Martha Santana-Chin, hija de inmigrantes mexicanos, creció con Medi-Cal, la versión californiana de Medicaid, el programa de atención médica administrado por el gobierno para personas con bajos ingresos y discapacidades.

Y hoy es CEO de L.A. Care, que administra lo que es, por lejos, el plan de Medi-Cal más grande, con más de 2,2 millones de beneficiarios, superando el número de inscripciones en Medicaid y en el Programa de Seguro de Salud Infantil (CHIP, por sus siglas en inglés) en 41 estados.

“Si no existieran redes de apoyo como el programa Medi-Cal, muchas personas estarían estancadas en la pobreza sin posibilidades de salir adelante”, dijo. “En lo personal, no tener que preocuparme por la atención médica me permitió concentrarme en lo que debía: mi educación”.

Al comenzar su segundo año al frente de L.A. Care, Santana-Chin enfrenta recortes presupuestarios federales y estatales que dificultan su misión de brindar atención médica a personas de bajos recursos y en situación de vulnerabilidad médica, inscritas en Medicaid. La aseguradora también ofrece planes de la Ley de Cuidado de Salud a Bajo Precio (ACA, en inglés) a través de Covered California.

Santana-Chin advierte que la ley republicana conocida como One Big Beautiful Bill Act, aprobada el año pasado y también llamada HR 1, podría provocar que 650.000 personas salgan del programa Medi-Cal de L.A. Care antes de que termine 2028. Esto afectará las finanzas del plan debido a la reducción en los ingresos. La aseguradora reportó ingresos de $11.700 millones en el último año fiscal.

Se estima que HR 1 recortará más de $900.000 millones de Medicaid en los próximos 10 años, incluidos más de $30.000 millones en California, según el Departamento de Servicios de Atención Médica del estado, que administra Medi-Cal.

Como otros estados con déficits grandes, California ha reducido su gasto en Medicaid mediante medidas como congelar nuevas inscripciones de inmigrantes sin estatus legal e imponer nuevamente un límite de activos. Todo esto incluso antes de que el estado tenga que afrontar los recortes derivados de la pérdida de fondos federales bajo HR 1.

Santana-Chin estuvo a cargo de las operaciones de Medi-Cal y Medicare para la aseguradora privada Health Net, antes de asumir la dirección de L.A. Care en enero de 2025. Asumió el cargo casi tres años después de que los reguladores estatales multaran a L.A. Care con $55 millones por infracciones que, según indicaron, comprometieron la salud y seguridad de sus afiliados. L.A. Care pagó $27 millones en multas al estado y acordó destinar $28 millones a proyectos comunitarios de salud.

En una amplia entrevista, Santana-Chin habló con Bernard J. Wolfson, corresponsal senior de KFF Health News, sobre los desafíos financieros que enfrenta L.A. Care y por qué considera que la atención médica no debería depender del estatus migratorio de una persona. Esta entrevista fue editada por razones de espacio y claridad.

Usted creció con Medicaid. ¿Cómo ha influido eso en su visión ahora que dirige uno de los planes más grandes del país?Lo que realmente me motiva es saber que muchas de las personas a las que servimos son como mi familia. Han enfrentado dificultades y han tenido que depender de sus propios hijos para traducir cosas muy complicadas. Yo recuerdo haber hecho eso por mi mamá. La dignidad humana básica exige tener acceso a atención médica.

¿Hay algo en su trabajo en Health Net o en L.A. Care que le haya recordado su experiencia infantil con Medi-Cal?En ese entonces no cubrían transporte y no teníamos auto. Hoy, una de las cosas que escuchamos de nuestros afiliados es la necesidad de contar con un transporte confiable, que llegue a tiempo y cuyos conductores los traten con respeto. Si mi mamá y yo hubiéramos tenido eso, la vida habría sido mucho más fácil.

¿Qué impacto cree que tendrá HR 1?Va a devastar el sistema de atención médica. Al estado le será imposible compensar la pérdida de fondos federales, y en los próximos años habrá cada vez menos dinero. Eso hará que el número de personas que cubrimos se reduzca significativamente. Esperamos que entre ahora y fines de 2028, unas 650.000 personas salgan de nuestras listas. Y eso es solo en L.A. Care.

Eso representa más de una cuarta parte de sus afiliados en Medi-CalSí, es muy, muy significativo. La reducción en los pagos y el aumento en la atención no remunerada van a afectar seriamente al sistema. A medida que ese sistema se debilite y hospitales y otros proveedores se vean obligados a cerrar servicios o reducir sus centros, el acceso a la atención se verá afectado. Y no solo para quienes pierdan la cobertura.

¿Cómo responderá L.A. Care?Obviamente vamos a tener una caída significativa en los ingresos. Estamos muy enfocados en operar de la manera más eficiente posible. Y estamos buscando formas creativas de usar la tecnología para que nuestro personal pueda asumir tareas de mayor nivel. Por ejemplo, mejorar nuestras herramientas para que los agentes del centro de llamadas puedan responder más rápido y resolver problemas. También estamos automatizando procesos del área de pagos de reclamos.

¿Qué le diría a los republicanos del Congreso que aprobaron HR 1?Estamos en un punto de inflexión en el sistema de salud. Y debemos reconocer que algunas partes de HR 1 tendrán consecuencias no deseadas a largo plazo, o tal vez sí eran deseadas, pero me cuesta creerlo. Probablemente haya aspectos que valga la pena reconsiderar.

¿Como cuáles?Los requisitos de trabajo son un ejemplo. Muchos pensaron que sería una buena forma de administrar responsablemente el dinero destinado a la salud. Pero es muy complejo y provocará que personas que realmente califican pierdan su cobertura. Es lamentable, y eso es algo que pediría que reconsideraran.

¿Qué impacto tendrá la decisión de California de congelar la inscripción en Medi-Cal para inmigrantes sin estatus legal?No importa cuál sea tu estatus migratorio, si eres un ser humano y necesitas atención médica, vas a buscarla donde puedas. Y eso va a generar presión en el sistema si no tienes seguro.

¿Qué ha hecho L.A. Care para responder a las preocupaciones del estado en 2022 sobre demoras en la autorización de servicios y en la atención de quejas?Se ha invertido mucho en la infraestructura de L.A. Care en los últimos años: en nuestras plataformas de tecnología, en el manejo de datos. También se ha sumado capacidad, se han reforzado muchos equipos y hay más personal para apoyar el trabajo.

¿Cómo han afectado las redadas migratorias federales en Los Ángeles a los afiliados de L.A. Care y a la comunidad en general?Definitivamente han tenido un efecto paralizante. Las familias tienen miedo de ir al médico. No están llevando a vacunar a sus hijos. Muchos proveedores en salas de emergencia nos han dicho que ha bajado el número de personas que llegan. Una de nuestras gestoras de casos estaba muy angustiada porque una persona decidió no recibir un tratamiento que le podía salvar la vida por miedo.

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Martha Santana-Chin, the daughter of Mexican immigrants, grew up on Medi-Cal, California’s version of Medicaid, the government-run health care program for people with low incomes and disabilities. Today, she is CEO of L.A. Care, which runs by far the biggest Medi-Cal health plan, with more than 2.2 million enrollees, exceeding the Medicaid and Children’s Health Insurance Program enrollments in 41 states.

“If it weren’t for safety nets like the Medi-Cal program, I think, many people would be stuck in poverty without an ability to get out,” she said. “For me personally, not having to worry about health care allowed me to really focus on what I needed to focus on, which was my education.”

As she begins her second year steering L.A. Care, Santana-Chin is grappling with federal and state spending cuts that complicate her task of providing health care to the poor and medically vulnerable enrollees in Medicaid. The insurer also provides Affordable Care Act marketplace plans through Covered California.

Santana-Chin warns that the GOP’s One Big Beautiful Bill Act, enacted last year and also known as HR 1, could result in 650,000 enrollees falling off L.A. Care’s Medi-Cal rolls by the end of 2028. This will strain the plan’s finances as revenues decline. The insurer had revenues of $11.7 billion in the last fiscal year.

HR 1 is expected to cut more than $900 billion from Medicaid over the next 10 years — including $30 billion or more in California, according to the Department of Health Care Services, which runs Medi-Cal.

Like other states facing big deficits, California has reduced its Medicaid spending through such steps as freezing new enrollments for immigrants without legal status and reintroducing an asset limit. And that’s before the state reckons with the spending cuts that likely will be required by the withdrawal of so many federal dollars under HR 1.

Santana-Chin oversaw Medi-Cal and Medicare operations for the for-profit insurer Health Net before taking the helm of L.A. Care in January 2025, nearly three years after state regulators fined L.A. Care $55 million over violations they said compromised the health and safety of its members. L.A. Care paid $27 million in penalties to the state and agreed to contribute $28 million to community health projects.

In a wide-ranging interview, Santana-Chin talked to KFF Health News senior correspondent Bernard J. Wolfson about the financial headwinds facing L.A. Care and why she believes health care shouldn’t be restricted based on a person’s immigration status. This interview has been edited for length and clarity.

Q: You grew up on Medicaid. How has that shaped your views now that you run one of the largest Medicaid plans in the country?

What really motivates me is knowing that many of the people that we’re serving are just like my family. They’ve struggled and have had to have their own children translate things that were very difficult to translate. I remember doing that for my own mother. You know, basic human dignity requires that you have access to health care.

Q: Has anything you’ve dealt with at Health Net or L.A. Care reminded you of your childhood experiences in Medi-Cal?

Back then they didn’t cover transportation, and we didn’t have a vehicle. Today, one of the issues we’ll hear from our members is the need to make sure we have trustworthy transportation that shows up on time, where the drivers treat them with respect. Had I had that, had my mother had that, life would have been much easier.

Q: What do you think the impact of HR 1 will be?

It’s going to devastate the delivery system. The state obviously isn’t going to be able to make up for the shortfalls in federal funding, and over the course of the next several years, funding is going to be less and less, and the people we cover are going to decrease significantly. We are expecting between now and the end of 2028 that we’re going to see 650,000 people drop off the rolls. That’s just L.A. Care.

Q: That’s over a quarter of your Medi-Cal enrollment.

Yes, it’s very, very significant. The reductions in payment and the rise in uncompensated care are really going to impact our delivery system. As the delivery system gets destabilized and hospitals and other health care providers are forced to close services or reduce the number of sites they have, it’s going to impact access. And it’s not only going to impact those that lose coverage.

Q: How will L.A. Care respond?

Obviously, we’re going to see a significant drop in revenue. We’re very focused on making sure that we are operating as efficiently as we can operate. And we are looking at creative ways to use technology to empower our people to do higher-level work. Mostly supporting our call center agents with smarter technology that helps them answer questions and resolve problems more quickly. Some of it is automating processes on the claims payment side.

Q: What do you have to say to congressional Republicans who passed HR 1?

We are at a point of inflection in the health care delivery system. And we have to recognize that some of the components of HR 1 will have long-term unintended consequences — maybe they were intended; I’ve got to believe that some of these things are not. There’s probably a need to reconsider some of the things that were passed.

Q: Such as?

Work requirements are an example of something that many people did believe was the right thing to do to be good stewards of the health care dollar. It is very complex and is going to cause people to lose coverage that actually do qualify. It’s unfortunate, and that would be something that I would urge folks to reconsider.

Q: What impact do you expect from California’s decision to freeze Medi-Cal enrollment for immigrants without legal status?

It doesn’t matter what immigration status you are. If you are a human being and you need health care, you’re going to try to access health care wherever you can. That’s going to put a strain on the delivery system if you’re uninsured.

Q: What has L.A. Care done to address the state’s concerns in 2022 that it delayed authorizing care and addressing patient grievances?

There has been quite a bit of investment in the L.A. Care infrastructure over the last several years — our IT platforms, our data. There’s also quite a bit of investment in adding new capacity, adding bandwidth to many of the teams, more folks to help support the work.

Q: How have federal immigration raids in L.A. affected L.A. Care members and the broader community?

It absolutely has had a chilling effect. Families are afraid to come in. They’re not taking their children to get vaccinated. I’ve had numerous providers in emergency departments say that they have experienced a drop in the volume of individuals coming in. One of our case managers was really distraught because there was an individual that decided to forgo serious lifesaving treatment because of fear.

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California, Massachusetts, Connecticut, and five other states have set caps on health care spending in a bid to rein in the intense financial pressure felt by many families, individuals, and employers who every year face increases in premiums, deductibles, and other health-related expenses.

Hospitals and other health care providers are citing Republicans’ One Big Beautiful Bill Act, signed by President Donald Trump in July, as one more reason to challenge those limits.

The law is expected to reduce federal Medicaid spending by more than $900 billion over a decade, which mathematically should help the overall health care system meet the caps. But the law is also expected to increase the number of uninsured Americans, mostly Medicaid beneficiaries, by an estimated 10 million people. Health care analysts predict hospitals and other providers will raise prices to cover the double whammy of lost Medicaid revenue and the cost of caring for an influx of newly uninsured patients.

Whether regulators in some states will allow providers to justify higher prices and exceed the spending caps is unclear. Only California and Oregon can penalize providers financially if they fail to meet targets.

“Are we going to say, ‘That’s OK’? Or are we going to say, ‘Well, you exceeded the target. We’re still going to penalize you for that’?” said Richard Pan, a former state lawmaker and a member of the California Office of Health Care Affordability’s board. “That has not yet been decided.”

The California Hospital Association, the industry’s main state lobbying group, filed a lawsuit in October asking a state court to strike down the spending caps, which it argued fail to account for all the cost pressures hospitals face. Those pressures, it said, include an aging, sicker population; the rising cost of labor; expensive advances in medical technology; large capital outlays on required seismic retrofitting; and changes in federal policy, including the One Big Beautiful Bill Act. The hospital group’s lawsuit also asserted that the state affordability office, by hastily imposing ill-considered cost-cutting targets, was undermining its other key mission of improving health care access, quality, and equity.

California’s affordability office last year set a five-year target to cap statewide spending growth, starting at 3.5% in 2025 and declining to 3% by 2029. The annual caps apply to a wide range of health care entities, including hospitals, medical groups, insurers, and other payers.

Earlier this year, it imposed much lower spending growth caps — starting at 1.8% in 2026 and declining to 1.6% by 2029 — for seven “high-cost” hospitals.

“The spending caps set by politically appointed bureaucrats could force cuts that result in many Californians traveling farther for care, facing longer emergency room wait times, experiencing more overcrowding, and losing access to critical services,” Carmela Coyle, the hospital association’s president and CEO, said in an October press release.

The California attorney general’s office, which will represent the affordability agency, has not yet filed a response to the hospital group’s complaint and did not respond to a request for comment.

Hospitals’ Pushback

California is not the only state taking a close look at hospital prices, which are widely considered a primary driver of health care costs.

“States, armed with information that points to payments to hospitals as a driver of what is way beyond affordable commercial premiums, have begun to take increasingly targeted actions focused on commercial hospital prices,” said Michael Bailit, founder of the Needham, Massachusetts-based consultancy Bailit Health, which has advised multiple states, including California, on ways to tame health care spending. “It is not surprising that the hospital industry is going to oppose such state actions.” 

In its lawsuit, the California Hospital Association said the affordability office’s own report showed that pharmaceutical and insurance companies are largely responsible for high costs.

Hospitals in some states with cost growth limits, including Connecticut and Massachusetts, have expressed objections similar to the ones raised in the California lawsuit. They could follow their counterparts in California if their lawsuit succeeds, said Peter Lee, who led California’s Affordable Care Act marketplace, Covered California, for over a decade and is now a senior scholar at Stanford Medicine’s Clinical Excellence Research Center.

Lee said the work of California’s affordability office and similar agencies in other states is just about the only systemwide effort being made to cut health care costs. They are basically saying, “‘Look, health care is taking money away from education, it is taking money away from the environment, it is taking money away from everything in the public sector, and in the private sector it is taking money away from wages,’” he said. “‘We don’t know how you, the health system, are going to do it, but it is your job not just to provide quality but to lower costs. Here’s the target.’”

To be sure, achieving the cost savings that California and those other states are seeking is no easy lift. It will ultimately require persuading large, financially powerful players that compete fiercely for health care dollars to adopt a different mindset and begin cooperating to reduce costs instead. And that, in many cases, will mean lower revenue.

But the status quo, as many people know all too well, means continued financial pain for millions.

In early 2020, Estevan Rodriguez, a bartender at California’s Monterey Beach Hotel, had surgery for a staph infection in his leg. The bill came to nearly $168,000. His insurance paid most of it, but he still owed $5,665, which took him two years to pay, more than $200 every month. “It may not be a lot to some people, but it was a lot to me,” Rodriguez said.

He said he dropped his Hulu subscription, switched to a lower-cost cellphone, and got cheaper car insurance. He started going to food banks rather than the grocery store, he said, and had a lot less time with his kids, because he was constantly working to pay off the hospital bill.

Community Hospital of the Monterey Peninsula, where Rodriguez had his surgery, is one of the seven hospitals identified by California’s affordability office as high-cost. A study by the office attributed high hospital prices in Monterey County to a lack of market competition “rather than higher operating costs or superior quality of care.”

The Monterey hospital referred a request for comment about its “high-cost” designation to the California Hospital Association. CHA spokesperson Jan Emerson-Shea declined to comment beyond the language of the lawsuit and Coyle’s press release statement.

Reduced Competition

Health care analysts worry the One Big Beautiful Bill Act will reduce market competition even further by stressing already weak hospitals, leading some to shut services, merge with larger health systems, or close. One study estimates 338 rural hospitals are at risk of closing nationwide.

Less competition, in addition to fewer Medicaid dollars and an increase in uninsured patients, will only strengthen the incentive of health systems with the requisite market clout to raise their commercial prices, increasing premiums for employers and individuals.

“We think commercial prices will continue to increase as health care providers, and hospitals in particular, will seek to preserve or increase their revenue,” said Rachel Block, a program officer at the Milbank Memorial Fund, a foundation that focuses on health equity.

That in turn could pose a challenge to state affordability regulators tasked with overseeing compliance with growth targets for health care spending.

California’s affordability office is required to consider mitigating factors, including changes in federal and state laws. But some of its board members have expressed skepticism about letting hospitals offset Medicaid losses with higher commercial prices.

“There’s a lot of talk about using HR 1 and other federal policies as an excuse to raise prices on commercial payers,” Ian Lewis, an affordability office board member and policy director for UNITE HERE Local 2, a hospitality workers union in the Bay Area, said at the agency’s July board meeting, referring to the One Big Beautiful Bill. “There’s no more blood to be squeezed from this stone.”

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And, they warn, the economic burden will steer many medical students to lucrative specialties in more affluent, urban areas rather than lower-paying primary care jobs in underserved and rural communities, where doctors are in shortest supply.

“The growing financial barriers may deter some individuals from pursuing a career in medicine, particularly those from low-income backgrounds,” said Deena McRae, a psychiatrist and associate vice president for academic health sciences at University of California Health.

The new federal loan limits, which are enshrined in the GOP legislation signed by Trump on July 4, cap the amount professional degree students can borrow at $50,000 a year, up to a maximum of $200,000 — well below the average cost of a four-year medical school education.

For students who graduated this year with an MD degree from a four-year medical school in the United States, the median cost of attendance was $318,825, according to Kristen Earle, director of student financial services at the Association of American Medical Colleges. And for those who entered a U.S. medical school in the 2024-25 academic year, the median first-year cost was $83,700.

Health care experts and politicians on both sides of the aisle agree that medical schools must find ways to lower their costs, but critics of the loan caps say limiting federal lending isn’t the answer. Congressional Republicans, who voted for the caps, say they are intended to stem a sharp rise in federal student lending over the past two decades that has driven the cost of attendance higher.

“Uncapped loan limits gave no incentives for schools to reduce any of their costs, recognizing that taxpayers, students, or students’ families would eventually foot the bill,” said Sara Robertson, a spokesperson for the GOP-controlled House Committee on Education and Workforce. “Our reforms and loan limits will put downward pressure on costs to provide better outcomes and lower debt for all students.”

The budget law brings back caps for graduate and professional education that Congress eliminated in 2006. Since then, students have been able to get federal loans that cover the total cost of their degree programs. Reimposing the caps, along with other changes to federal student loans, is expected to save the federal government $349 billion over 10 years, according to the Congressional Budget Office.

Whether the new federal loan policy will push down tuition costs remains to be seen.

Robertson pointed to a 2023 study by the National Bureau of Economic Research showing that the more generous federal lending policy since 2006 has led to “significantly higher program prices” in graduate education. The study also found that the additional federal support failed to increase enrollment in graduate programs, including for underrepresented students.

However, data provided by the Association of American Medical Colleges shows that cost-of-living increases, not tuition, drove up the expense of studying medicine in recent years.

Students already in medical school who have taken out federal loans before the new rules take effect on July 1 will be exempted from the cap. But students whose loans are capped under the new law will need to make up the difference, in many cases by taking out private sector loans, which typically have less flexible repayment terms and require a strong credit rating — a heavy lift for students from low-income communities.

Robertson cited a 2017 analysis showing that nearly 60% of graduate students could have obtained a private loan at a lower interest rate than any available federal loan. Federal loans, however, come with advantages that private loans don’t. For instance, federal loans can include monthly repayments calibrated to income, and they offer two debt forgiveness paths, including the Public Service Loan Forgiveness program, which erases the balance for those who work in a government or nonprofit organization and make their monthly payments for 10 years.

Critics and proponents agree on at least one thing: Now is the time for medical schools to think creatively about lowering costs for students. This might include reduced tuition, more chances for debt forgiveness, and accelerated programs that allow students to graduate in three years rather than four, reducing costs by 25% and getting them more quickly into paid jobs.

“I hope that coming out of this, medical schools and others find a way to seize the moment and help us figure out how to reduce the total cost of medical school,” said Martha Santana-Chin, CEO of L.A. Care. “Maybe this is an opportunity for us to rethink how the system is working.”

Roughly a fifth of medical schools offering an MD degree have accelerated programs, including the University of California-Davis, according to the Consortium of Accelerated Medical Pathway Programs.

A data analysis of eight medical schools led by the NYU Grossman School of Medicine, whose core MD curriculum is three years, shows that students in three-year programs derive a lifetime financial gain totaling over $240,000 due to the cost savings of less time in medical school, interest not paid on the corresponding amount not borrowed, and faster progression to a salaried position.

In addition to lowering costs, accelerated medical programs seek to address health care workforce shortages by training physicians more quickly. And with the new loan caps about to make it more difficult for many students to finance their medical education, these programs suddenly have a new timeliness.

Students who spend three years in medical school instead of four have lower debt and get to a higher salary sooner, said Caroline Roberts, a family physician and director of rural education at the University of North Carolina’s School of Medicine. UNC offers a three-year track for students who want to be primary care doctors and work in rural areas of the state, where doctor shortages are a major problem.

Zoe Priddy, who is in her second year of UNC’s three-year program, said that if the federal loan limits had been in place at the time she was making plans to attend medical school, she would have needed a job that paid better than the research lab where she worked after completing her undergraduate degree.

“I would have had to change my trajectory if I still wanted to pursue medicine, and I don’t know if it would have been possible for me,” Priddy said. However, the lower debt associated with the three-year track “eased my decision” to go into pediatrics, a lower-paying specialty, she said.

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Analistas del sector salud advierten que la cantidad de personas sin seguro médico en el país aumentará significativamente si los legisladores federales no renuevan los subsidios creados durante la pandemia de covid, que el Congreso aprobó en 2021 como complemento a los subsidios de ACA.

Es un tema que tiene apoyo popular. Según una encuesta de KFF, más de tres cuartas partes de los adultos, incluyendo el 59% de los republicanos, quieren que el Congreso extienda los subsidios mejorados para personas de ingresos bajos y moderados.

Estos subsidios adicionales han reducido las primas mensuales, han ayudado a millones de estadounidenses a pagar los seguros de salud de ACA y han disminuido la tasa nacional de personas sin seguro.

La semana del 6 de octubre, el presidente Donald Trump insinuó que podría haber un acuerdo sobre salud. Y la legisladora Marjorie Taylor Greene, republicana de Georgia, alineada desde hace tiempo con el movimiento “Make America Great Again” (MAGA), pareció respaldar una extensión de los subsidios, al publicar en redes sociales que estaba “absolutamente indignada de que las primas de los seguros médicos se DUPLIQUEN si los subsidios expiran este año”.

Sin embargo, los líderes republicanos quieren reabrir el gobierno primero, mientras que los demócratas buscan que el acuerdo esté incluido en el proyecto de ley para terminar con el cierre.

Si los subsidios adicionales no se extienden más allá de este año, se espera que el costo que pagan estos consumidores por sus planes médicos de ACA suba más del doble en promedio.

Eso representaría un fuerte aumento en el costo de vida para más de 24 millones de personas inscritas en los mercados de seguros, incluyendo un 90% de los casi 2 millones que tienen seguro a través de Covered California, el mayor mercado de seguros médicos administrado por un estado. Analistas advierten que la pérdida de estos subsidios mejorados provocaría que millones de personas cancelen su cobertura a nivel nacional, incluyendo a cientos de miles en California.

El cierre del gobierno federal se debe principalmente a un desacuerdo entre los legisladores demócratas, que quieren extender los subsidios, y los republicanos, que se oponen al costo y, en muchos casos, a la propia ley de salud.

Una estimación calcula que la extensión tendría un costo de $350.000 millones en 10 años. Los demócratas esperan que su postura les ayude a recuperar la Cámara de Representantes en las elecciones intermedias del próximo año, como ocurrió en 2018 tras el fallido intento republicano de derogar ACA.

La temporada de inscripción para los planes de salud de ACA de 2026 comienza el 1 de noviembre en la mayoría de los estados, incluido California, y los inscritos aún no saben si sus primas aumentarán de forma exorbitante el próximo año.

“Las personas necesitan poder comparar planes de salud”, dijo Jessica Altman, directora ejecutiva de Covered California. “Estamos en un momento decisivo”.

En julio, Covered California envió notificaciones a sus consumidores detallando la parte adicional de su subsidio federal que está por expirar. La intención era advertirles cuánto podrían aumentar sus costos si decidían mantener el mismo plan el próximo año.

En el caso de personas de ingresos medios, desaparecería el subsidio completo de $200 al mes. Otro inscrito perdería un tercio de los $600 mensuales que recibía en ayuda, según ejemplos de notificaciones proporcionadas por Covered California.

Los subsidios adicionales han brindado asistencia financiera a muchos compradores de planes medicos, con ingresos medios, que no calificaban para los subsidios originales, y han incrementado la ayuda para muchas otras personas.

El líder de la mayoría en el Senado, John Thune, dijo a finales de septiembre que no descartaba una extensión de los subsidios, pero que “tendría que venir acompañada de algunas reformas”.

Estas podrían incluir cambios para reducir la cantidad de personas que califican para la ayuda adicional, según sus ingresos, y reducir o eliminar los planes sin primas, que se volvieron ampliamente disponibles con la llegada de estos subsidios.

Si se terminan los subsidios mejorados, Covered California estima que quienes los reciben verán aumentar sus primas en un 97% de promedio. Pero los aumentos no serán iguales para todos. Según la edad, los ingresos y la ubicación, algunas personas verán aumentos menores, mientras que otras podrían ver que sus costos de bolsillo se triplican, explicó Altman.

Las personas que viven en zonas rurales, especialmente en los condados del norte, del este y en la región de Monterey Coast, enfrentarán aumentos de costos desproporcionadamente altos, según proyecciones de Covered California. Los inscritos con ingresos superiores a $62.600 perderán toda la ayuda financiera, lo que dejará a algunas personas de entre 55 y 64 años con facturas de primas que podrían representar hasta el 30% de sus ingresos.

Sin los subsidios mejorados, “veremos a más personas endeudadas por gastos médicos, más personas sin seguro o con seguro insuficiente”, dijo Cary Sanders, directora de políticas de la organización sin fines de lucro California Pan-Ethnic Health Network. “Y esa es la forma más rápida en que una familia puede perder su seguridad económica”.

Covered California estima que unas 400.000 personas abandonarían el mercado de seguros y probablemente se quedarían sin cobertura. Y eso, advierten profesionales y activistas de la salud, solo aumentará la presión —en forma de salas de emergencia y clínicas comunitarias más saturadas— sobre un sistema de salud ya estresado.

Sin embargo, el impacto proporcional en California será menor que en algunos estados liderados por republicanos como Florida, Texas y Georgia. Como esos estados no ampliaron el programa Medicaid de ACA, millones de residentes recurrieron a los planes del mercado de Obamacare, especialmente después de que los subsidios mejorados hicieron que la cobertura fuera mucho más accesible.

Entre 2020 y 2025, la inscripción en el mercado de ACA aumentó casi 2.5 veces en Florida, alcanzando los 4,7 millones —más del doble que en California. En Texas, se triplicó a casi 4 millones. En Georgia también se triplicó, alcanzando los 1,5 millones.

California cuenta con aproximadamente $190 millones para 2026 en fondos estatales para ayudar a compensar la pérdida de los subsidios adicionales. Pero ese dinero se usa para ayudar a rebajar los deducibles, copagos y otros gastos de bolsillo de los inscritos. Y es una cantidad pequeña en comparación con los $2.500 millones anuales que los inscritos de Covered California reciben hoy día gracias a los subsidios que están por expirar.

“Mucha gente se va a sorprender con lo que viene”, señaló Rachel Linn Gish, vocera de la organización sin fines de lucro Health Access California. “Van a tener que tomar decisiones muy difíciles como: ‘¿Recorto el gasto en comida, en la renta, o me quedo sin seguro?’”.

Muy pronto, Covered California y otros mercados de ACA tendrán que enviar cartas formales de inscripción abierta, notificando a los inscritos exactamente qué esperar para la cobertura de 2026.

Covered California normalmente envía estas cartas el 1 de octubre, pero las ha retrasado hasta alrededor del 15 de octubre con la esperanza de que Washington aclare la situación. Por ahora, la agencia tiene dos versiones listas: una con la extensión de los subsidios y otra sin ellos.

Altman dijo que esperaba una acción del Congreso antes de enviar la versión con los grandes aumentos en las primas. Pero puede que no tenga otra opción.

“Ese es el escenario que tenemos, es decir, lo que ocurrirá si nada cambia”, dijo Altman. “Y también es el peor escenario posible, desafortunadamente”.

Le preocupa que, si Covered California informa a los inscritos de un probable y enorme aumento en sus primas, eso ahuyentará a muchas personas, aunque más adelante el Congreso decida extender los subsidios.

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Health care analysts say the nation’s uninsured population will rise significantly if federal lawmakers do not agree to renew covid-era tax credits, which Congress authorized in 2021 to supplement ACA subsidies.

They’re popular too. According to a KFF poll, more than three-quarters of adults, including 59% of Republicans, say they want Congress to extend the enhanced tax credits for people with low and moderate incomes. KFF is a health information nonprofit that includes KFF Health News, the publisher of California Healthline.

The additional credits have lowered premiums, helped millions of Americans afford the cost of ACA insurance, and lowered the nation’s uninsured rate.

Last week, President Donald Trump suggested a health care deal might be in the works. And Republican U.S. Rep. Marjorie Taylor Greene of Georgia, long aligned with the “Make America Great Again” movement, appeared to endorse an extension of the tax credits, saying in a social media post that she was “absolutely disgusted that health insurance premiums will DOUBLE if the tax credits expire this year.”

However, Republican leaders want to reopen the government first, while Democrats want a deal in a bill that ends the shutdown.

If the supplemental subsidies are not extended beyond this year, the amount subsidized consumers pay for their ACA health plans is expected to more than double on average. That would be a painful cost-of-living increase for most of the country’s more than 24 million marketplace enrollees, including almost 90% of the nearly 2 million people in Covered California, the largest state-run health insurance marketplace. Analysts say the loss of enhanced credits would lead millions to drop their coverage nationally, including hundreds of thousands in California.

The federal government shutdown stems primarily from a disagreement between Democratic lawmakers, who want to extend the tax credits, and Republicans opposed to the cost and, in many cases, to the landmark health care law itself. One estimate puts the price tag at $350 billion over 10 years. The Democrats hope their stance can help them win back the House in next year’s midterm elections, as they did in 2018 following a failed GOP effort to repeal the ACA.

Open enrollment season for 2026 ACA health plans starts Nov. 1 in most states, including California, and enrollees still have no clue whether their premiums will rise exorbitantly next year.

“People need to be able to shop for health plans,” says Jessica Altman, executive director of Covered California. “We are at a pivotal moment.”

In July, Covered California sent notices to enrollees breaking out the enhanced portion of their federal subsidy that is set to expire. The idea was to give them a warning of how much their costs might rise if they chose to keep the same health plan next year.

In one case, a common scenario for middle-income enrollees, the entire subsidy of $200 a month would go away. Another enrollee stood to lose one-third of a total $600 per month in aid, according to sample notices provided by Covered California.

The additional tax credits have provided financial assistance to many middle-income health plan shoppers who didn’t qualify for the original subsidies and increased the amount of aid for many others.

Senate Majority Leader John Thune in late September left the door open to extending the otherwise-expiring tax credits but said “it would have to come with some reforms.”

Those might include changes that would reduce the number of enrollees eligible for the extra financial aid, based on income, and reduce or eliminate zero-premium plans, which have become widely available with the advent of the additional tax credits.

If the enhanced subsidies end, Covered California projects its enrollees receiving enhanced subsidies will see their premium costs rise an average of 97%. But the increases will not be borne equally. Depending on age, income, and location, some people will see smaller jumps while others could see their out-of-pocket costs triple, Altman says.

Rural residents, especially in the northern and eastern counties, and along the Monterey Coast, will see disproportionately large cost increases, according to projections from Covered California. Enrollees with incomes over $62,600 will lose financial aid altogether, leaving some who are ages 55-64 with premium bills as high as 30% of their income.

Without the enhanced subsidies, “we’re going to see more people experiencing medical debt, more people being either uninsured or underinsured,” says Cary Sanders, senior policy director at the nonprofit California Pan-Ethnic Health Network. “And that is the quickest way for families to lose their economic security.”

Covered California estimates about 400,000 people would leave the exchange and likely go without insurance. And that, health care professionals and advocates warn, will only heap stress — in the form of more crowded emergency rooms and community clinics — on an already stressed health care system.

But the proportional impact in California will be smaller than in some Republican-led states such as Florida, Texas, and Georgia. Since those states did not embrace the ACA’s Medicaid expansion, millions of residents thronged to Obamacare marketplace plans, particularly after the enhanced tax credits made coverage eminently more affordable.

From 2020 to 2025, ACA marketplace enrollment grew nearly 2.5 times in Florida to 4.7 million — more than double California’s marketplace enrollment. In Texas, it more than tripled to just under 4 million. Georgia’s tripled, too, to 1.5 million.

California has about $190 million for 2026 in state funds to help offset the loss of the enhanced premium subsidies. But that money is currently used to help offset enrollee deductibles, coinsurance payments, and other out-of-pocket expenses. And it’s a drop in the bucket compared with the $2.5 billion annually in financial aid Covered California enrollees currently receive from the expiring tax credits.

“A lot of people are going to be shocked at what they’re facing,” says Rachel Linn Gish, a spokesperson for the nonprofit advocacy group Health Access California. “They’re going to have to make super hard choices of, ‘Do I cut back on my groceries, or my rent, or do I go uninsured?’”

Very soon, Covered California and other ACA marketplaces will have to send out formal open enrollment letters, notifying enrollees precisely what to expect for 2026 coverage.

Covered California typically sends those letters out Oct. 1 but has delayed them to around Oct. 15 in the hope that Washington will provide clarity. For now, Covered California has two versions of the letter on ice, one with tax credit extensions and one without.

Altman says she is hoping for congressional action before sending the one with whopping premium increases. But she may have no choice.

“That’s the default here, as in the thing that will happen if nothing changes,” Altman says. “It is also the worst-case scenario, unfortunately.”

She fears that if Covered California informs enrollees that their rates will likely rise sharply, it will scare many away, even if Congress later agrees to extend the credits.

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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Owlett is one of four residents in the inaugural class of a three-year family medicine residency program run by the local nonprofit Healthy Rural California. She is the kind of doctor the organization seeks to draw to the far north of California, a region with severe physician shortages.

That’s because Owlett knows in her gut what a lack of health care means, having seen family members drive hours to see a specialist or simply forgo care in her hometown of Wellsboro, a hamlet in Pennsylvania. She did rural training at medical school in Colorado. And because her husband attended Chico State, the couple has a strong social network here, making them likely to remain.

“With the growing family medicine residency program here, it’s a great opportunity to bring more doctors into the area, and I’d love to be a part of that,” Owlett said.

Owlett exemplifies what leaders in rural Northern California want more of: doctors trained locally who stay to work in the area. They have ambitious plans to attract more Owletts and expand the medical workforce, but recent state and federal spending cuts will pull dollars out of an already frayed health system, exacerbating the shortage of care and making their efforts more challenging.

“We need help up here, and cutting funding is not going to help us,” said Debra Lupeika, associate dean for rural and community-based education at the University of California-Davis School of Medicine and a family physician at the tribal Rolling Hills Clinic in Red Bluff, about 40 miles northwest of Chico. “We are in dire straits. We need doctors.”

California’s far northern region is a collection of sparsely populated counties stretching from just north of Sacramento all the way up to Oregon and from the Pacific coast to the Nevada border. The shortages are so pervasive that support for one of the costliest solutions — a proposed $200 million health care training campus — transcends partisanship.

“It’s about what are the priorities, right? And health care certainly is a priority — should be a priority,” said California Assembly Republican Leader James Gallagher, who represents Chico and the surrounding area. “I think it’s been pretty bipartisan, this kind of stuff.”

Republicans in Congress, including the nine GOP lawmakers in California’s delegation, voted in July to cut nearly a trillion dollars from Medicaid. Area Rep. Doug LaMalfa said the bill ensures “those eligible for benefits continue to receive them.” Meanwhile, the Democratic-controlled California legislature has scaled back its health care coverage for immigrants who lack legal status.

California’s health care shortage is driven by the struggles of rural hospitals; an aging physician workforce; the inherent appeal to up-and-coming doctors of more urban areas; and the financial pressures of doing business in a region with a high proportion of low-paying government insurance, especially Medi-Cal, the state’s version of the Medicaid program, for people with low incomes and disabilities.

Almost everyone who lives up here is affected by the shortages, ranging from people with complex medical needs to those with simple, straightforward ones.

When Lupeika’s 24-year-old daughter, Ashley, injured her shoulder this summer, she couldn’t get an MRI for nearly a month, despite her severe pain.

Ginger Alonso, an assistant professor of political science and public administration at Chico State, said she drives 70 miles to Redding for OB-GYN care.

The long waits or distances people must travel often lead them to delay or forgo care. As a result, they show up at emergency rooms, urgent care, or community clinics with illnesses that are more severe than they would have been had they received medical attention sooner.

“We see sicker patients, bottom line,” said Tanya Layne, a primary care physician in Chico who recently closed her private practice for financial reasons and works at an urgent care clinic in town, owned by Enloe Health, which also runs the sole hospital in town.

Patients walk through the door with undiagnosed cancers, uncontrolled asthma, raging diabetes, and severely high blood pressure, Layne said.

In many northern counties, specialists in acutely short supply include neurologists, gastroenterologists, rheumatologists, endocrinologists, OB-GYNs, oncologists, and urologists.

“We have whole areas with no specialists at all, or where specialists are so overworked that the waits are really long, and people are forgoing care,” said Doug Matthews, a Chico-based colorectal surgeon and regional medical director of Partnership HealthPlan, which provides Medi-Cal coverage in 24 northern counties.

The health care shortage in the region grew more acute after the catastrophic 2018 Camp Fire devastated the town of Paradise, 15 miles east of Chico, shuttering the local hospital and sending dozens of doctors out of the region.

In response, local leaders created Healthy Rural California, which launched a four-year residency in psychiatry last year followed by the family medicine program this year. The group also runs a program to expose high school students to potential careers in health care, and it is behind early plans for the $200 million “interprofessional” health care campus that would train future doctors, nurses, physician assistants, and others.

The startup cost would likely need to come from California’s state legislature, but lawmakers are limited by severe budget pressures. Nevertheless, James Schlund, a radiologist and board member of the organization, is discussing it with officials from UC Davis and Touro University.

“We are building the coalition,” Schlund said, “to go to the legislature with an empty bucket and ask them to fill it with money at the hardest of possible times.”

Meanwhile, medical and political leaders in Chico and Redding, the two largest cities in California’s far north, are each exploring building a medical school, possibly in collaboration and under the auspices of UC Davis, which considers rural medicine integral to its mission.

A medical school, paired with more residency slots, would keep graduating students in the area long enough for them to establish roots, buy homes, and start families, boosting the supply of local physicians, said Paul Dhanuka, a gastroenterologist and member of the Redding City Council.

But some say the region’s small population makes it a challenge to train more residents.

“The number of residents you can accommodate is limited by the ability to get the right kinds of patients with the right kind of cases that give the residents the training they need,” said Duane Bland, a physician who runs the family practice residency program at Mercy Medical Center in Redding.

Dhanuka said that in sparsely populated areas, a low number of childbirths limits how many residents can be trained in family medicine. But that is not the case with other specialties such as surgery, psychiatry, cardiology, and gastroenterology. And, he said, across the whole northern region, “there are multiple hospitals as well as clinics which absolutely are looking for more residency participation.”

Residency programs are largely funded with federal dollars through Medicare, and that funding is not at imminent risk — though the number of residency slots paid for by Washington has not significantly increased in about 30 years.

However, some graduate medical education is state-funded, and in California many of those slots rely on revenue generated from a tax on Medi-Cal health plans, which California voters earmarked for that and other purposes last fall by passing Proposition 35. That revenue is projected to plummet by billions of dollars under changes in the budget law and a similar rule proposed by the Centers for Medicare & Medicaid Services.

“We could lose that Prop. 35 funding,” said Mark Servis, vice dean for medical education at the UC Davis School of Medicine. “And we have been planning on it for over a year as a way to build out graduate medical education.”

It’s already begun: Glenn Medical Center in Willows, about 30 miles from Chico, announced last month it would shut down its ER and hospital services in October after losing its federal designation as a “critical access” hospital, which afforded it higher payments and more regulatory flexibility.

A $50 billion rural health care fund in the budget law will offset a little more than a third of the money that rural areas are expected to lose because of the Medicaid cuts, according to research from KFF. And it’s not clear how, or to which states, that money will be distributed.

Civic and medical industry leaders in Chico and Redding say the message needs to get out that a robust health care system will serve the interests of everyone, across political lines.

“Health care is such a human need, because we all hurt the same, regardless of race, color,” Dhanuka said. “We can address this. And we don’t need to take sides on this.”

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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And presto: You’ve got people dropping coverage; rising costs; and a smaller, sicker group of enrollees, which translates to higher premiums.

The Trump administration and congressional Republicans have just checked that achievement off their list.

They have done it with the sprawling tax and spending law President Donald Trump signed on July 4 and a related set of new regulations released by the Centers for Medicare & Medicaid Services that will govern how the ACA marketplaces are run.

Among the many provisions, there’s this: Large numbers of lawfully present immigrants currently enrolled in Obamacare health plans will lose their subsidies and be forced to pay full fare or drop their coverage.

Wait. What?

I understand that proponents of the new policies think the government spends too much on taxpayer subsidies, especially those who believe the ACA marketplaces are rife with fraud. It makes sense that they would support toughening enrollment and eligibility procedures and even slashing subsidies. But taking coverage away from people who live here legally is not health care policy. It’s an echo of the federal immigration raids in Los Angeles and elsewhere.

“It’s creating a very hostile environment for them, especially after having to leave their countries because of some very traumatic experiences,” says Arturo Vargas Bustamante, a professor of health policy and management at UCLA’s Fielding School of Public Health. “For those who believe health care is a human right, this is like excluding that population from something that should be a given.”

In Covered California, 112,600 immigrants, or nearly 6% of total enrollees, stand to lose their federal tax subsidies when the policy takes effect in 2027, according to data provided by the exchange. In the Massachusetts and Maryland marketplaces, the figure is closer to 14%, according to their directors, Audrey Morse Gasteier and Michele Eberle, respectively.

It’s not clear exactly how much financial aid those immigrants currently receive in ACA marketplaces. But in Covered California, for example, the average for all subsidized enrollees is $561 per month, which covers 80% of the $698 average monthly premium per person. And immigrants, who tend to have lower-than-average incomes, are likely to get more of a subsidy.

The immigrants who will lose their subsidies include victims of human trafficking and domestic violence, as well as refugees with asylum or with some temporary protected status. And “Dreamers” will no longer be eligible for ACA marketplace health plans because they will not be considered lawfully present. Immigrants who are not in the country legally cannot get coverage through Covered California or most other ACA marketplaces.

The nearly 540,000 Dreamers in the United States arrived in the U.S. as kids without immigration papers and were granted temporary legal status by President Barack Obama in 2012. Of those, an estimated 11,000 have ACA health plans and would lose them, including 2,300 in Covered California.

Supporters of the policy changes enshrined in the CMS rule and budget law think it’s high time to rein in what they say are abuses in the system that started under the Biden administration with expanded tax credits and overly flexible enrollment policies.

“It’s about making Obamacare lawful and implementing it as drafted rather than what Biden turned it into, which was a fraud and a waste-infused program,” says Brian Blase, president of Arlington, Virginia-based Paragon Health Institute, which produces policy papers with a free-market bent and influenced the Republican-driven policies.

But Blase doesn’t have much to say about the termination of Obamacare subsidies for lawfully present immigrants. He says Paragon has not focused much on that subject.

Jessica Altman, executive director of Covered California, expects most immigrants who lose subsidies will discontinue their enrollment. “If you look at where those populations fall on the income scale, the vast majority are not going to be able to afford the full cost of the premium to stay covered,” she says.

Apart from the human hardship cited by Bustamante, the exodus of immigrants could compromise the financial stability of coverage for the rest of Covered California’s 1.9 million enrollees. That’s because immigrants tend to be younger than the average enrollee and use fewer medical resources, thus helping offset the costs of older and sicker people who are more expensive to cover.

Covered California data shows that immigrant enrollees targeted by the new federal policies pose significantly lower medical risk than U.S. citizens. And a significantly higher percentage of immigrants in the exchange are ages 26 to 44, while 55- to 64-year-olds make up a smaller percentage.

Still, it would be manageable if immigrants were the only younger people to leave the exchange. But that is unlikely to be the case. More red tape and higher out-of-pocket costs — especially if enhanced tax credits disappear — could lead a lot of young people to think twice about health insurance.

The covid-era enhanced tax credits, which have more than doubled ACA marketplace enrollment since their advent in 2021, are set to expire at the end of December without congressional action. And, so far, Republicans in Congress do not seem inclined to renew them. Ending them would reverse much of that enrollment gain by jacking up the amount consumers would have to spend on premiums out of their own pockets by an average of 66% at Covered California and more than 75% nationally.

And an analysis by the Congressional Budget Office shows that a consequent exodus of younger, healthier people from the marketplaces would lead to even greater costs over time.

Enhanced tax credits aside, consumers face additional hurdles: The annual enrollment period for Covered California and other marketplaces will be shorter than it is now. Special enrollment periods for people with the lowest incomes will be effectively eliminated. So will automatic renewals, which have greatly simplified the process for a majority of enrollees at Covered California and some other marketplaces. Enrollees will no longer be able to start subsidized coverage, as they can now, before all their information is fully verified.

“Who are the people who are going to decide to go through hours and hours of onerous paperwork?” says Morse Gasteier. “They’re people who have chronic conditions. They have health care issues they need to manage. The folks we would expect not to wade through all that red tape would be the younger, healthier folks.”

California and 20 other states this month challenged some of that red tape in a federal lawsuit to stop provisions of the CMS rule that erect “unreasonable barriers to coverage.” California Attorney General Rob Bonta said he and his fellow attorneys general hoped for a court ruling before the rule takes effect on Aug. 25.

“The Trump administration claims that their final rule will prevent fraud,” Bonta said. “It’s obvious what this is really about. It’s yet another political move to punish vulnerable communities by removing access to vital care and gutting the Affordable Care Act.”

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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El proyecto de ley, aprobado por el Senado el martes 1 de julio, revertiría muchos de los avances en cobertura médica de las administraciones Biden y Obama, cuyas políticas facilitaron el acceso a la atención médica a millones de personas y redujeron la tasa de personas sin seguro en el país a mínimos históricos.

El plan del Senado para recortar drásticamente la financiación de Medicaid y los mercados de ACA podría hacer que unas 12 millones de personas más no tuvieran seguro para 2034, según estima la CBO.

Esto, a su vez, perjudicaría las finanzas de hospitales, residencias de adultos mayores y centros de salud comunitarios —que tendrían que absorber una mayor parte del costo del tratamiento de las personas sin cobertura— y podría obligarlos a reducir servicios y personal, hasta a cerrar instalaciones.

La legislación está en el escritorio de Trump a la espera de su firma, aunque primero el Senado y la Cámara de Representantes deben aprobar la misma versión. La Cámara de Representantes aprobó su propia versión en mayo y se espera que considere la versión del Senado hoy (2 de julio), según Tom Emmer, líder de la mayoría en la Cámara.

A continuación, se presentan cinco maneras en que los planes del Partido Republicano podrían afectar el acceso a la atención médica.

¿Necesita Medicaid? Entonces consigue un trabajo

Los recortes más profundos al gasto en atención médica provienen de la propuesta de un requisito de trabajo para Medicaid, que cortaría la cobertura a millones de afiliados que no cumplen con estos nuevos estándares.

En 40 estados y Washington, D.C., que han ampliado Medicaid bajo ACA, algunos beneficiarios de Medicaid tendrían que presentar regularmente documentación que demuestre que trabajan, hacen voluntariado o asisten a la escuela al menos 80 horas al mes, o que califican para una exención, como por ejemplos el cuidado de un niño pequeño.

El requisito del proyecto de ley no se aplicaría a las personas en los 10 estados, mayoritariamente republicanos, que no han ampliado Medicaid.

Investigadores de salud afirman que la política tendría poco impacto en el empleo. Según KFF, la mayoría de los beneficiarios de Medicaid en edad laboral que no reciben prestaciones por discapacidad ya trabajan o buscan trabajo, o no pueden hacerlo porque tienen una discapacidad, asisten a la escuela o cuidan a un familiar.

Los experimentos estatales con requisitos de trabajo se han visto plagados de problemas administrativos, como la pérdida de cobertura de los beneficiarios elegibles por problemas con el papeleo, y más gasto.

El requisito de trabajo de Georgia, que se implementó oficialmente en julio de 2023, ha costado más de $90 millones, de los cuales solo 26 millones se han destinado a prestaciones de salud, según el  Georgia Budget & Policy Institute, una organización de investigación no partidista.

“Los costos ocultos son astronómicos”, afirmó Chima Ndumele, profesor de la Escuela de Salud Pública de Yale.

Menos dinero significa menos atención en las comunidades rurales

Las medidas de ajuste que se aplicarían a los estados podrían traducirse en una disminución de los servicios de salud, profesionales médicos e incluso hospitales, especialmente en las comunidades rurales.

El plan del Partido Republicano reduciría una práctica conocida como impuestos a los proveedores, que casi todos los estados han utilizado durante décadas para aumentar los pagos de Medicaid a hospitales, residencias de adultos mayores y otros proveedores, así como a empresas privadas de atención médica administrada.

Los estados suelen utilizar el dinero federal generado a través de los impuestos para pagar a las instituciones más de lo que Medicaid pagaría de otra manera. (Medicaid generalmente paga las tarifas más bajas por la atención médica, en comparación con Medicare, el programa para personas mayores de 65 años y algunas personas con discapacidad, y los seguros privados).

Los hospitales y residencias de adultos mayores afirman que utilizan estos fondos adicionales de Medicaid para ampliar o añadir nuevos servicios y mejorar la atención para todos los pacientes.

Los hospitales rurales suelen operar con márgenes de ganancia reducidos y dependen de los pagos de impuestos de Medicaid para sostenerlos. Investigadores del Cecil G. Sheps Center for Health Services Research que examinaron el proyecto de ley de la Cámara concluyeron que este obligaría a más de 300 hospitales rurales, muchos de ellos en Kentucky, Louisiana, California y Oklahoma, a reducir sus servicios o cerrar.

Los senadores republicanos agregaron un fondo de $50 mil millones a su versión del proyecto de ley para amortiguar el impacto en los hospitales rurales.

Más dificultad para obtener, y mantener, la cobertura de ACA

Para quienes tienen cobertura del mercado de seguros de salud de ACA, el plan republicano dificultaría la inscripción y el conservar los planes.

Los asegurados del mercado de seguros estarían obligados a actualizar sus ingresos, estatus migratorio y otra información cada año, en lugar de reinscribirse automáticamente, algo que más de 10 millones de personas hicieron este año.

También tendrían menos tiempo para inscribirse; el proyecto de ley acorta el período anual de inscripción abierta en aproximadamente un mes.

Las personas que soliciten cobertura fuera de ese período —por ejemplo, porque pierden su trabajo u otro seguro, o necesitan agregar a un recién nacido o cónyuge a una póliza existente— tendrían que esperar a que se procesen todos sus documentos antes de recibir subsidios del gobierno para ayudar a pagar sus primas mensuales. Actualmente, reciben hasta 90 días de ayuda con las primas durante el proceso de solicitud, que puede tardar semanas.

Los legisladores republicanos y algunos centros de estudios de políticas conservadoras, incluido el Paragon Health Institute, afirman que los cambios son necesarios para reducir las inscripciones fraudulentas, mientras que los opositores afirman que son el último intento de desmantelar el Obamacare.

La legislación tampoco contempla una extensión de los subsidios mejorados implementados durante la pandemia de covid-19. Si el Congreso no actúa, estos subsidios expirarán a finales de año, lo que resultará en un aumento promedio del 75% en las primas el próximo año, según KFF.

¿Tienes Medicaid? Se pagará más por las consultas médicas

Muchos beneficiarios de Medicaid podrían tener que pagar más de su bolsillo por las citas.

El proyecto de ley exigiría a los estados que han ampliado Medicaid cobrar a los beneficiarios hasta $35 por algunos servicios si sus ingresos se encuentran entre el nivel federal de pobreza (este año, $15.650 por persona) y el 138% de esa cantidad ($21.597).

Los beneficiarios de Medicaid generalmente no pagan nada cuando buscan servicios médicos, ya que estudios han demostrado que cobrar incluso copagos pequeños lleva a las personas de bajos ingresos a renunciar a atención necesaria. En los últimos años, algunos estados han agregado cargos inferiores a $10 por algunos servicios.

Esta política no se aplicaría a las personas que buscan atención primaria, atención de salud mental o tratamiento de adicciones.

Recortes para inmigrantes con residencia legal

El plan republicano podría provocar que al menos cientos de miles de inmigrantes con residencia legal —incluyendo solicitantes de asilo, víctimas de tráfico humano y refugiados— pierdan su cobertura del mercado de seguros al eliminar los subsidios que hacen que las primas sean asequibles. La restricción no se aplicaría a los titulares de tarjetas de residencia permanente (Green Card o tarjeta verde).

Dado que los inmigrantes que perderían subsidios bajo este plan tienden a ser más jóvenes que la población general, su salida dejaría una población de afiliados de mayor edad, con mayor riesgo de enfermedad y costos más elevados, lo que incrementaría aún más las primas del mercado, según directores de los mercados de seguros de salud en California, Maryland y Massachusetts, y analistas de salud.

Quitar el acceso a la atención médica a los inmigrantes que viven legalmente en el país “causará un daño irreparable a las personas que hemos prometido proteger e impondrá costos innecesarios a los sistemas locales que ya están sobrecargados”, declaró John Slocum, director ejecutivo del Refugee Council USA, un grupo de defensa, en un comunicado.

Tanto la versión de la Cámara de Representantes como la del Senado del proyecto de ley reflejan el enfoque restrictivo de la administración Trump hacia la inmigración.

Sin embargo, debido a que contravenía las normas del Senado, la legislación no incluirá una propuesta que habría reducido los pagos federales de Medicaid a estados como California, que utilizan sus propios fondos para cubrir a inmigrantes sin papeles.

La corresponsal principal de KFF Health News en Washington, Julie Rovner, contribuyó con este artículo.

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 bill, passed in both the House and the Senate without a single Democratic vote, is expected to reverse many of the health coverage gains of the Biden and Obama administrations. Their policies made it easier for millions of people to access health care and reduced the U.S. uninsured rate to record lows, though Republicans say the trade-off was far higher costs borne by taxpayers and increased fraud.

Under the legislation Trump’s expected to sign on Friday, Independence Day, reductions in federal support for Medicaid and Affordable Care Act marketplaces will cause nearly 12 million more people to be without insurance by 2034, the Congressional Budget Office estimates. That in turn is expected to undermine the finances of hospitals, nursing homes, and community health centers — which will have to absorb more of the cost of treating uninsured people. Some may reduce services and employees or close altogether.

Here are five ways the GOP’s plans may affect health care access.

Need Medicaid? Then Get a Job

The deepest cuts to health care spending come from a proposed Medicaid work requirement, which is expected to end coverage for millions of enrollees who do not meet new employment or reporting standards.

In 40 states and Washington, D.C., all of which have expanded Medicaid under the Affordable Care Act, some Medicaid enrollees will have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption, such as caring for a young child. The new requirement will start as early as January 2027.

The bill’s requirement doesn’t apply to people in the 10 largely GOP-led states that have not expanded Medicaid to nondisabled adults.

Health researchers say the policy will have little impact on employment. Most working-age Medicaid enrollees who don’t receive disability benefits already work or are looking for work, or are unable to do so because they have a disability, attend school, or care for a family member, according to KFF, a health information nonprofit that includes KFF Health News.

State experiments with work requirements have been plagued with administrative issues, such as eligible enrollees’ losing coverage over paperwork problems, and budget overruns. Georgia’s work requirement, which officially launched in July 2023, has cost more than $90 million, with only $26 million of that spent on health benefits, according to the Georgia Budget & Policy Institute, a nonpartisan research organization.

“The hidden costs are astronomical,” said Chima Ndumele, a professor at the Yale School of Public Health.

Less Cash Means Less Care in Rural Communities

Belt-tightening that targets states could translate into fewer health services, medical professionals, and even hospitals, especially in rural communities.

The GOP’s plan curtails a practice, known as provider taxes, that nearly every state has used for decades to increase Medicaid payments to hospitals, nursing homes, and other providers and to private managed-care companies.

States often use the federal money generated through the taxes to pay the institutions more than Medicaid would otherwise pay. Medicaid generally pays lower fees for care than Medicare, the program for people over 65 and some with disabilities, and private insurance. But thanks to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Hospitals and nursing homes say they use these extra Medicaid dollars to expand or add new services and improve care for all patients.

Rural hospitals typically operate on thin profit margins and rely on payments from Medicaid taxes to sustain them. Researchers from the Cecil G. Sheps Center for Health Services Research who examined the original House version of the bill concluded it would push more than 300 rural hospitals — many of them in Kentucky, Louisiana, California, and Oklahoma — toward service reductions or closure.

Republicans in the Senate tacked a $50 billion fund onto the legislation to cushion the blow to rural hospitals. The money will be distributed starting in 2027 and continue for five years.

Harder To Get, and Keep, ACA Coverage

For those with Obamacare plans, the new legislation will make it harder to enroll and to retain their coverage.

ACA marketplace policyholders will be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll — something more than 10 million people did this year. They’ll also have less time to enroll; the bill shortens the annual open enrollment period by about a month.

People applying for coverage outside that period — for instance because they lose a job or other insurance or need to add a newborn or spouse to an existing policy — will have to wait for all their documents to be processed before receiving government subsidies to help pay their monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take weeks.

Republican lawmakers and some conservative policy think tanks, including the Paragon Health Institute, say the changes are needed to reduce fraudulent enrollments, while opponents say they represent Trump’s best effort to undo Obamacare.

The legislation also does not call for an extension of more generous premium subsidies put in place during the covid pandemic. If Congress doesn’t act, those enhanced subsidies will expire at year’s end, resulting in premiums rising by an average of 75% next year, according to KFF.

On Medicaid? Pay More To See Doctors

Many Medicaid enrollees can expect to pay more out-of-pocket for appointments.

Trump’s legislation requires states that have expanded Medicaid to charge enrollees up to $35 for some services if their incomes are between the federal poverty level (this year, $15,650 for an individual) and 138% of that amount ($21,597).

Medicaid enrollees often don’t pay anything when seeking medical services because studies have shown charging even small copayments prompts low-income people to forgo needed care. In recent years, some states have added charges under $10 for certain services.

The policy won’t apply to people seeking primary care, mental health care, or substance abuse treatment. The bill allows states to enact even higher cost sharing for enrollees who seek emergency room care for nonemergencies. But if Medicaid patients fail to pay, hospitals and other providers could be left to foot the bill.

Cuts for Lawfully Present Immigrants

The GOP plan could cause at least hundreds of thousands of immigrants who are lawfully present — including asylum-seekers, victims of trafficking, and refugees — to lose their ACA marketplace coverage by cutting off the subsidies that make premiums affordable. The restriction won’t apply to green-card holders.

Because the immigrants who will lose subsidies under the legislation tend to be younger than the overall U.S. population, their exit would leave an older, sicker, and costlier population of marketplace enrollees, further pushing up marketplace premiums, according to marketplace directors in California, Maryland, and Massachusetts and health analysts.

Taking health care access away from immigrants living in the country legally “will do irreparable harm to individuals we have promised to protect and impose unnecessary costs on local systems already under strain,” John Slocum, executive director of Refugee Council USA, an advocacy group, said in a statement.

The bill reflects the Trump administration’s restrictive approach to immigration. But because it ran afoul of Senate rules, the legislation doesn’t include a proposal that would have reduced federal Medicaid payments to states such as California that use their own money to cover immigrants without legal status.

KFF Health News chief Washington correspondent Julie Rovner contributed reporting.

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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This story can be republished for free (details).