ALBANY, Ga. — Belinda McLoyd has been thinking about peanut butter.

McLoyd, 64, receives a small monthly payment through the federal Supplemental Nutrition Assistance Program, previously known as food stamps.

“They don’t give you that much to work with,” she said. To fit her tight budget, she eats ramen noodles — high on sodium and low on nutrition — multiple times a week.

If she had more money, said McLoyd, who has been diagnosed with multiple sclerosis and heart problems, she’d buy more grapes, melons, chuck roast, ground turkey, cabbage, and turnip greens. That’s what she did when lawmakers nearly doubled her SNAP benefit during the pandemic.

But now that a GOP-led Congress has approved $186 billion in cuts to the food assistance program through 2034, McLoyd, who worked in retail until she retired in 2016, isn’t sure how she will be able to eat any healthy food if her benefits get reduced again.

McLoyd said her only hope for healthy eating might be to resort to peanut butter, which she heard “has everything” in it.

“I get whatever I can get,” said McLoyd, who uses a walker to get around her senior community in southwestern Georgia. “I try to eat healthy, but some things I can’t, because I don’t have enough money to take care of that.”

The second Trump administration has said that healthy eating is a priority. It released a “Make America Healthy Again” report citing poor diet as a cause of childhood illnesses and chronic diseases. And it’s allowing states — including Arkansas, Idaho, and Utah — to limit purchases of unhealthy food with federal SNAP benefits for the first time in the history of the century-old anti-hunger program.

President Donald Trump also signed a tax and spending law on July 4 that will shift costs to states and make it harder for people to qualify for SNAP by expanding existing work requirements. The bill cuts about 20% of SNAP’s budget, the deepest cut the program has faced. About 40 million people now receive SNAP payments, but 3 million of them will lose their nutrition assistance completely, and millions more will see their benefits reduced, according to an analysis of an earlier version of the bill by the nonpartisan Congressional Budget Office.

Researchers say SNAP cuts run counter to efforts to help people prevent chronic illness through healthy food.

“People are going to have to rely on cheaper food, which we know is more likely to be processed, less healthy,” said Kate Bauer, an associate professor of nutritional sciences at the University of Michigan School of Public Health.

“It’s, ‘Oh, we care about health — but for the rich people,’” she said.

About 47 million people lived in households with limited or uncertain access to food in 2023, according to the U.S. Department of Agriculture. The agency’s research shows that people living in food-insecure households are more likely to develop hypertension, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

The Trump administration counters that the funding cuts would not harm people who receive benefits.

“This is total fearmongering,” said White House spokesperson Anna Kelly in an email. “The bill will ultimately strengthen SNAP for those who need it by implementing cost-sharing measures with states and commonsense work requirements.”

McLoyd and other residents in Georgia’s Dougherty County, where Albany is located, already face steep barriers to accessing healthy food, from tight budgets and high rates of poverty to a lack of grocery stores and transportation, said Tiffany Terrell, who founded A Better Way Grocers in 2017 to bring fresh food to people who can’t travel to a grocery store.

More than a third of residents receive SNAP benefits in the rural, majority-Black county that W.E.B. Du Bois described as “the heart of the Black Belt” and a place “of curiously mingled hope and pain,” where people struggled to get ahead in a land of former cotton plantations, in his 1903 book, “The Souls of Black Folk.”

Terrell said that a healthier diet could mitigate many of the illnesses she sees in her community. In 2017, she replaced school bus seats with shelves stocked with fruits, vegetables, meats, and eggs and drove her mobile grocery store around to senior communities, public housing developments, and rural areas.

But cuts to food assistance will devastate the region, setting back efforts to help residents boost their diet with fruits, vegetables, and other nutritious food and tackle chronic disease, she said.

Terrell saw how SNAP recipients like McLoyd ate healthier when food assistance rose during the pandemic. They got eggs, instead of ramen noodles, and fresh meat and produce, instead of canned sausages.

Starting in 2020, SNAP recipients received extra pandemic assistance, which corresponded to a 9% decrease in people saying there was sometimes or often not enough food to eat, according to the Institute for Policy Research at Northwestern University. Once those payments ended in 2023, more families had trouble purchasing enough food, according to a study published in Health Affairs in October. Non-Hispanic Black families, in particular, saw an increase in anxiety, the study found.

“We know that even short periods of food insecurity for kids can really significantly harm their long-term health and cognitive development,” said Katie Bergh, a senior policy analyst on the food assistance team at the Center on Budget Policy and Priorities. Cuts to SNAP “will put a healthy diet even farther out of reach for these families.”

The Trump administration said it’s boosting healthy eating for low-income Americans through restrictions on what they can buy with SNAP benefits. It has begun approving state requests to limit the purchase of soda and candy with SNAP benefits.

“Thank you to the governors of Indiana, Arkansas, Idaho, Utah, Iowa, and Nebraska for their bold leadership and unwavering commitment to Make America Healthy Again,” said Health and Human Services Secretary Robert F. Kennedy Jr. in a press release about the requests. “I call on every governor in the nation to submit a SNAP waiver to eliminate sugary drinks — taxpayer dollars should never bankroll products that fuel the chronic disease epidemic.”

Although states have asked for such restrictions in the past, previous administrations, including the first Trump administration, never approved them.

Research shows that programs encouraging people to buy healthy food are more effective than regulating what they can buy. Such limits increase stigma on families that receive benefits, are burdensome to retailers, and often difficult to implement, researchers say.

“People make incredibly tough choices to survive,” said Gina Plata-Nino, the deputy director of SNAP at the Food Research & Action Center, a nonprofit advocacy group, and a former senior policy adviser in the Biden administration.

“It’s not about soda and candy,” she said. “It’s about access.”

Terrell said she is unsure how people will survive if their food benefits are further trimmed.

“What are we thinking people are going to do?” said Terrell of A Better Way Grocers, who also opened a bustling community market last year that sells fresh juices, smoothies, and wellness shots in downtown Albany. “We’ll have people choosing between food and bills.”

That’s true for Stephen Harrison, 22, whose monthly SNAP benefit supports him, along with his parents and younger brother. During the pandemic, he used the extra assistance to buy strawberries and grapes, but now he comes into A Better Way Grocers to buy an orange when he can.

Harrison, who is studying culinary arts at Albany Technical College, said his family budgets carefully to afford meals like pork chops with cornbread and collard greens, but he said that, if his benefits are cut, the family will have to resort to cheaper foods.

“I’d buy hot dogs,” he said with a shrug.

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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When Lawrence and Penny Higgins of Fairfield, Maine, first learned in 2020 that high levels of toxic chemicals called PFAS taint their home’s well water, they wondered how their health might suffer. They had consumed the water for decades, given it to their pets and farm animals, and used it to irrigate their vegetable garden and fruit trees.

“We wanted to find out just what it’s going to do to us,” Penny Higgins said. They contacted a couple of doctors, but “we were met with a brick wall. Nobody knew anything.”

Worse still, she added, they “really didn’t want to hear about it.”

Many clinicians remain unaware of the health risks linked to PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, despite rising medical and public awareness of the chemicals and their toxicity. PFAS can affect nearly every organ system and linger in bodies for decades, raising risks of cancer, immune deficiencies, and pregnancy complications.

These “forever chemicals” have been widely used since the 1950s in products including cosmetics, cookware, clothing, carpeting, food packaging, and firefighting foam. Researchers say they permeate water systems and soils nationwide, with a federal study estimating that at least 45% of U.S. tap water is contaminated. PFAS can be detected in the blood of nearly all Americans, according to the Centers for Disease Control and Prevention.

Maine was among the first states to begin extensive water and soil testing and to try to limit further public exposure to PFAS through policy action, after discovering that farms and residences — like the Higgins’ property — had been contaminated by land-spreading of wastewater sludge containing PFAS. Exposure can also be high for people living near military bases, fire training areas, landfills, or manufacturing facilities.

In regions where testing reveals PFAS hot spots, medical providers can be caught flat-footed and patients left adrift.

Rachel Criswell, a family practice doctor and environmental health researcher, is working to change that. She was completing her residency in Central Maine around the time that the Higginses and others there began discovering the extent of the contamination. Her medical training at Columbia University included more than a year in Norway researching the effects of PFAS and other chemicals on maternal and infant health.

When patients began asking about PFAS, Criswell and the state toxicologist offered primary care providers lunchtime presentations on how to respond. Since then, she has fielded frequent PFAS questions from doctors and patients throughout the state.

Even knowledgeable providers can find it challenging to stay current given rapidly evolving scientific information and few established protocols. “The work I do is exhausting and time-consuming and sometimes frustrating,” Criswell said, “but it’s exactly what I should be doing.”

Phil Brown, a Northeastern University sociology professor and a co-director of the PFAS Project Lab, said the medical community “doesn’t know a lot about occupational and environmental health,” adding that “it’s a very minimal part of the medical school curriculum” and continuing education.

Courtney Carignan, an environmental epidemiologist at Michigan State University, said learning of PFAS exposure, whether from their drinking water or occupational sources, “is a sensitive and upsetting situation for people” and “it’s helpful if their doctors can take it seriously.”

Clinical guidance concerning PFAS improved after the National Academies of Sciences, Engineering, and Medicine released a report on PFAS in 2022. It found strong evidence associating PFAS with kidney cancer, high cholesterol, reduced birth weights, and lower antibody responses to vaccines, and some evidence linking PFAS to breast and testicular cancer, ulcerative colitis, thyroid and liver dysfunction, and pregnancy-induced hypertension.

That guidance “revolutionized my practice,” Criswell said. “Instead of being this hand-wavey thing where we don’t know how to apply the research, it brought a degree of concreteness to PFAS exposure that was kind of missing before.”

The national academies affirmed what Criswell had already been recommending: Doctors should order blood tests for patients with known PFAS exposures.

Testing for PFAS in blood — and for related medical conditions if needed — can help ease patients’ anxiety.

“There isn’t a day that goes by,” Lawrence Higgins said, “that we don’t think and wonder when our bodies are going to shut down on us.”

‘Devastating but Incredibly Helpful’

After finding out in 2021 that his family was exposed to PFAS through sludge spread on their Unity, Maine, farm decades earlier, Adam Nordell discovered that “it was exceedingly difficult” to get tested. “Our family doctor had not heard of PFAS and didn’t know what the test was,” he said. A lab technician needed coaching from an outside expert to source the test. The lab analyzing the samples had a backlog that left the family waiting three months.

“The results were devastating but incredibly helpful,” Nordell said. Their blood serum levels for PFAS were at roughly the 99th percentile nationally, far higher than their well-water levels would have predicted — indicating that additional exposure was probably coming from other sources such as soil contact, dust, and food.

Blood levels of PFAS between 2 and 20 nanograms per milliliter may be problematic, the national academies reported. In highly contaminated settings, blood levels can run upward of 150 times the 20-ng/mL risk threshold.

Nordell and his family had been planning to remain on the farm and grow crops less affected by PFAS, but the test results persuaded them to leave. “Knowledge is power,” Nordell said, and having the blood data “gave us agency.”

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The national academies’ guidance paved the way for more clinicians to order PFAS blood tests. The cost, typically $400 to $600, can be prohibitive if not picked up by insurance, and not all insurers cover the testing. Deductibles and copays can also limit patients’ capacity to get tested. Less costly finger-prick tests, administered at home, appear to capture some of the more commonly found PFAS as accurately as blood serum tests, Carignan and colleagues found.

Maine legislators recently passed, with overwhelming support, a bill — modeled after one in New Hampshire — that would require insurers to consider PFAS blood testing part of preventive care, but it was carried over to the next legislative session.

“In my mind, it’s a no-brainer that the PFAS blood serum test should be universally offered — at no cost to the patient,” said Nordell, who now works as a campaign manager for the nonprofit Defend Our Health. Early screening for the diseases associated with PFAS, he said, is “a humane policy that’s in the best interests of everyone involved” — patients, providers, and insurance companies.

Criswell tells colleagues in family practice that they can view elevated PFAS blood levels as a risk factor, akin to smoking. “What’s challenging as a primary care doctor is the nitty-gritty” of the testing and screening logistics, she said.

In trainings, she shares a handout summarizing the national academies’ guidance — including associated heath conditions, blood testing, clinical follow-up, and exposure reduction — to which she has added details about lab test order codes, insurance costs and coverage, and water filtration.

Criswell served on an advisory committee tasked with allocating $60 million in state funds to address PFAS contamination from past sludge-spreading in Maine. The group recommended that labs analyzing PFAS blood tests should report the results to state public health authorities.

That change, slated to take effect this summer, will allow Maine health officials to follow up with people who have high PFAS blood levels to better determine potential sources and to share information on health risks and medical screening. As with many earlier PFAS policies, Maine is among the first states to adopt this measure.

Screening for PFAS is falling short in many places nationwide, said Kyle Horton, an internist in Wilmington, North Carolina, and founder of the nonprofit On Your Side Health. She estimates that only about 1 in 100 people facing high PFAS exposure are getting adequate medical guidance.

Even in her highly contaminated community, “I’m not aware of anyone who is routinely screening or discussing PFAS mitigation with their patients,” Horton said. Knowledge of local PFAS threats, she added, “hasn’t translated over to folks managing patients differently or trying to get through to that next phase of medical monitoring.”

Patients as Advocates

In heavily affected communities — including in Michigan, Maine, and Massachusetts — patients are pushing the medical field to better understand PFAS.

More doctors are speaking out as well. Testifying before a Maine legislative committee this year in support of a bill that would limit occupational PFAS exposure, Criswell said, “We, as physicians, who are sworn to protect the health of our patients, must pay attention to the underlying causes of the illnesses we treat and stand up for policy solutions that reduce these causes.”

Even where policy changes are instituted, the physical and psychological toll of “forever chemicals” will extend far into the future. Criswell and other Maine doctors have observed chronic stress among patients.

Nordell, the former farmer, described his family’s contamination as “deeply, deeply jarring,” an ordeal that has at times left him “unmoored from a sense of security.”

To assess the mental health consequences of PFAS exposure in rural residents, Criswell and Abby Fleisch, a pediatric endocrinologist at the MaineHealth Institute for Research, teamed up on a study. In its first phase, winding up this summer, they collected blood samples and detailed lifestyle information from 147 people.

Nordell, the Higginses, and other Central Maine residents sit on an advisory board for the study, a step Criswell said was critical to ensuring that their research helps those most affected by PFAS.

“The urgency from the community is really needed,” she said. “I don’t think I would be as fired up if my patients weren’t such good advocates.”

Criswell has faced what she calls “cognitive dissonance,” caught between the deliberate pace of peer-reviewed medical research and the immediate needs of patients eager to lower their PFAS body burden. Initially she considered inviting residents to participate in a clinical trial to test therapies that are considered safe and may help reduce PFAS levels in the body, such as high-fiber diets and a drug designed to reduce cholesterol called cholestyramine. But the clinical trial process could take years.

Criswell and Fleisch are instead planning to produce a case series on PFAS blood-level changes in patients taking cholestyramine. “We can validate the research results and share those,” Criswell said, potentially helping other patients.

Alan Ducatman, an internist and occupational physician who helped design the largest PFAS cohort study to date, said providers should convey that “there is no risk-benefit analysis” for any of the current treatments, although they’re generally well known and low-risk.

“Some people want to be treated, and they should be allowed to be treated,” he said, because knowing they have high PFAS levels in their bodies “preys on them.”

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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“Almost 5 million able-bodied Medicaid recipients ‘simply choose not to work’ and ‘spend six hours a day socializing and watching television.’”

Scott Jennings on “CNN NewsNight with Abby Phillip” on July 1

Republicans defended the GOP megabill’s Medicaid changes as targeting a group of people they believe shouldn’t qualify: people who can work but instead choose to stay home and chill.

Several Republican politicians and pundits, including CNN senior political commentator Scott Jennings, pegged that group’s size at about 5 million people.

“There are like almost 5 million able-bodied people on Medicaid who simply choose not to work,” Jennings said July 1 on “CNN NewsNight with Abby Phillip.” “They spend six hours a day socializing and watching television. And if you can’t get off grandma’s couch and work, I don’t want to pay for your welfare.”

Centers for Medicare & Medicaid Services Administrator Mehmet Oz picked up on some of these points during a July 14 appearance on Fox News. “When the program was created 60 years ago, it never dawned on anyone that you would take able-bodied individuals who could work and put them on Medicaid. Today the average able-bodied person on Medicaid who doesn’t work, they watch 6.1 hours of television or just hang out,” Oz said.

Medicaid is a federal-state health insurance program that covers medical care for lower-income people.

Jennings cited two pieces of data: an estimate of how many fewer people would have coverage because of the work requirement and an analysis of how nonworking Medicaid recipients spend their time. But he made assumptions that the data doesn’t support.

Jennings Misrepresents CBO Estimate

The 4.8 million figure stems from a June 24 Congressional Budget Office analysis of a preliminary House version of the massive tax and spending package. The office, Congress’ nonpartisan research arm, projected that provisions of the bill would cause 7.8 million fewer people to have health coverage by 2034. They would include 4.8 million people previously eligible for Medicaid described as “able-bodied” adults 19 to 64 years old who have no dependents and who “do not meet the community engagement requirement” of doing “work-related activities” at least 80 hours a month.

Apart from working, doing community service and attending school also fulfill the community engagement requirement.

Jennings paired that statistic with a separate analysis of how nondisabled adult Medicaid recipients without dependent children spend their time.

But the CBO estimate was a projection — it doesn’t represent the current number of nondisabled Medicaid recipients, nor does it say 4.8 million people in this group “choose not to work.” The figure represented how many fewer people would have coverage because of the bill’s community engagement requirement.

“The challenge with Jennings’ comments — and they’ve been echoed elsewhere by elected Republicans — is that CBO never said that 4.8 million people were out of compliance with the proposed work requirements; they said that 4.8 million people would lose coverage because of the work requirements,” said Adrianna McIntyre, an assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health.

Among the Medicaid expansion population, the law requires most adults without dependent children and parents of children older than 13 to work or participate in other qualifying activities 80 hours every month. States will need to verify that applicants met the work requirement for one to three months before they applied. States will also be required to verify that existing enrollees met the work requirement for at least a month between eligibility determinations, which will be required at least twice a year.

Research into Medicaid work requirements imposed at the state level has shown that people found it difficult to fulfill them and submit documentation, contributing to coverage losses.

In Arkansas, which added a work requirement to Medicaid in 2018, a study based on nearly 6,000 respondents found that about 95% of the target population were already working or qualified for an exemption, but a third of them did not hear about the work requirements. As a result, nearly 17,000 Medicaid recipients subject to work requirements lost coverage.

KFF found that adults ages 50 to 64 are more at risk of losing Medicaid coverage because of the new work requirements. More than 1 in 10 in that age group said they had retired, and among them, 28% reported being disabled, said KFF, a health information nonprofit that includes KFF Health News.

Benjamin Sommers, a health care economics professor at the Harvard Chan school, said many of the 4.8 million “able-bodied” people in the CBO estimate “will actually be engaged in the activities they are supposed to be doing, and lose coverage because they are not able to navigate the reporting requirements with the state and lose coverage from red tape.”

When Recipients Don’t Work, It’s Rarely From Lack of Interest

There is no universal definition for “able-bodied”; disability can be assessed in different ways. But other studies offer much smaller estimates than 4.8 million Medicaid recipients without dependents who can work but choose not to.

Millions of working-age, nondisabled adults joined the Medicaid ranks in states that expanded eligibility under the Affordable Care Act. There were about 34 million working-age nondisabled Medicaid enrollees in 2024, according to the CBO, 15 million of whom enrolled through the ACA.

A KFF analysis found a smaller figure of 26 million Medicaid-covered adults, ages 19 to 64, who don’t receive Supplemental Security Income, Social Security Disability Insurance, or Medicare benefits.

Among this group, KFF estimated, 64% were working either full time or part time. The reasons the rest were not working included caregiving (12%); illness or disability (10%); retirement, inability to find work, or other reason (8%); and school attendance (7%).

Few people cited lack of interest in working as the reason for their unemployment. An Urban Institute study found 2% of Medicaid expansion enrollees without dependents who neither worked nor attended school — or 300,000 people out of a projected 15 million subject to work requirements — cited a lack of interest in working as the reason they were unemployed.

This was consistent with the Brookings Institution’s June 5 analysis that found that, of 4.3 million adult enrollees who worked fewer than 80 hours a month and did not have any activity limitations or illnesses, about 300,000 reported that they “did not work because they did not want to.”

Mostly Women, Mostly With a High School Degree or Less

When Republicans have described nondisabled adult Medicaid recipients, they have often portrayed them as men in their 30s “playing video games” in their parents’ basement or who “smoke weed all day.” Research paints a different picture.

Jane Tavares and Marc Cohen, of the University of Massachusetts-Boston Gerontology Department, researched Medicaid recipients who are not disabled or working, have no dependent children under 18, and are not in school. They cited 2023 census data from the American Community Survey.

They found:

• The average age of this population is 41, and 26% are older than 50.
• Almost 80% are female.
• Most, 80%, have a high school education or less.
• Their median individual income is $0, and their median household income is $44,800.
• About 56% worked in the past five years, and 23% worked in the prior year. About 30% are looking or available for work.

“They are not healthy young adults just hanging out,” the authors, along with health law experts Sara Rosenbaum and Alison Barkoff, wrote April 30.

“It’s clear based on their prior work history and family size/income that they are exceptionally poor and have likely left the workforce to care for adult children or older adults,” Tavares told PolitiFact. “Even if these individuals could work, they would have very few job opportunities and it would come at the cost of the people they are providing care for.”

AEI Study Not Definitively Linked to CBO Estimate

On the social platform X, Jennings posted the CBO letter and a May 29 analysis by the American Enterprise Institute, a conservative think tank, about “how nondisabled Medicaid recipients without children spend their time.” PolitiFact contacted CNN to reach Jennings but did not receive a reply.

The author of that study, American Enterprise Institute senior fellow Kevin Corinth, analyzed survey data and found that Medicaid recipients who do not report working spend on average 6.1 hours a day “on all socializing, relaxing and leisure activities (including television and video games).”

But it’s uncertain whether the people in the survey population he analyzed overlap with the people included in the CBO analysis, said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.

Corinth told PolitiFact “it is difficult to say” how the population he analyzed differs from the CBO’s. Tavares, Cohen, Rosenbaum, and Barkoff said Corinth’s dataset defined disability narrowly, leading to a “serious underestimation of disability” among the population of Medicaid recipients he looked into. It focused on Medicaid recipients who receive Supplemental Security Income or have a health condition that prevents them from working. The researchers said this approach is too narrow because the SSI program accounts for only those “most deeply impoverished adults with severe disabilities.”

The group gave a hypothetical example of a 54-year-old woman with a serious heart condition who can work only a few hours a week. She may not be considered disabled under the SSI program, but she may be limited in the work she can do and may need time to rest.

“Using her ‘leisure time’ to justify a work requirement grossly misrepresents her reality,” the group wrote.

Corinth’s analysis also shows that nonworking Medicaid recipients spend less time socializing, relaxing, or engaged in leisure activities than nonworking people who aren’t covered by Medicaid. Nonworking Medicaid recipients also spend more time looking for work and doing housework and errands, it found.

Our Ruling

Jennings said almost 5 million nondisabled Medicaid recipients “simply choose not to work” and “spend six hours a day socializing and watching television.”

The 5 million figure stems from a CBO projection that 4.8 million people would go without coverage by 2034 as a result of not fulfilling the community engagement requirements. It is not descriptive of current enrollees and does not specify that these people choose not to work.

Jennings cited an American Enterprise Institute analysis on how nondisabled Medicaid recipients with no dependents spend their time, but it is uncertain if the population in that analysis overlaps with that in the CBO estimate.

Current snapshots of the population Jennings described produce a smaller number. A survey by the Urban Institute found that 2% of Medicaid expansion enrollees without dependents who were neither working nor attending school — about 300,000 people — cited a lack of interest in working. Other research has found reasons this group doesn’t work include caregiving, illness or disability, retirement, and inability to find work.

Studies of nonworking Medicaid recipients have found the majority are women and have a high school education or less. Their average age is 41, and more than half have a work history in the past five years.

We rate Jennings’ statement False.

Our Sources

Email interview, Jane Tavares, University of Massachusetts-Boston adjunct instructor in gerontology, July 2, 2025

Email interview, Marc Cohen, University of Massachusetts-Boston professor of gerontology, July 2, 2025

Email interview, Sara Rosenbaum, George Washington University Milken Institute School of Public Health professor emerita of health law and policy, July 2, 2025

Email interview, Alison Barkoff, George Washington University Milken Institute School of Public Health associate professor of health law and policy, July 2, 2025

Email interview, Edwin Park, Georgetown University McCourt School of Public Policy Center for Children and Families research professor, July 2, 2025

Email interview, Benjamin Sommers, Harvard T.H. Chan School of Public Health professor of health care economics, July 2, 2025

Phone interview, Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, July 2, 2025

Email interview, Adrianna McIntyre, Harvard T.H. Chan School of Public Health assistant professor of health policy and politics, July 2, 2025

Phone interview, Michael Karpman, Urban Institute Health Policy Division principal research associate, July 3, 2025

Email exchange, Congressional Budget Office spokesperson, July 2, 2025

Email interview, Kevin Corinth, American Enterprise Institute senior fellow, July 3, 2025

X post by Rapid Response 47, June 30, 2025

Transcript of “CNN NewsNight with Abby Phillip,” July 1, 2025

Congressional Budget Office, “Re: Information Concerning Medicaid-Related Provisions in Title IV of H.R. 1,” June 24, 2025

Benjamin D. Sommers, M.D., Ph.D., Anna L. Goldman, M.D., M.P.A., M.P.H., Robert J. Blendon, Sc.D., E. John Orav, Ph.D., and Arnold M. Epstein, M.D., “Medicaid Work Requirements — Results From the First Year in Arkansas,” June 19, 2019

Congressional Budget Office, Baseline Projections, Medicaid, June 2024

KFF, “Understanding the Intersection of Medicaid and Work: An Update,” May 30, 2025

Urban Institute, “Many Working People Would Be Shut Out of Medicaid Under Proposed Work Requirements,” June 11, 2025

Wisconsin Watch, “Have Millions of Nondisabled, Working-Age Adults Been Added to Medicaid?” July 2, 2025

CBS News, “Too Sick To Work, Some Americans Worry Trump’s Bill Will Strip Their Health Insurance,” June 26, 2025

Brookings Institution, “Any Way You Look at It You Lose: Medicaid Work Requirements Will Either Fall Short of Anticipating Savings or Harm Vulnerable Beneficiaries,” June 5, 2025

X post by Scott Jennings, July 2, 2025

American Enterprise Institute, “How Nondisabled Medicaid Recipients Without Children Spend Their Time,” May 29, 2025

Congressional Budget Office, “Estimated Budgetary Effects of an Amendment in the Nature of a Substitute to H.R. 1, the One Big Beautiful Bill Act, Relative to CBO’s January 2025 Baseline,” June 29, 2025

Geiger Gibson Program in Community Health, George Washington University Milken Institute School of Public Health, “The Fundamental Flaw in ‘How Workers Spend Their Time’,” June 4, 2025

X post by Aaron Rupar, July 1, 2025

X post by Congressman Brandon Gill, July 2, 2025

LeadingAge LTSS Center @UMass Boston, “Profile of Medicaid Population Age 18-64, Working and Non-Working Medicaid Beneficiaries, and ‘Able-Bodied’ Non-Working Medicaid Beneficiaries,” May 2025

The Milbank Quarterly, “Who’s Affected by Medicaid Work Requirements? It’s Not Who You Think,” April 30, 2025

KFF, “Different Data Source, but Same Results: Most Adults Subject to Medicaid Work Requirements Are Working or Face Barriers to Work,” June 25, 2025

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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HHS under the leadership of Secretary Robert F. Kennedy, Jr. announced a major initiative to begin reforming the organ transplant system

SHREVEPORT, La. — When Robert Smith met his future girlfriend in 2010, he wanted to take things slowly. For Smith, no relationship had been easy in the years since he was diagnosed with the human immunodeficiency virus, or HIV. People often became afraid when they learned his status, even running away when he coughed.

The couple waited months to have sex until Smith felt he could share his medical status. To prepare her, Smith said, he took his girlfriend to his job in HIV prevention at the Philadelphia Center, a northwestern Louisiana nonprofit that offers resources to people with HIV, which also provided him housing at the time.

Finally, he revealed the news: Smith was diagnosed with HIV in 1994 and started taking daily antiviral pills in 2006. The virus could no longer be detected in his blood, and he couldn’t transmit it to a sexual partner.

Smith said his girlfriend seemed comfortable knowing his status. When it came to sex, there was no hesitation, he said. But a couple of years later, when Smith wanted to break up, he said, her tone shifted.

“She was like, ‘If you try to leave me, I’m gonna put you in jail,’” recalled Smith, now 68. “At the time, I really didn’t know the sincerity of it.”

After they broke up, she reported him to the police, accusing him of violating a little-known law in Louisiana — a felony called “intentional exposure to HIV.” He disputed the allegations, but in 2013 accepted a plea deal to spend six months in prison on the charge. He had a few months left on parole from a past conviction on different charges, and Smith thought this option would let him move past the relationship faster. He didn’t realize the conviction would also land him on the state’s sex offender registry.

For nearly two decades, Smith had dealt with the stigma associated with having HIV; the registry added another layer of exclusion, severely restricting where he could live and work to avoid minors. Not many people want to hire a sex offender, he said. Smith has been told by the local sheriff’s office he’s not allowed to do simple things, like go to a public park or a high school football game, since the conviction.

“I’ve been undetectable for 15 years, but that law still punishes us,” Smith said.

Louisiana is one of 30 states with criminal penalties related to exposing or transmitting HIV. Most of the laws were passed in the 1980s during the emergence of the AIDS epidemic. Since then, several states have amended their laws to make them less punitive or repealed them outright, including Maryland and North Dakota this year.

But Louisiana’s law remains among the harshest. The state is one of five that may require people such as Smith to register as a sex offender if convicted, a label that can follow them for over a decade. And state lawmakers considered a bill to expand the law to apply to other sexually transmitted infections, then failed to pass it before the session ended.

Meanwhile, people with HIV also face the threat that federal funding cuts will affect their access to treatment, along with prevention efforts, supportive services, and outreach. Such strategies have proved to slow the HIV/AIDS epidemic, unlike the laws’ punitive approach.

The tax and domestic policy law previously known as the “One Big Beautiful Bill” will likely affect HIV-positive people enrolled in Medicaid by reducing federal support for Medicaid and restricting eligibility. About 40% of adults under 65 with HIV rely on Medicaid.

The Trump administration proposed in its fiscal 2026 budget request to eliminate HIV prevention programs at the Centers for Disease Control and Prevention and to cancel a grant that helps fund housing for people with HIV. The Ryan White HIV/AIDS program, the largest federal fund dedicated to supporting HIV-positive people, also faces cuts. The program serves more than half of the people in the U.S. diagnosed with HIV, including in Louisiana, according to KFF, a health information nonprofit that includes KFF Health News.

Public health officials maintain that state laws criminalizing HIV exposure hurt efforts to end the HIV epidemic. Epidemiologists and other experts on AIDS agree that the enforcement of such laws is often shaped by fear, not science. For example, in many states that criminalize HIV exposure, people living with HIV can face heightened criminal penalties for actions that can’t transmit the virus, such as spitting on someone. The laws further stigmatize and deter people from getting tested and treatment, undermining response to the epidemic, experts say.

At least 4,400 people in 14 states have been arrested under these laws, though data is limited and the actual number is likely higher, and the arrests aren’t decreasing, according to analyses by UCLA’s Williams Institute.

“ Some people think it’s an issue that’s gone away, and that simply isn’t the case,” said Nathan Cisneros, a researcher at the Williams Institute.

In Louisiana, a 2022 Williams Institute analysis found at least 147 allegations reported to law enforcement under the state’s HIV law from 2011 to mid-2022. Black people made up nearly three-quarters of the people convicted and placed on the sex offender registry. Most were Black men, like Smith. At the time of the analysis, Black people made up about two-thirds of HIV diagnoses in the state.

“ We see over and over that Black people are disproportionately affected by the HIV epidemic and disproportionately affected by policing and incarceration in the United States,” Cisneros said.

Nationally, other marginalized groups such as women, sex workers, the queer community, or people who overlap across more than one group are also disproportionately arrested and prosecuted under similar criminalization laws, Cisneros said.

Ensnared in the System

Louisiana’s law hinges on the requirement that if a person knows they have HIV, they must disclose their HIV status and receive consent before exposing someone to the virus.

Louisiana District Attorneys Association Executive Director Zach Daniels said these cases don’t come up often and can be difficult to prosecute. Daniels said the intimate nature of the cases can lead to little evidence in support of either side, especially if the accuser doesn’t contract HIV.

When it comes to talking about one’s sex life, Daniels said, “there are often no other witnesses, besides the two participants.”

Louisiana’s law is written so that “intentional exposure” can occur through “any means or contact.” That includes sex and needle-sharing, practices known to transmit the virus. But the language of the law is so broad that actions known not to transmit the virus — like biting or scratching — could be included, said Dietz, the statewide coordinator for the Louisiana Coalition on Criminalization and Health, an advocacy network founded by people living with HIV that has opposed the law.

The broad nature of the law creates opportunities for abuse, as the threat of being reported under the law can be used as a coercive tool in relationships, said Dietz, who goes by one name and uses they/them pronouns. Such threats, Dietz said, have kept people in abusive relationships and loomed over child custody battles. Dietz said they’ve supported people accused of exposing their children to HIV in ways that are not medically possible.

“ ‘Any means or contact’ could be just merely being around your kids,” they said.

The prosecutors’ organization still supports the law as a recourse for emergency responders who, in rare instances, come into contact with blood or syringes containing the virus. In one recent high-profile case in New Orleans, the law was used against a local DJ accused of knowingly transmitting HIV to several women without informing them of his status or using a condom.

The person accused of violating the law, not the accuser, must prove their case — that they disclosed their HIV status beforehand. Without a signed affidavit or tape recording, courts can end up basing their decisions on conflicting testimonies with little supporting evidence.

That’s what Smith alleged happened to him.

After his relationship ended, he said, he remembered being called into a meeting with his parole officer where a detective waited for him, asking about his former relationship and whether his girlfriend had known about his HIV status.

Smith said yes. But that’s not what she had told police.

Verite News could not find a working phone number for Smith’s former girlfriend but corroborated the story with the incident’s police report. His attorney at the time, a public defender named Carlos Prudhomme, said he didn’t remember much about the case, and court documents are sealed because it was a sex offense.

In court, it was her word against his. So when he was offered six months in prison instead of the 10-year maximum, he switched his plea from not guilty to guilty. But he said he didn’t know his new conviction would require him to register as a sex offender once he got out — worsening the stigma.

“When people see ‘sex offender,’ the first thing that comes to their mind is rape, child molester, predator,” Smith said. “This law puts me in a category that I don’t care to be in.”

He has tried to make the most of it, despite the expense of paying fees each year to reregister. After being rejected from jobs, he started a catering business and built a loyal clientele. But he said he’s still stuck living in a poorly maintained apartment complex primarily inhabited by sex offenders.

“I understand their strategy for creating this law to prevent the spread, but it’s not helping. It’s hurting; it’s hindering. It’s destroying people’s lives instead of helping people’s lives, especially the HIV community,” he said. “They don’t care about us.”

The Case for Reform

Since 2014, there has been a nationwide effort to update or repeal state laws that criminalize HIV nondisclosure, exposure, or transmission. A dozen states have changed their laws to align more closely with modern science, and four have gotten rid of them completely in hopes of reducing stigma and improving public health outcomes, according to the Center for HIV Law and Policy.

Sean McCormick, an attorney with the center, said these changes are influenced partly by a growing body of evidence showing the laws’ negative consequences.

McCormick said the laws offer a “clear disincentive” for people to get tested for HIV. If they don’t know their status, there’s no criminal liability for transmission or exposure.

A 2024 survey by Centers for Disease Control and Prevention and DLH Corp. researchers found that after California updated its HIV criminalization law in 2018, respondents were more likely to get tested. Meanwhile, survey respondents in Nevada, which still had a more punitive law on the books, were less likely to get tested.

There’s no one-size-fits-all solution, McCormick said. His center works with HIV-positive people across the country to determine what legislative changes would work best in their states.

Texas was the first to repeal its HIV law in 1994.

“As a person living with HIV in Texas, I’m deeply appreciative that we don’t have an HIV-specific statute that puts a target on my back,” said Michael Elizabeth, the public health policy director for the Equality Federation.

But Elizabeth points out that Texans living with HIV still face steeper penalties under general felony laws for charges such as aggravated assault or aggravated sexual assault after state courts in Texas equated the bodily fluids of a person with HIV with a “deadly weapon.”

Louisiana activists have pushed lawmakers in the state to amend the law in three ways: removing the sex offender registration requirement, requiring transmission to have occurred, and requiring clear intent to transmit the virus.

“Our strategy, as opposed to repeal, is to create a law that actually addresses the kind of boogeyman that they ostensibly created the law for: the person who successfully, maliciously, intentionally transmits HIV,” said Dietz with the Louisiana Coalition on Criminalization and Health.

In 2018, a bill to narrow the statute was amended in ways that expanded the law. For example, the updated law no longer had any definition of which actions “expose” someone to HIV.

In 2023, state lawmakers created a task force that recommended updating Louisiana’s law to align with the latest public health guidelines, limit the potential for unintended consequences, and give previously convicted people a way to clear their record.

Lawmakers in the state House pushed forward a bill this year to criminalize other sexually transmitted infections, including hepatitis B and the herpes simplex virus. That bill died in the Senate, but it spurred the creation of another legislative task force with a nearly identical mission to that of the first.

“ This state has no idea how closely we just dodged a bullet,” Dietz said.

In the meantime, the Louisiana coalition is helping Smith petition the state to take his name off the sex offender registry. Louisiana law allows people to petition to have their names removed from the registry after 10 years without any new sex crime convictions. Smith expects his case to be approved by the end of the year.

Despite the difficulty of the past 12 years, he said, he’s grateful for the chance to be free from the registry’s restrictions.

“It’s like a breath of fresh air,” Smith said. “I can do stuff that I wanted to do that I couldn’t. Like, go to a football game. Simple stuff like that, I’m going to be ready to do.”

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Every time Ashton Alexander sees an ad for Georgia Pathways to Coverage, it feels like a “kick in the face.”

Alexander tried signing up for Pathways, the state’s limited Medicaid expansion, multiple times and got denied each time, he said, even though he met the qualifying terms because he’s a full-time student.

Georgia is one of 10 states that haven’t expanded Medicaid health coverage to a broader pool of low-income adults. Instead, it offers coverage to those who can prove they’re working or completing 80 hours a month of other qualifying activities, like going to school or volunteering. And it is the only state currently doing so.

“Why is this marketing out here?” said the 20-year-old, who lives in Conyers, east of Atlanta. “It’s truly not accessible.”

Each denial used the same boilerplate language, Alexander said, and his calls to caseworkers were not returned. State offices couldn’t connect him with caseworkers assigned to him from the same state agency. And when he requested contact information for a supervisor to appeal his denial, he said, the number rang to a fax machine.

“It’s impenetrable,” Alexander said. “I’ve literally tried everything, and there’s no way.”

Millions of Americans trying to access Medicaid benefits could soon find themselves navigating similar byzantine state systems and work rules. Legislation signed into law by President Donald Trump on July 4 allocates $200 million to help states that expanded Medicaid create systems by the end of next year to verify whether some enrollees are meeting the requirements.

Conservative lawmakers have long argued that public benefits should go only to those actively working to get off of government assistance. But the nation’s only Medicaid work requirement program shows they can be costly for states to run, frustrating for enrollees to navigate, and disruptive to other public benefit systems. Georgia’s budget for marketing is nearly as much as it has spent on health benefits. Meanwhile, most enrollees under age 65 are already working or have a barrier that prevents them from doing so.

What Georgia shows is “just how costly setting up these administrative systems of red tape can be,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

Over the past two years, KFF Health News has documented the issues riddling Georgia’s Pathways program, launched in July 2023. More than 100,000 Georgians have applied to the program through March. Just over 8,000 were enrolled at the end of June, though about 300,000 would be eligible if the state fully expanded Medicaid under the terms of the Affordable Care Act.

The program has cost more than $100 million, with only $26 million spent on health benefits and more than $20 million allocated to marketing contracts, according to a KFF Health News analysis of state reports.

“That was truly a pretty shocking waste of taxpayer dollars,” Alker said.

The Government Accountability Office is investigating the costs of the program after a group of Democratic senators — including both members of the Georgia delegation — asked the government watchdog to look into the program. Findings are expected this fall.

A state report to the federal government from March said Georgia couldn’t effectively determine if applicants meet the qualifying activities criteria. The report also said the state hadn’t suspended anyone for failing to work, a key philosophical pillar of the program. Meanwhile, as of March, more than 5,000 people were waiting to have their eligibility verified for Pathways.

The Pathways program has strained Georgia’s eligibility system for other public benefits, such as food stamps and cash assistance.

In April, the state applied to the federal government to renew Pathways. In its application, officials scaled back key elements, such as the requirement that enrollees document work every month. Critics of the program also say the red tape doesn’t help enrollees find jobs.

“Georgia’s experience shows that administrative complexity is the primary outcome, not job readiness,” said Natalie Crawford, executive director of Georgia First, which advocates for fiscal responsibility and access to affordable health care.

Despite the struggles, Garrison Douglas, a spokesperson for Georgia’s Republican governor, Brian Kemp, defended the program. “Georgia Pathways is doing what it was designed to do: provide free healthcare coverage to low-income, able-bodied Georgians who are willing to engage in one of our many qualifying activities,” he said in an emailed statement.

New federal requirements in the tax and spending legislation mean that the 40 states (plus Washington, D.C.) that expanded Medicaid will need to prepare technology to process the documentation some Medicaid recipients will now have to regularly file.

The federal law includes exemptions for people with disabilities, in addiction treatment, or caring for kids under 14, among others.

The Trump administration said other states won’t face a bumpy rollout like Georgia’s.

“We are fully confident that technology already exists that could enable all parties involved to implement work and community engagement requirements,” said Mehmet Oz, head of the Centers for Medicare & Medicaid Services, in an emailed statement.

In a written public comment on Georgia’s application to extend the program, Yvonne Taylor of Austell detailed the difficulties she faced trying to enroll.

She said she tried to sign up several times but that her application was not accepted. “Not once, not twice,  but 3 times. With no response from customer service,” she wrote in February. “So now I am without coverage.”

Victoria Helmly of Marietta wrote in a January comment that she and her family members take care of their dad, but the state law doesn’t exempt caregivers of older adults.

“Georgia should recognize their sacrifices by supporting them with health insurance,” she wrote. “Let’s simplify this system and in the end, save money and lives.”

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The Rural Health Transformation Program calls for federal regulators to hand states $10 billion a year for five years starting in fiscal year 2026.

But the “devil’s in the details in terms of implementing,” said Sarah Hohman, director of government affairs at the National Association of Rural Health Clinics.

“An investment of this amount and this style into rural — hopefully it goes to rural — is the type of investment that we and other advocates have been working on for a long time,” said Hohman, whose organization represents 5,600 rural health clinics.

People who live in the nation’s rural expanses have more chronic diseases, die younger, and make less money. Those compounding factors have financially pummeled rural health infrastructure, triggering hospital closures and widespread discontinuation of critical health services like obstetrics and mental health care.

Nearly 1 in 4 people in rural America use Medicaid, the state and federal program for low-income and disabled people. So, as Senate Republicans heatedly debated Medicaid spending reductions, lawmakers added the $50 billion program to quell opposition. But health advocates and researchers doubt it will be enough to offset expected cuts in federal funding.

Senate Majority Leader John Thune, a Republican from South Dakota, which has one of the largest percentages of rural residents in the nation, led the push to pass the budget bill. His website touts support for strengthening access to care in rural areas. But his office declined to respond on the record to questions about the rural health program included in the bill.

Sen. Susan Collins, a Republican from Maine who introduced an initial amendment to add the rural program, also did not respond to a request for comment. On July 15, Sen. Josh Hawley, a Republican from Missouri, introduced a bill to reverse future cuts to Medicaid and add to the rural program.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank headquartered in Washington, D.C., said the money was set aside because of politics and not necessarily for rural patients.

“As long as it’s a government slush fund where politics decides where the money goes, then there’s going to be a mismatch between where those funds go and what it is consumers need,” Cannon said.

The nonpartisan Congressional Budget Office estimates federal Medicaid spending will be reduced by about $1 trillion over the next decade.

“These dollar amounts translate to actual people,” said Fredric Blavin, a senior fellow and researcher at the Urban Institute, a Washington D.C.-based think tank that focuses on social and economic research.

Most states expanded their Medicaid programs to cover more low-income adults under the Affordable Care Act. That has lowered medical debt, improved health, and even reduced death rates, Blavin said.

By 2034, about 11.8 million people are expected to lose their health insurance from this bill, said Alice Burns, an associate director for KFF’s Program on Medicaid and the Uninsured. And she said the Medicaid rollback may have an outsize impact on rural areas.

In rural areas, federal Medicaid spending is expected to decline by $155 billion over 10 years, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

If the goal of the rural program was to transform rural health care, as its name suggests, it will fall short, Burns said. The $50 billion rural program distributed over five years won’t offset the losses expected over a decade of Medicaid reductions, she said.

In Kansas, Holton Community Hospital Chief Executive Carrie Lutz said she doesn’t “feel that the sky is falling right now.”

Lutz, whose 14-bed hospital is on the northern plains of the state, said she is bracing for the potential loss of Medicaid-covered patients and limits to provider taxes, which nearly all states use to get extra federal Medicaid money.

The reduction in provider taxes has been delayed until fiscal year 2028, Lutz said, but she still wants her state’s leaders to apply for a portion of the rural program funding, which is expected to be distributed sooner.

“Every little penny helps when you’ve got very negative margins to begin with,” Lutz said.

The program’s $50 billion will be spread over five years and may not be limited to bolstering rural areas or their hospitals. Half of the money will be distributed “equally” among states that apply to and win approval from the Centers for Medicare & Medicaid Services. The law’s current language “raises the possibility” that a small state like Vermont could receive the same amount as a large state like Texas, Burns said.

States are required to submit a “detailed rural health transformation plan” by the end of this year, according to the law.

The law says states should use the funds to pursue goals including improving access to hospitals and other providers, improving health outcomes, enhancing economic opportunity for health care workers, and prioritizing the use of emerging technologies.

Mehmet Oz, a Trump appointee leading Medicare and Medicaid, will determine how to distribute the other half, or $25 billion, using a formula based on states’ rural population and need. The law says the money is to be used for such things as increasing use of robotics, upgrading cybersecurity, and helping rural communities “to right size their health care delivery systems.”

Spokespeople for CMS did not respond to a list of questions.

Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, said there is “a pretty significant degree of discretion” for the White House and the Medicare and Medicaid administrator in approving state plans.

“We will urge states to include robust telehealth and virtual care options within their proposals going up to the federal government,” Zebley said.

Alexa McKinley Abel, government affairs and policy director for the National Rural Health Association, said that while the law calls for states to create and submit plans, it’s unclear what state agencies will perform the task, McKinley Abel said.

“There are a lot of gaps around application and implementation,” she said, noting that an earlier version of the bill called for state plans to be developed in consultation with federally funded state offices of rural health.

But those offices are proposed to be eliminated in Trump’s federal budget, which will face congressional approval in the fall. McKinley Abel said her organization supports state offices of rural health helping develop the plans and working with states to disburse the money, “since they intimately know the rural health community.”

Hohman, with the rural health clinic association, said she is not sure money from the transformation program will even reach her members. About 27% of the patients treated at rural health clinics are enrolled in Medicaid, she said.

“There’s just some confusion about who actually gets this money at the end of the day,” Hohman said. “What is it actually going to be used for?”

KFF Health News senior correspondent Phil Galewitz contributed to this report.

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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KFF Health News Nevada correspondent Jazmin Orozco Rodriguez discussed the potential impact of Medicaid cuts on rural hospitals on KNPR’s “State of Nevada” on July 17.

• Click here to hear Orozco Rodriguez on “State of Nevada.”
• Read Orozco Rodriguez’s “‘One Big Beautiful Bill’ Would Batter Rural Hospital Finances, Researchers Say.”

KFF Health News chief Washington correspondent Julie Rovner discussed Medicaid cuts in President Donald Trump’s megabill on WAMU’s “1A” on July 16. Rovner also discussed immigrant health coverage on MSNBC’s “Velshi” on July 13.

• Click here to hear Rovner on “1A.”
• Click here to watch Rovner on “Velshi.”

Céline Gounder, KFF Health News’ editor-at-large for public health, discussed how artificial food dyes can affect health on CBS News’ “CBS Mornings” on July 15. She also discussed how to prevent tick bites on CBS News’ “CBS Mornings” on July 11.

• Click here to watch Gounder discuss food dyes on “CBS Mornings.”
• Click here to watch Gounder discuss tick bite prevention on “CBS Mornings.”

KFF Health News chief rural correspondent Sarah Jane Tribble discussed the impact of Trump’s tax and spending bill on rural health on Ideastream Public Media’s “Sound of Ideas” on July 15.

• Click here to hear Tribble on “Sound of Ideas.”

KFF Health News senior correspondent Renuka Rayasam discussed Medicaid work requirements on WUGA’s “The Georgia Health Report” on July 11.

• Click here to hear Rayasam on “The Georgia Health Report.”

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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Federal health officials do not inform consumers about severe safety violations in hospitals that specialize in physical rehabilitation. Nor does Medicare impose fines as it does for nursing homes, or provide easy-to-understand five-star ratings as it does for general hospitals, according to an investigation by KFF Health News and The New York Times. 

Medical rehab hospitals have become a highly lucrative niche within the health care industry, collectively generating profits of 10%, more than general hospitals, which earn about 6%, and far more than skilled nursing homes, which make less than 0.5%, according to the most recent data from the Medicare Payment Advisory Commission, an independent congressional agency known as MedPAC. 

But MedPAC and independent researchers have found that for-profit rehabs tend to have higher rates of patients being readmitted to general hospitals than nonprofits do. 

In 2023, stand-alone for-profit rehabilitation hospitals overtook nonprofits as the places where most annual patient admissions occur, a KFF Health News and New York Times analysis found. These facilities are required to provide three hours of physical, occupational, or speech therapy a day, five days a week. 

Congress has not authorized Medicare to fine rehab hospitals for violations uncovered during inspections, even ones that resulted in death, as it has done with nearly 8,000 nursing homes during the last three years, imposing average fines of about $28,000. 

The only option is to entirely cut off a rehab hospital’s reimbursement for all services by Medicare and Medicaid, which cover most patients. That step would most likely put it out of business and is almost never used. Even the most serious violations effectively carry no punishments so long as the hospital puts steps in place to avert future problems. 

The federal government’s overall quality oversight efforts are limited. Medicare docks payment to rehab facilities for patients readmitted to a general hospital during shorter-than-average rehab stays, but unlike at general hospitals, there are no financial penalties when recently discharged rehab patients are hospitalized for critical health issues. 

The Biden administration announced last year it intended to develop a rating scale of 1 to 5 stars for rehab facilities on its Care Compare website. The industry’s trade association, the American Medical Rehabilitation Providers Association, requested a delay in the creation of star ratings until the current quality measures were refined. The Trump administration has not determined whether it will continue the effort to rate rehab facilities. 

Also read our consumer guide to finding the right place to get physical, occupational or speech therapy.

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HHS Secretary and Secretary of State issued a joint statement of formal U.S. rejection of the 2024 International Heath Regulations (IHR) Amendments by the WHO.

The State Department and HHS issued a joint statement of official U.S. rejection of the 2024 amendments to the International Heath Regulations (IHR).

Last year in Massachusetts, after finding lumps in her breast, Jessica Chen went to Lowell General Hospital-Saints Campus, part of Tufts Medicine, for a mammogram and sonogram. Before the screenings, she asked the hospital for the estimated patient responsibility for the bill using her insurance, Tufts Health Plan. Her portion, she was told, would be $359 — and she paid it. She was more than a little surprised weeks later to receive a bill asking her to pay an additional $1,677.51. “I was already trying to stomach $359, and this was many times higher,” Chen, a physician assistant, told me.

The No Surprises Act, which took effect in 2022, was rightly heralded as a landmark piece of legislation, which “protects people covered under group and individual health plans from receiving surprise medical bills,” according to the Centers for Medicare & Medicaid Services. And yet bills that take patients like Chen by surprise just keep coming.

With the help of her software-wise boyfriend, she found the complicated “machine-readable” master price list that hospitals are required to post online and looked up the negotiated rate between Lowell General and her insurer. It was $302.56 — less than she had paid out-of-pocket.

CMS is charged with enforcing the law, so Chen sent a complaint about the surprising bill to the agency. She received a terse email in return: “We have reviewed your complaint and have determined that the rights and protections of the No Surprises Act do not apply.”

When I asked the health system to explain how such a surprising off-estimate bill could be generated, Tufts Medicine spokesperson Jeremy Lechan responded by email: “Healthcare billing is complex and includes various factors and data points, so actual charges for care provided may differ from initial estimates. We understand the frustration these discrepancies can cause.”

Here’s the problem: While the No Surprises Act has been a phenomenal success in taking on some unfair practices in the wild West of medical billing, it was hardly a panacea.

In fact, the measure protected patients primarily from only one particularly egregious type of surprise bill that had become increasingly common before the law’s enactment: When patients unknowingly got out-of-network care at an in-network facility, or when they had no choice but to get out-of-network care in an emergency. In either case, before President Donald Trump signed the law late in his first term, patients could be hit with tens or hundreds of thousands of dollars in out-of-network bills that their insurance wouldn’t pay.

The No Surprises Act also provided some protection from above-estimate bills, but at the moment, the protection is only for uninsured and self-pay patients, so it wouldn’t apply in Chen’s case since she was using health insurance.

But patients who do qualify generally are entitled to an up-front, good-faith estimate for treatment they schedule at least three business days in advance or if they request one. Patients can dispute a bill if it is more than $400 over the estimate. (The No Surprises Act also required what amounted to a good-faith estimate of out-of-pocket costs for patients with insurance, but that provision has not been implemented, since, nearly five years later, the government still has not issued rules about exactly what form it should take.)

So, surprising medical bills — bills that the patient could not have anticipated and never consented to — are still stunning countless Americans.

Jessica Robbins, who works in product development in Chicago, was certainly surprised when, out of the blue, she was recently billed $3,300 by Endeavor Health for a breast MRI she had received two years earlier, with prior authorization from her then-insurer, Blue Cross and Blue Shield of Illinois. In trying to resolve the problem, she found herself caught in a Kafkaesque circle involving dozens of calls and emails. The clinic where she had the procedure no longer existed, having been bought by Endeavor. And she no longer had Blue Cross.

“We are actively working with the patient and their insurer to resolve this matter,” Endeavor spokesperson Allie Burke said in an emailed response to my questions.

Mary Ann Bonita of Fresno, California, was starting school this year to become a nursing assistant when, on a Friday, she received a positive skin test for tuberculosis. Her school’s administration said she couldn’t return to class until she had a negative chest X-ray. When her doctor from Kaiser Permanente didn’t answer requests to order the test for several days, Bonita went to an emergency room and paid $595 up front for the X-ray, which showed no TB. So she and her husband were surprised to receive another bill, for $1,039, a month later, “with no explanation of what it was for,” said Joel Pickford, Bonita’s husband.

In the cases above, each patient questioned an expensive, unexpected medical charge that came as a shock — only to find that the No Surprises Act didn’t apply.

“There are many billing problems out there that are surprising but are not technically surprise bills,” Zack Cooper, an associate professor of economics at Yale University, told me. The No Surprises Act fixed a specific kind of charge, he said, “and that’s great. But, of course, we need to address others.”

Cooper’s research has found that before the No Surprises Act was passed, more than 25% of emergency room visits yielded a surprise out-of-network bill.

CMS’ official No Surprises Help Desk has received tens of thousands of complaints, which it investigates, said Catherine Howden, a CMS spokesperson. “While some billing practices, such as delayed bills, are not currently regulated” by the No Surprises Act, Howden said, complaint trends nonetheless help “inform potential areas for future improvements.” And they are needed.

Michelle Rodio, a teacher in Lakewood, Ohio, had a lingering cough weeks after a bout of pneumonia that required treatment with a course of antibiotics. She went to Cleveland Clinic’s Lakewood Family Health Center for an examination. Her X-ray was fine. As was her nasal swab — except for the stunning $2,700 bill it generated.

“I said, ‘This is a surprise bill!’” Rodio recalled telling the provider’s finance office. The agent said it was not.

“So I said, ‘Next time I’ll be sure to ask the doctor for an estimate when I get a nose swab.’”

“The doctors wouldn’t know that,” the agent replied, as Rodio recalled — and indeed physicians generally have no idea how much the tests they order will cost. And in any case, Rodio was not legally entitled to a binding estimate, since the part of the No Surprises Act that grants patients with insurance that right has not been implemented yet.

So she was stuck with a bill of $471 (the patient responsibility portion of the $2,700 charge) that she couldn’t have consented to (or rejected) in advance. It was surprising — shocking to her, even — but not a “surprise bill,” according to the current law. But shouldn’t it be?

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Most of the 24 million people in Affordable Care Act health plans face a potential one-two punch next year — double-digit premium increases along with a sharp drop in the federal subsidies that most consumers depend on to buy the coverage, also known as Obamacare.

Insurers want higher premiums to cover the usual culprits — rising medical and labor costs and usage — but are tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes advanced by the Trump administration and the Republican-controlled Congress. One key factor built into their filings with state insurance departments: uncertainty over whether Congress allows more generous, covid-era ACA tax subsidies to expire at the end of December.

“The out-of-pocket change for individuals will be immense, and many won’t actually be able to make ends meet and pay premiums, so they will go uninsured,” said JoAnn Volk, co-director of the Center on Health Insurance Reforms at Georgetown University.

Especially if the higher subsidies expire, insurance premiums will be among the first financial pains felt by health care consumers after policy priorities put forward by President Donald Trump and the GOP. Many other changes — such as additional paperwork requirements and spending cuts to Medicaid — won’t occur for at least another year. But spiking ACA premiums, as the nation heads into key midterm elections, invites political pushback. Some on Capitol Hill are exploring ways to temper the subsidy reductions.

“I am hearing on both sides — more from Republicans, but from both the House and Senate” — that they are looking for levers they can pull, said Pennsylvania-based insurance broker Joshua Brooker, who follows legislative actions as part of his job and sits on several insurance advisory groups.

In initial filings, insurers nationally are seeking a median rate increase — meaning half of the proposed increases are lower and half higher — of 15%, according to an analysis for the Peterson-KFF Health System Tracker covering 19 states and the District of Columbia. KFF is a national health information nonprofit that includes KFF Health News.

That’s up sharply from the last few years. For the 2025 plan year, for example, KFF found that the median proposed increase was 7%.

Health insurers “are doing everything in their power to shield consumers from the rising costs of care and the uncertainty in the market driven by recent policy changes,” wrote Chris Bond, a spokesperson for AHIP, the industry’s lobbying group. The emailed response also called on lawmakers “to take action to extend the health care tax credits to prevent skyrocketing cost increases for millions of Americans in 2026.”

Neither the White House nor the Department of Health and Human Services responded to requests for comment.

These are initial numbers and insurance commissioners in some states may alter requests before approval.

Still, “it’s the biggest increase we’ve seen in over five years,” said analysis co-author Cynthia Cox, a KFF vice president and director of its Program on the ACA.

Premiums will vary based on where consumers live, the type of plan they choose, and their insurer.

For example, Maryland insurers have requested increases ranging from 8.1% to 18.7% for the upcoming plan year, according to an analysis of a smaller set of insurers by Georgetown University researchers. A much larger swing is seen in New York, where one carrier is asking for less than a 1% increase, while another wants 66%. Maryland rate filings indicated the average statewide increase would shrink to 7.9% from 17.1% — if the ACA’s enhanced tax credits are extended.

Most insurers are asking for 10% to 20% increases, the KFF report says, with several factors driving those increases. For instance, insurers say underlying medical costs — including the use of expensive obesity drugs — will add about 8% to premiums for next year. And most insurers are also adding 4% above what they would have charged had the enhanced tax credits been renewed.

But rising premiums are just part of the picture.

A bigger potential change for consumers’ pocketbooks hinges on whether Congress decides to extend more generous tax credits first put in place during President Joe Biden’s term as part of the American Rescue Plan Act in 2021, then extended through the Inflation Reduction Act in 2022.

Those laws raised the subsidy amounts people could receive based on their household income and local premium costs and removed a cap that had barred higher earners from even partial subsidy assistance. Higher earners could still qualify for some subsidy but first had to chip in 8.5% of their household income toward the premiums.

Across the board, but especially among lower-income policyholders, bigger subsidies helped fuel record enrollment in ACA plans.

But they’re also costly.

A permanent extension could cost $335 billion over the next decade, according to the Congressional Budget Office.

Such an extension was left out of the policy law Trump signed on July 4 that he called the “One Big Beautiful Bill.” Without action, the extra subsidies will expire at the end of this year, after which the tax credits will revert to less generous pre-pandemic levels.

That means two things: Most enrollees will be on the hook to pay a larger share of their premiums as assistance from federal tax credits declines. Secondly, people whose household income exceeds four times the federal poverty level — $84,600 for a couple or $128,600 for a family of four this year — won’t get any subsidies at all.

If the subsidies expire, policy experts estimate, the average amount people pay for coverage could rise by an average of more than 75%. In some states, ACA premiums could double.

“There will be sticker shock,” said Josh Schultz, strategic engagement manager at Softheon, a New York consulting firm that provides enrollment, billing, and other services to about 200 health insurers, many of which are bracing for enrollment losses.

And enrollment could fall sharply. The Wakely Consulting Group estimates that the combination of expiring tax credits, the Trump law’s new paperwork, and other requirements will result in ACA enrollment dropping by as much as 57%.

According to KFF, insurers added premium increases of around 4% just to cover the expiration of the enhanced tax credits, which they fear will lead to lower enrollment. That would further raise costs, insurers say, because people who are less healthy are more likely to grit their teeth and reenroll, leaving insurers with a smaller, but sicker, pool of members.

Less common in the filings submitted so far, but noticeable, are increases pegged to Trump administration tariffs, Cox said.

“What they are assuming is tariffs will drive drug costs up significantly, with some saying that can have around a 3-percentage-point increase” in premiums as a result, she said.

Consumers will learn their new premium prices only late in the fall, or when open enrollment for the ACA begins on Nov. 1 and they can start shopping around.

Congress could still act, and discussions are ongoing, said insurance broker Brooker.

Some lawmakers, he said, are consulting with the CBO about the fiscal and coverage effects of various scenarios that don’t extend the subsidies as they currently exist but may offer a middle ground. One possibility involves allowing subsidies for families earning as much as five or six times the poverty level, he said.

But any such effort will draw pushback.

Some conservative think tanks, such as the Paragon Health Institute, say the more generous subsides led people to fudge their incomes to qualify and led to other types of fraud, such as brokers signing people up for ACA plans without authorization.

But others note that many consumers — Democratic and Republican — have come to rely on the additional assistance. Not extending it could be risky politically. In 2024, 56% of ACA enrollees lived in Republican congressional districts, and 76% were in states won by Trump.

Allowing the enhanced subsidies to expire could also reshape the market.

Brooker said some people may drop coverage. Others will shift to plans with lower premiums but higher deductibles. One provision of Trump’s new tax law allows people enrolled in either “bronze” or “catastrophic”-level ACA plans, which are usually the cheapest, to qualify for health savings accounts, which allow people to set aside money, tax-free, to cover health care costs.

“Naturally, if rates do start going up the way we anticipate, there will be a migration to lower-cost options,” Brooker 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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The Centers for Medicare & Medicaid Services (CMS) continue to crush fraud, waste, and abuse in America’s healthcare programs

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.

The Senate has passed — and sent back to the House — a bill that would allow the Trump administration to claw back some $9 billion in previously approved funding for foreign aid and public broadcasting. But first, senators removed from the bill a request to cut funding for the President’s Emergency Plan for AIDS Relief, President George W. Bush’s international AIDS/HIV program. The House has until Friday to approve the bill, or else the funding remains in place.

Meanwhile, a federal appeals court has ruled that West Virginia can ban the abortion pill mifepristone despite its approval by the Food and Drug Administration. If the ruling is upheld by the Supreme Court, it could allow states to limit access to other FDA-approved drugs.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Sandhya Raman CQ Roll Call @SandhyaWrites @SandhyaWrites.bsky.social Read Sandhya's stories.

Among the takeaways from this week’s episode:

• The Senate approved the Trump administration’s cuts to foreign aid and public broadcasting, a remarkable yielding of congressional spending power to the president. Before the vote, Senate GOP leaders removed President Donald Trump’s request to cut PEPFAR, sparing the funding for that global health effort, which has support from both parties.
• Next Congress will need to pass annual appropriations bills to keep the government funded, but that is expected to be a bigger challenge than the recent spending fights. Appropriations bills need 60 votes to pass in the Senate, meaning Republican leaders will have to make bipartisan compromises. House leaders are already delaying health spending bills until the fall, saying they need more time to work out deals — and those bills tend to attract culture-war issues that make it difficult to negotiate across the aisle.
• The Trump administration is planning to destroy — rather than distribute — food, medical supplies, contraceptives, and other items intended for foreign aid. The plan follows the removal of workers and dismantling of aid infrastructure around the world, but the waste of needed goods the U.S. government has already purchased is expected to further erode global trust.
• And soon after the passage of Trump’s tax and spending law, at least one Republican is proposing to reverse the cuts the party approved to health programs — specifically Medicaid. It’s hardly the first time lawmakers have tried to change course on their own policies, though time will tell whether it’s enough to mitigate any political (or actual) damage from the law.

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

Julie Rovner: The New York Times’ “UnitedHealth’s Campaign to Quiet Critics,” by David Enrich.

Joanne Kenen: The New Yorker’s “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” by Dhruv Khullar.

Shefali Luthra: The New York Times’ “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True,” by Apoorva Mandavilli.

Sandhya Raman: The Nation’s “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons from Sweden,” by Cecilia Nowell.

Also mentioned in this week’s podcast:

• The Atlantic’s “The Trump Administration Is About To Incinerate 500 Tons of Emergency Food,” by Hana Kiros.
• KFF Health News’ “Vested Interests. Influence Muscle. At RFK Jr.’s HHS, It’s Not Pharma. It’s Wellness,” by Stephanie Armour.
• The Washington Post’s “A Clinic Blames Its Closing on Trump’s Medicaid Cuts. Patients Don’t Buy It,” by Hannah Knowles.

Credits Francis Ying Audio producer Emmarie Huetteman Editor

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

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In the wake of January’s deadly wildfires, Los Angeles County leaders are weighing a disaster registry intended to help disabled and senior residents get connected to emergency responders to bring them to safety during disasters.

County supervisors approved a feasibility study this spring for such a voluntary database. Supporters applauded the effort to give more notice and assistance to the more than 1 million county residents with some type of disability, such as cognitive impairment or limited mobility.

“If we know that people perish in these situations, what are our answers?” said Hilary Norton, who runs FASTLinkDTLA, a nonprofit focused on mobility issues. “This is the time for people to really understand the magnitude for people in need when things like this happen.”

Amid the increasing frequency of natural disasters across the U.S. — brought into sharp relief by the recent deadly floods in Texas — state and local governments from Oregon to North Carolina have turned to disaster registries to prioritize help for vulnerable residents when fires, hurricanes, and other environmental catastrophes strike. But while some politicians say these registries are a potential solution to a public health problem, many disability advocates see them as ineffective tools that give people a false sense of security because there is no guarantee of evacuation help.

“They’re described in a way that communicates that if you place your information in this registry and you will need assistance, they will be able to plan for it, so in a disaster you will be safer. And in reality, that is simply not the case,” said Maria Town, president and CEO of the American Association of People with Disabilities.

Town, who has cerebral palsy, had been in Houston for six months when Hurricane Harvey hit in 2017. Texas makes a free registry called the State of Texas Emergency Assistance Registry available to cities and counties to help them identify needs in their communities, but how or if they use it is up to them. Fewer than 5% of people who registered were contacted during Harvey, and even fewer got evacuation assistance, according to a 2023 study by the National Council on Disability, a federal agency that advises on disability policies and programs. The hurricane took 89 lives.

“I heard people say, ‘I thought I was safe. I registered,’” Town said of the calls she got during and after Harvey.

Neither the Texas Division of Emergency Management nor officials in Kerr County, the area hit hardest by the recent floods in Texas Hill Country, responded to questions about whether any accommodations were made for residents on the registry during the early July catastrophe.

Many registries, like Florida’s Special Needs Registry, expressly tell participants they still must make their own evacuation plans. The Florida Department of Health oversees the registry and, like in Texas, shares the information with local emergency management officials for their use. In North Carolina’s Rockingham County, individuals must apply to be on the registry, and inclusion is not guaranteed. The registry page for Jackson and Josephine counties in Oregon warns that it can take up to three months for residents’ information to be made available to rescue workers.

The National Council on Disability says registries are harmful. “They are ineffective and provide a false sense of security of future guaranteed assistance,” Nicholas Sabula, a spokesperson for the organization, said in a statement.

The California Governor’s Office of Emergency Services also “strongly discourages” using registries, saying they can deter people from making their own disaster plans and raise privacy concerns. Disability advocates have also cited privacy as a concern.

But Los Angeles politicians behind the registry effort insist they are worth looking into — at least a third of those who died in the Eaton Fire had issues that could affect their mobility and therefore their ability to flee in the face of disaster, according to a Los Angeles Times analysis. Anthony Mitchell Sr., an amputee in a wheelchair, and his 35-year-old son, Justin, who had cerebral palsy, were among the 18 people killed when the wildfire ripped through the Los Angeles County community of Altadena in January.

Further driving the initiative is the aging of L.A. County’s population: The California Department of Finance’s Demographic Research Unit has estimated that more than a quarter of Los Angeles County residents will be 60 or over by 2030 — about 2.5 million people.

Supervisor Kathryn Barger, who represents Altadena and proposed the registry study along with Supervisor Janice Hahn, “wants to drill down and explore its usefulness,” according to her communications director, Helen Chavez Garcia. Barger had not yet talked to the first responder community or had conversations about how emergency services would use the registry, according to Chavez Garcia.

Victoria Jump, an assistant director at the county’s Aging & Disabilities Department, is conducting the feasibility study — which she noted does not include cost estimates — and will make a recommendation to the Board of Supervisors this month on whether to support the project. The board will decide whether to move forward. Jump said she’s gotten largely positive feedback in more than a dozen community sessions.

It’s not the first time Los Angeles has considered and even implemented a disaster registry. The county maintained a voluntary disaster registry called Specific Needs Awareness Planning, but acknowledged in 2016 that the program did “not guarantee priority service to those who register” and had a “low return on investment.” It was discontinued, and registrants were migrated to a mass emergency alert system called Alert LA County.

“We’ve been through this before with the county. It didn’t work. It hasn’t worked around the country,” said Los Angeles resident June Kailes, a disability advocate who uses a power scooter.

Kailes sees what happened in the Eaton Fire as a problem with emergency planning, saying that the county needs to better understand how to offer people with disabilities emergency transportation. She pointed to Galen Buckwalter, a paralyzed Eaton Fire survivor who reportedly drove his motorized wheelchair a mile in the dark to evacuate when he realized it would be impossible for a ride-hailing service to pick him up given the conditions.

Norton, of the mobility nonprofit FASTLinkDTLA, said the registry needs to be about more than just collecting names of disabled residents. “No one wants to create false hope,” Norton said. “It’s an agreement to explore the possibilities. It’s that balance of asking now, in order to make sure in the next disaster they are not left behind.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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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LISTEN: Federal law entitles patients to interpreters if they don’t have a strong grasp of English. KFF Health News correspondent Vanessa G. Sánchez appeared on WAMU’s “Health Hub” on July 9 to explain why some Trump administration policies are leaving patients fearful to ask for language services. 

Patients need to communicate clearly with their health care provider. But that’s getting more difficult for those in the U.S. who don’t speak English. 

Budget cuts by the Trump administration have left some providers scrambling to keep qualified medical interpreters. And an executive order designating English the official language of the United States has created confusion among providers about what services should be offered. 

Patients who don’t speak English are left afraid, and perhaps at risk for medical mistakes. What happens when those who need help are too frightened to ask? 

In WAMU’s July 9 “Health Hub” segment, KFF Health News correspondent Vanessa G. Sánchez explained why health advocates worry these changes could lead to worse patient outcomes. 

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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One of the world’s biggest genetic databases comprises DNA data donated over the years by more than a million retired military service members. It’s part of a project run by the Department of Veterans Affairs.

The initiative, dubbed the Million Veteran Program, is a “crown jewel of the country,” said David Shulkin, a physician who served as VA secretary during the first Trump administration. Data from the project has contributed to research on the genetics of anxiety and peripheral artery disease, for instance, and has resulted in hundreds of published papers. Researchers say the repository has the potential to help answer health questions not only specific to veterans — like who is most vulnerable to post-service mental health issues, or why they seem more prone to cancer — but also relevant to the nation as a whole.

“When the VA does research, it helps veterans, but it helps all Americans,” Shulkin said in an interview.  

Researchers now say they fear the program is in limbo, jeopardizing the years of work it took to gather the veterans’ genetic data and other information, like surveys and blood samples.

“There’s sort of this cone of silence,” said Amy Justice, a Yale epidemiologist with a VA appointment as a staff physician. “We’ve got to make sure this survives.”

Genetic data is enormously complex, and analyzing it requires vast computing power that VA doesn’t possess. Instead, it has relied on a partnership with the Energy Department, which provides its supercomputers for research purposes.

In late April, VA Secretary Doug Collins disclosed to Sen. Richard Blumenthal, the top Democrat on the Senate Veterans’ Affairs Committee, that agreements authorizing use of the computers for the genomics project remained unsigned, with some expiring in September, according to materials shared with KFF Health News by congressional Democrats.

Spokespeople for the two agencies did not reply to multiple requests for comment. Other current and former employees within the agencies — who asked not to be identified, for fear of reprisal from the Trump administration — said they don’t know whether the critical agreements will be renewed.

One researcher called computing “a key ingredient” to major advances in health research, such as the discovery of new drugs.

The agreement with the Energy Department “should be extended for the next 10 years,” the researcher said.

The uncertainty has caused “incremental” damage, Justice said, pointing to some Million Veteran Program grants that have lapsed. As the year progresses, she predicted, “people are going to be feeling it a lot.”

Because of their military experience, maintaining veterans’ health poses different challenges compared with caring for civilians. The program’s examinations of genetic and clinical data allow researchers to investigate questions that have bedeviled veterans for years. As examples, Shulkin cited “how we might be able to better diagnose earlier and start thinking about effective treatments for these toxic exposures” — such as to burn pits used to dispose of trash at military outposts overseas — as well as predispositions to post-traumatic stress disorder.

“The rest of the research community isn’t likely to focus specifically” on veterans, he said. The VA community, however, has delivered discoveries of importance to the world: Three VA researchers have won Nobel Prizes, and the agency created the first pacemaker. Its efforts also helped ignite the boom in GLP-1 weight loss drugs.

Yet turbulence has been felt throughout VA’s research enterprise. Like other government scientific agencies, it’s been buffeted by layoffs, contract cuts, and canceled research.

“There are planned trials that have not started, there are ongoing trials that have been stopped, and there are trials that have fallen apart due to staff layoffs — yes or no?” said Sen. Patty Murray (D-Wash.), pressing Collins in a May hearing of the Senate Veterans’ Affairs Committee.

The agency, which has a budget of roughly $1 billion for its research arm this fiscal year, has slashed infrastructure that supports scientific inquiry, according to documents shared with KFF Health News by Senate Democrats on the Veterans’ Affairs Committee. It has canceled at least 37 research-related contracts, including for genomic sequencing and for library and biostatistics services. The department has separately canceled four contracts for cancer registries for veterans, creating potential gaps in the nation’s statistics.

Job worries also consume many scientists at the VA.

According to agency estimates in May, about 4,000 of its workers are on term limits, with contracts that expire after certain periods. Many of these individuals worked not only for the VA’s research groups but also with clinical teams or local medical centers.

When the new leaders first entered the agency, they instituted a hiring freeze, current and former VA researchers told KFF Health News. That prevented the agency’s research offices from renewing contracts for their scientists and support staff, which in previous years had frequently been a pro forma step. Some of those individuals who had been around for decades haven’t been rehired, one former researcher told KFF Health News.

The freeze and the uncertainty around it led to people simply departing the agency, a current VA researcher said.

The losses, the individual said, include some people who “had years of experience and expertise that can’t be replaced.”

Preserving jobs — or some jobs — has been a congressional focus. In May, after inquiries from Sen. Jerry Moran, the Republican who chairs the Veterans’ Affairs Committee, about staffing for agency research and the Million Veteran Program, Collins wrote in a letter that he was extending the terms of research employees for 90 days and developing exemptions to the hiring freeze for the genomics project and other research initiatives.

Holding jobs is one thing — doing them is another. In June, at the annual research meeting of AcademyHealth — an organization of researchers, policymakers, and others who study how U.S. health care is delivered — some VA researchers were unable to deliver a presentation touching on psychedelics and mental health disparities and another on discrimination against LGBTQ+ patients, Aaron Carroll, the organization’s president, told KFF Health News.

At that conference, reflecting a trend across the federal government, researchers from the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality also dropped out of presenting. “This drop in federal participation is deeply concerning, not only for our community of researchers and practitioners but for the public, who rely on transparency, collaboration, and evidence-based policy grounded in rigorous science,” Carroll said.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

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Participating states to test outcomes-based payments for sickle cell disease treatments, improving care while lowering long-term costs

La terapia de rehabilitación puede ser una bendición después de una hospitalización por un derrame cerebral, una caída, un accidente, un reemplazo de articulación, una quemadura grave o una lesión de la médula espinal, entre otras afecciones.

La fisioterapia, la terapia ocupacional y la terapia del habla se ofrecen en diversos entornos: hospitales, residencias de adultos mayores, clínicas y a domicilio.

Es fundamental encontrar una opción segura y de alta calidad con profesionales con experiencia en el tratamiento de tu afección.

¿Qué tipos de terapia de rehabilitación podría necesitar?

La fisioterapia ayuda a los pacientes a mejorar su fuerza, estabilidad y movimiento, y a reducir el dolor, generalmente a través de ejercicios específicos.

Algunos fisioterapeutas se especializan en problemas neurológicos, cardiovasculares u ortopédicos. También hay especialistas en geriatría y pediatría. La terapia ocupacional se centra en actividades específicas (llamadas “ocupaciones”), que suelen requerir habilidades motoras finas, como cepillarse los dientes, cortar alimentos con un cuchillo o vestirse.

La terapia del habla y del lenguaje ayuda a las personas a comunicarse. Algunos pacientes pueden necesitar terapia respiratoria si tienen dificultad para respirar o necesitan que se les retire el respirador.

¿Los seguros cubren las sesiones de rehabilitación?

Medicare, las aseguradoras de salud, la compensación laboral y los planes de Medicaid en algunos estados cubren las terapias de rehabilitación, pero los planes pueden negarse a pagar en ciertos entornos y limitar la cantidad de sesiones.

Algunas aseguradoras pueden pedir una preautorización y otras cancelar la cobertura si no se mejora. Las aseguradoras privadas suelen establecer límites anuales para la terapia ambulatoria.

El Medicare tradicional suele ser el menos restrictivo, mientras que los planes privados Medicare Advantage pueden supervisar de cerca el progreso y limitar los lugares en dónde los pacientes pueden recibir terapia.

¿Debería buscar rehabilitación hospitalaria?

Los pacientes que aún necesitan atención médica o de enfermería, pero que pueden tolerar tres horas de terapia cinco días a la semana, podrían calificar para ser admitidos en un hospital de rehabilitación especializado o en una unidad que funcione dentro de un hospital general.

Los pacientes suelen necesitar al menos dos de los principales tipos de terapia de rehabilitación: fisioterapia, terapia ocupacional o terapia del habla. Las estadías duran un promedio unos 12 días.

¿Cómo elijo?

Busca un centro especializado en el tratamiento de personas con tu diagnóstico; muchos hospitales enumeran las especialidades en sus sitios de internet. Las personas con afecciones médicas complejas o graves podrían preferir un hospital de rehabilitación conectado a un centro médico académico a la vanguardia de los nuevos tratamientos, incluso si está a un vuelo de distancia.

“Verás a pacientes jóvenes con lesiones catastróficas”, como daño de la médula espinal, viajando a otro estado para recibir tratamiento, dijo Cheri Blauwet, directora médica de Spaulding Rehabilitation en Boston, uno de los 15 hospitales que el gobierno federal ha elogiado por su trabajo de avanzada.

Sin embargo, elegir un hospital cerca de familiares y amigos que puedan ayudar después del alta tiene sus ventajas. Los terapeutas pueden ayudar a capacitar a los que serán cuidadores en casa.

¿Cómo encuentro hospitales de rehabilitación?

El planificador de altas o el trabajador social del hospital de agudos debería ofrecerte opciones. Puedes buscar centros de rehabilitación para pacientes internados por ubicación o nombre en el sitio web Care Compare de Medicare. Allí puedes ver cuántos pacientes con tu misma afección ha tratado ese hospital; cuantos más, mejor.

Puedes buscar por especialidad a través de la Asociación Americana de Proveedores de Rehabilitación Médica, un grupo comercial que publica una lista de sus miembros.

Averigüa qué tecnologías especializadas tiene un hospital, como simuladores de manejo (un auto o camión que permite al paciente practicar subir y bajar de un vehículo) o una mesa de cocina con utensilios para practicar cocinar.

¿Cómo puedo saber si un hospital de rehabilitación es confiable?

No es fácil: Medicare no analiza al personal ni publica en su sitio de internet los resultados de las inspecciones de seguridad como sí lo hace con las residencias de adultos mayores. Puedes pedir a la agencia de salud pública de tu estado o al hospital que te proporcionen informes de inspección de los últimos tres años. Estos informes pueden ser técnicos, pero te ayudarán a comprender lo esencial. Si el informe indica que se declaró un “riesgo inmediato”, significa que los inspectores identificaron problemas de seguridad que ponen en peligro a los pacientes.

La tasa de pacientes readmitidos en un hospital general por una razón potencialmente prevenible es una medida de seguridad clave. En general, los centros de rehabilitación con fines de lucro tienen tasas de readmisión más altas que los que son sin fines de lucro, pero hay algunos con tasas de readmisión más bajas y otros con tasas más altas. Puede que no tengas otra opción cerca: hay menos de 400 hospitales de rehabilitación y la mayoría de los hospitales generales no cuentan con una unidad de rehabilitación.

Puedes encontrar las tasas de readmisión de un hospital en la sección de calidad de Care Compare. Las tasas inferiores al promedio nacional son mejores.

Otra medida de calidad es la frecuencia con la que los pacientes son lo suficientemente funcionales como para irse a casa después de terminar la rehabilitación en lugar de ir a una residencia de adultos mayores, un hospital o una institución médica. Esta medida se denomina “alta a la comunidad” y se encuentra en la sección de calidad de Care Compare. Las tasas superiores al promedio nacional son mejores.

Busca reseñas del hospital en Yelp y otros sitios web. Pregunta si los pacientes ven al mismo terapeuta casi todos los días o no. Y si tienen certificaciones en la especialidad que necesitas.

Si es posible, visita el hospital y observa cómo opera. Si es posible, observa si las enfermeras responden rápido a las luces de llamada, si parecen estar sobrecargadas con demasiados pacientes o están mirando sus celulares. Pregunta a los pacientes actuales y a sus familiares si están satisfechos con la atención.

¿Qué pasa si no puedo tolerar tres horas de terapia al día?

Una residencia de personas mayores que ofrece rehabilitación podría ser adecuada para pacientes que no necesitan la supervisión de un médico, pero que no están listos para irse a casa. Las instalaciones generalmente brindan atención de enfermería las 24 horas. La duración de la rehabilitación varía según el paciente. Hay más de 14.500 centros de enfermería especializada en el país, 12 veces más que los hospitales que ofrecen rehabilitación, por lo que una de estas residencias podría ser tu mejor opción.

Puedes buscarlas a través del sitio web Care Compare de Medicare.

¿Qué sucede si los pacientes son demasiado frágiles incluso para una residencia de adultos mayores?

Podrían necesitar un hospital de cuidados de largo plazo. Estos se especializan en pacientes en coma, con respiradores y con afecciones médicas agudas que requieren la presencia de un médico. Los pacientes permanecen allí al menos cuatro semanas, y algunos meses. Care Compare te ayuda a buscar. Hay menos de 350 hospitales de este tipo.

Si tengo la fuerza suficiente para ir a casa. ¿Cómo recibo terapia?

Muchos hospitales de rehabilitación ofrecen terapia ambulatoria. También puedes ir a una clínica o un terapeuta puede ir a tu domicilio. Puedes contratar una agencia de atención médica a domicilio o encontrar un terapeuta que reciba tu seguro y haga visitas a domicilio.

Tu médico u hospital podría derivarte a otros profesionales. En Care Compare, las agencias de atención médica a domicilio indican si ofrecen fisioterapia, terapia ocupacional o terapia del habla. Puedes buscar terapeutas certificados en el sitio web de la Asociación Americana de Fisioterapia (APTA).

Durante la rehabilitación, los pacientes a veces se trasladan del hospital a un centro de enfermería y luego a su hogar, a menudo por insistencia de sus aseguradoras. Alice Bell, especialista senior de la APTA, señaló que los pacientes deberían intentar limitar el número de traslados, por su propia seguridad.

“Cada vez que un paciente cambia de un entorno a otro se encuentra en una zona de mayor riesgo”, afirmó.

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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