur. A staff member I hadn’t met before told me they were still reaching out to hospitals across the region. The search for a bed continued.

(Oona Zenda/KFF Health News)

‘No One Wants To Pay for Any of This Care’

Last year, members of Congress introduced two bills to change the 16-bed Medicaid funding cap at inpatient psychiatric facilities, the Repealing the Institution for Mental Diseases Exclusion Act and the Michelle Alyssa Go Act, which would increase the cap to 36 beds. Both have stalled in the House.

According to the Congressional Budget Office, a federal agency that analyzes budgetary and economic issues, eliminating the 16-bed limit would increase Medicaid expenditures by $33.5 billion from 2024 to 2033.

“No one wants to pay for any of this care that people need,” said Colorado state Sen. Judy Amabile, a Democrat who has witnessed limitations to Colorado’s mental healthcare system firsthand because her son has schizoaffective disorder.

In lieu of federal action, states are stepping up to bridge the gaps.

Colorado, 15 other states, and Washington, D.C., now operate under waivers allowing Medicaid to fund inpatient facilities with more than 16 beds for mental health treatment, according to KFF data. Seven additional states have waivers pending. One 2025 study found that these waivers may be tied to fewer hospitalizations, emergency department visits, and incarcerations among adults with serious mental illness.

Yet even local efforts to improve mental healthcare face resistance. In California, Colorado, Iowa, Missouri, Nebraska, and New York, locals have pushed back against proposed psychiatric facilities for minors, claiming such facilities will worsen safety and lower property values. Behavioral health advocates have disputed these claims and argued they are rooted in stigma.

That psychiatric facility in Colorado was ultimately greenlit. The state has nearly 20 inpatient beds per 100,000 people, ranking 24th nationwide, according to 2022 data across all 50 states plus Washington, D.C., collected by the Treatment Advocacy Center. Wyoming ranked first with 47.3 beds per 100,000 residents, although, as the least populous state, it has only 275 total inpatient beds compared with California’s 5,703. Minnesota ranked last, with only 4.3 inpatient beds per 100,000 residents.

While increasing the number of inpatient psychiatric beds is vital, mental health advocates are also calling for more community-based supports, such as peer support specialists and clubhouses, where people with serious mental illnesses can learn life skills and find community.

(Oona Zenda/KFF Health News)

When it came time for me to use our mental health safety net, I was among the fortunate ones: At noon the day after my hold began, a bed opened at a hospital in Denver — a rare stroke of luck in a system in which many people wait days or weeks for the care they need. An ambulance transferred me to the hospital at 3 p.m., marking 21 hours into my 72-hour hold.

Two days later, on my last day at the psychiatric hospital, I stood outside the nurse’s station awaiting discharge papers.

A man I had not seen before looked at me and asked, “Are you leaving?”

“Yes,” I said. “Are you being admitted?”

“Yeah,” he responded. “This is my third time being hospitalized in a year.”

I shook his hand. “Good luck,” I said, and I walked out the door.

KFF Health 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 KFF.

This <a target="_blank" href="https://kffhealthnews.org/health-industry/psychiatric-bed-shortage-overburdened-health-system/">article</a&gt; first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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HHS launched the Make Hospital Food Healthier Pledge, a nationwide initiative inviting hospitals to serve healthier, more nutritious meals.

For the second year in a row, many Affordable Care Act insurers are proposing double-digit premium increases, driven by rising medical costs as well as policy changes by Congress and the Trump administration.

In preliminary filings with state regulators, insurers are seeking a median rate increase of 14% for 2027, according to an analysis of filings in 16 states and the District of Columbia by the Peterson-KFF Health System Tracker.

If those rates are ultimately approved, it would be the second-highest increase since 2018.

That would be a “triple whammy“ for consumers, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at KFF, because they have already had to pay higher premiums in 2026 and saw the expiration of more generous tax credits to offset their premiums at the end of last year.

President Joe Biden sought to bolster the program known as Obamacare by enacting more generous tax subsidies, driving down out-of-pocket costs for consumers and increasing enrollment to more than 20 million Americans. But under President Donald Trump, Republicans have sought to scale back taxpayer support for ACA coverage, allowing the Biden-era enhanced subsidies to expire.

As of February, ACA enrollment had fallen by about 3 million people compared with the same time last year. While Cox and other policy experts say that’s because increased costs for the plans drove out people who feel they can get by without insurance, the Trump administration asserts that much of the enrollment growth under Biden was fraudulent.

The main factor driving proposed premium increases for 2027, as in most years, is the rising cost and use of medical care.

There’s growing demand for costly specialty medications and for the weight loss drugs known as GLP-1s, the Peterson-KFF report notes.

But the report also said that about 4 percentage points’ worth of the premium increases insurers proposed are due to lasting effects of the expiration of enhanced subsidies. Insurers expect that with young and healthy people leaving the program rather than paying higher premiums, their remaining customers will be older, sicker, and therefore costlier on average.

 “It’s likely that the people who dropped their coverage were also the healthier people, because sicker people were probably going to try to make it work however they could, to stretch their budget to keep their health insurance,” said Cox, of KFF, a health information nonprofit that includes KFF Health News.

In their rate filings, some insurers also said they had to raise premiums in part because of policy changes by the Trump administration that are expected to make it harder for some people to enroll.

Together with the expiration of the larger subsidies, the new rules “account for 12.7% of the requested rate change,” the insurer UnitedHealthcare wrote in its rate filing with New York state, according to the Peterson-KFF report.

“It is not surprising insurance conglomerates that profited massively off of Biden-era fraud are complaining about efforts to clean up the program,” White House spokesman Kush Desai said in a statement. He added that the administration “has made it clear that it will not follow its predecessors in giving out taxpayer funded subsidies to big insurance companies through the form of fraudulent and corrupt polices” and that it would “hold big insurance companies accountable.”

Another driver of higher premiums cited by several insurers is that claims submitted on behalf of patients have tended to be for more intense — and costly — levels of care than in the past. Such increased severity may be because patients are actually sicker, or it may reflect that hospitals or doctors are using artificial intelligence to find billing codes that can maximize their payments, the report noted.

The use of AI to maximize bills is also a factor driving up the cost of health coverage offered by employers, according to the consulting firm PwC, which forecast that the cost of caring for people with job-based coverage will rise by 9% in 2027.

In the ACA, premium increases will primarily affect enrollees with incomes just above 400% of the federal poverty level, amounting to about $62,600 this year for an individual. That’s because they’re no longer eligible for subsidies following the expiration of the enhanced tax credits.

People below that level get tax credits to help pay their monthly premium, based on how much they earn and the cost of a “benchmark” ACA plan where they live. As a result, as premiums rise, so do subsidies, shielding many consumers from rising prices but also raising costs for the federal government.

They may have to shop around when enrollment opens for 2027 coverage in October, however. Depending on their particular plan’s premium, they may need to switch plans to keep premiums fixed, said Matthew Fiedler, a senior fellow at the Brookings Institution.

KFF Health News senior correspondent Julie Appleby contributed to this report.

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

KFF Health 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 KFF.

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By the time Derion Blackman collapsed in front of a Dollar General in Kissimmee, Florida, in March, he had been waiting two months to regain access to some of the vital medications he’d been taking since undergoing a heart transplant two years ago.

“He was on a nasty, dirty ground in front of a store,” recalled Sonja Smith, who is enraged about the circumstances that led to her husband’s heart failure. “He didn’t deserve to die like that.”

Problems started last year when the couple learned the monthly premium payment for their Federal Employees Health Benefits plan would more than double to $307 and their deductible would also go up. They decided to switch Blackman’s primary coverage to CHAMPVA, a health benefits program for dependents of disabled veterans, which had no premium and a $3,000 deductible.

Smith thought she and Blackman had carefully prepared so that the transition between health plans would be seamless. It was anything but.

After the new health plan became active in January, Smith said, Blackman faced one hurdle after another getting approval for the antirejection medications needed to prevent his body from attacking his transplanted heart. Patients who rely on these drugs can develop severe and life-threatening heart issues if they miss even a few days. She said Blackman had enough medication to last only about a month into the new plan year. He told her just before his death that he had run out.

“I screamed at CHAMPVA. I screamed at the Trump administration. I screamed at the overall healthcare system in this godforsaken country,” she said. “Everybody played a part in what happened to my husband.”

Derion Blackman pictured with his wife, Sonja Smith. Blackman died from heart failure after waiting two months for his new insurer to approve the expensive medications he had needed to take daily since undergoing a heart transplant two years ago. (Sonja Smith)

The Department of Veterans Affairs declined to comment on the record about Blackman’s case.

While the couple’s situation was extreme, their challenge of trying to continue a treatment is faced by many who shop for cheaper options as health insurance costs have soared across the country. The United States already has a fragmented health system, in which insurers, clinicians, and drugmakers are largely left on their own to hash out the cost of each medication or service. That lack of standardization leads to layers of bureaucracy for patients; moving to a new plan can ensnare patients in a thicket of red tape, keeping them from care.

Making matters more challenging, Congress didn’t renew covid pandemic-era subsidies that helped lower premiums for Affordable Care Act marketplace plans before this year. The Trump administration is also adding hurdles for people to access Medicaid, a state-federal health insurance program for Americans with low incomes or disabilities, so more people may lose their current coverage.

“We’ve basically set up a series of cracks in our healthcare system that we ask people to jump over,” said Adrianna McIntyre, an assistant professor of health policy at the Harvard T.H. Chan School of Public Health. “But if you don’t jump over those cracks, you can lose coverage, or lose access to your doctor, or lose access to your medications.”

‘This Is a Lot’

Insurers calibrate plan prices by negotiating rates with individual clinicians, hospital systems, and drugmakers, leading to varying levels of coverage. Plans with lower monthly costs often have narrower networks of doctors and hospitals, and less generous drug coverage.

As a result, when patients choose an insurer — or even a new plan with the same insurer — they may lose access to medications or doctors that they have had for years, said Sabrina Corlette, a research professor in health policy at Georgetown University. There are so many ways “patients could get tripped up,” she said. “When you switch to a new insurance company, they’re going to apply their rules.”

In a pledge announced by the Trump administration last year, many insurers voluntarily agreed to reduce some red tape by honoring existing prior authorizations for 90 days when a patient switches health plans. As required by law, they also offer resources such as plain-language plan descriptions and searchable online clinician directories to help patients coordinate care, according to AHIP, the main health insurance industry trade group.

“The goal is to ensure every member understands their benefits and can access the care they need without interruption,” said Conner Coles, an AHIP spokesperson.

But patients say understanding their benefits can still be a challenge.

Monique Acosta, 54, had to navigate two health insurance changes after she was laid off from her job at a disability nonprofit in October. The heart transplant recipient and cancer survivor said she paid nearly $900 a month to continue her employer coverage under COBRA, the Consolidated Omnibus Budget Reconciliation Act. Then, in January, the Woodbridge, Virginia, resident switched to Medicaid.

During the transitions, Acosta said, she lost coverage for a postchemotherapy drug. So, she changed her care team to qualify for lower-cost medications through a local hospital’s charity program. Then one of her new doctors reduced the frequency of an injection she had gotten for years. During that time, she said, her red and white blood cell counts plummeted and she struggled to recover from a heart catheterization procedure.

Eventually, her new physician upped the frequency of her injections back to twice a month. “He needed to document it so he could see it himself,” Acosta said. “I was very, very fatigued, very weak, and it’s unnecessarily so.”

Acosta said she is putting off a mammogram until she can better understand her Medicaid plan or find a job with better benefits. “This is overwhelming,” she said. “This is a lot.”

Burden on the Patient

Federal regulations, 43 states, and Washington, D.C., have continuity of care protections that require health plans to continue covering doctors and drugs when there is a network change, like when a clinician or hospital that a patient goes to is terminated from the insurer’s network of providers.

But Corlette said that not all the protections address the trip wires people face when they switch insurers on their own, such as during open enrollment or after a major life change.

Still, people can be proactive in a few ways about maintaining care when they change plans, said Shelli Quenga, an insurance agent in South Carolina.

She advises patients to keep written records of their medical and drug history for new providers. Quenga tells her customers to get their new insurance information to their doctors as soon as they switch, not to wait until an appointment. In addition, she said patients can request a case manager with their insurer so they don’t have to repeat their concerns to different staffers.

Even when a patient does homework, doctors can drop out of a network and insurers can change the contours of their plans, McIntyre said.

“Nobody has an incentive to make it make sense,” she said. “This puts a lot of burden on the patient.”

They Switched to a Lower-Cost Plan. Then the Bureaucracy Battle Began.

Sonja Smith, 50 
Kissimmee, Florida 

Sonja Smith and her husband, Derion Blackman, switched insurers last year when the premium payments for their previous plan were set to more than double. The couple planned to make the transition seamless. But after the new health plan became active in January, Smith said, Blackman faced one hurdle after another getting approval for the antirejection medications needed to prevent his body from attacking his transplanted heart. In mid-March, Blackman collapsed and died.  

“I screamed at the overall healthcare system in this godforsaken country,” Smith said. “Everybody played a part in what happened to my husband.” — Renuka Rayasam 

The cost-sharing program Blackman was part of, which has about 1 million enrollees, doesn’t work like traditional insurance. It has no networks or third-party appeals process, according to Caira Benson, a staffer at Code of Support Foundation, an organization that supports veterans. Instead, the program covers part of a patient’s cost of care.

Blackman qualified for the program because Smith was declared permanently disabled due to physical and mental injuries she sustained following an assault on an Air Force base during her service. CHAMPVA was Blackman’s secondary insurance previously.

One of his medications was about $800 a month, more than half his disability check. Knowing that these heart medications were crucial, Smith said, the couple in November called CHAMPVA, which she said confirmed it would cover the drugs. But they still got caught in red tape.

CHAMPVA had Blackman’s previous insurance listed as his primary, even though he had canceled that plan. That took six weeks to resolve. Some but not all of his medications came, because the health plan said his provider needed to clarify his prescriptions.

“Now I’m left here trying to piece together all the things that happened,” Smith said.

And she is full of regrets, too.

“I would have kissed him one more time before he walked out the door,” she said through sobs. “I feel so cheated.”

KFF Health News South Carolina correspondent Lauren Sausser contributed to this report.

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

KFF Health 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 KFF.

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