Kennedy squeaked through a narrow Senate vote to be confirmed as head of the Department of Health and Human Services, only after making a number of public and private guarantees about how he would handle vaccine funding and recommendations as secretary.

Here’s a look at some of the promises Kennedy made during his confirmation process.

The Childhood Vaccine Schedule

In two hearings in January 2025, Kennedy repeatedly assured senators that he supported childhood vaccines, noting that all his children were vaccinated.

Sen. Elizabeth Warren (D-Mass.) grilled Kennedy about the money he’s made in the private sector from lawsuits against vaccine makers and accused him of planning to profit from potential future policies making it easier to sue.

“Kennedy can kill off access to vaccines and make millions of dollars while he does it,” Warren said during the Senate Finance Committee hearing. “Kids might die, but Robert Kennedy can keep cashing in.”

Warren’s statement prompted an assurance by Kennedy.

“Senator, I support vaccines,” he said. “I support the childhood schedule. I will do that.”

Days later, Sen. Bill Cassidy of Louisiana, chair of the Senate Health, Education, Labor, and Pensions Committee, declared Kennedy had pledged to maintain existing vaccine recommendations if confirmed. Cassidy, a physician specializing in liver diseases and a vocal supporter of vaccination, had questioned Kennedy sharply in a hearing about his views on shots.

“If confirmed, he will maintain the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices’ recommendations without changes,” Cassidy said during a speech on the Senate floor explaining his vote for Kennedy.

A few months after he was confirmed, Kennedy fired all the incumbent members of the vaccine advisory panel, known as ACIP, and appointed new members, including several who, like him, oppose some vaccines. The panel’s recommendations soon changed drastically.

Last month, the CDC removed its universal recommendations for children to receive seven immunizations, those protecting against respiratory syncytial virus, meningococcal disease, flu, covid, hepatitis A, hepatitis B, and rotavirus. The move followed a memorandum from the White House calling on the CDC to cull the schedule.

Now, those vaccines, which researchers estimate have prevented thousands of deaths and millions of illnesses, are recommended by the CDC only for children at high-risk of serious illness or after consultation between doctors and parents.

In response to questions about Kennedy’s actions on vaccines over the past year, HHS spokesperson Andrew Nixon said the secretary “continues to follow through on his commitments” to Cassidy.

“As part of those commitments, HHS accepted Chairman Cassidy’s numerous recommendations for key roles at the agency, retained particular language on the CDC website, and adopted ACIP recommendations,” Nixon added. “Secretary Kennedy talks to the chairman at a regular clip.”

Cassidy and his office have repeatedly rebuffed questions about whether Kennedy, since becoming secretary, has broken the commitments he made to the senator.

Vaccine Funding Axed

Weeks after Kennedy took over the federal health department, the CDC pulled back $11 billion in covid-era grants that local health departments were using to fund vaccination programs, among other initiatives.

That happened after Kennedy pledged during his confirmation hearings not to undermine vaccine funding.

Kennedy replied “Yes” when Cassidy asked him directly: “Do you commit that you will not work to impound, divert, or otherwise reduce any funding appropriated by Congress for the purpose of vaccination programs?”

A federal judge later ordered HHS to distribute the money.

The National Institutes of Health, part of HHS, also yanked dozens of research grants supporting studies of vaccine hesitancy last year. Kennedy, meanwhile, ordered the cancellation of a half-billion dollars’ worth of mRNA vaccine research in August.

A Discredited Theory About Autism

Cassidy said in his floor speech that he received a guarantee from Kennedy that the CDC’s website would not remove statements explaining that vaccines do not cause autism.

Technically, Kennedy kept his promise not to remove the statements. The website still says that vaccines do not cause autism.

But late last year, new statements sprung up on the same webpage, baselessly casting doubt on vaccine safety. “The claim ‘vaccines do not cause autism’ is not an evidence-based claim because studies have not ruled out the possibility that infant vaccines cause autism,” the page on autism now misleadingly reads.

The webpage also states that the public has largely ignored studies showing vaccines do cause autism.

That is false. Over decades of research, scientific studies have repeatedly concluded that there is no link between vaccines and autism.

A controversial 1998 study that captured global attention did link the measles, mumps, and rubella vaccine to autism. It was retracted for being fraudulent — though not until a decade after it was published, during which there were sharp declines in U.S. vaccination rates.

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Ponerlos al tanto de estos riesgos podría disuadirlos de inscribirse en un programa llamado Medicaid de Emergencia, a través del cual el gobierno reembolsa a los hospitales el costo de la atención médica de urgencias a inmigrantes que no califican para la cobertura regular de Medicaid.

Pero si los hospitales no revelan que la información personal de los pacientes se comparte con las autoridades migratorias federales, estos podrían no saber que su cobertura médica los expone al riesgo de ser localizados por el Servicio de Inmigración y Control de Aduanas (ICE).

“Si los hospitales le dicen a la gente que sus datos de Medicaid de Emergencia se compartirán con el ICE, es previsible que muchos inmigrantes simplemente dejen de buscar tratamiento médico de emergencia”, afirmó Leonardo Cuello, profesor investigador del Centro para Niños y Familias de la Universidad de Georgetown.

“La mitad de los casos de Medicaid de Emergencia son partos de bebés ciudadanos estadounidenses. ¿Queremos que esas madres eviten ir al hospital cuando comienzan el trabajo de parto?”, agregó.

Durante más de una década, hospitales y estados aseguraron a los pacientes que su información personal, incluyendo su estatus migratorio y la dirección de su casa, no sería compartida con funcionarios de inmigración cuando solicitaban cobertura médica federal.

Un memorando de política del ICE de 2013 garantizaba que la agencia no usaría información de solicitudes de cobertura médica para actividades de control migratorio.

Pero eso cambió el año pasado, luego de que el presidente Donald Trump regresara a la Casa Blanca y ordenara una de las campañas de represión migratoria más agresivas de la historia reciente. Su administración empezó a canalizar datos de varias agencias gubernamentales al Departamento de Seguridad Nacional, incluida la información fiscal enviada al Servicio de Impuestos Internos (IRS).

Los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), que forman parte del Departamento de Salud y Servicios Humanos, aceptaron en la primavera pasada darle a ICE acceso directo a una base de datos de Medicaid que incluye las direcciones y el estatus migratorio de las personas inscritas.

Veintidós estados, todos gobernados por demócratas excepto uno, presentaron demandas para bloquear ese acuerdo de intercambio de datos de Medicaid, que no había sido anunciado formalmente por el gobierno hasta que un juez federal ordenó hacerlo el verano pasado. El juez falló en diciembre que, en esos estados, ICE solo podría acceder a la información de la base de datos de Medicaid correspondiente a personas que están en el país de forma irregular.

KFF Health News contactó a más de una docena de hospitales y asociaciones hospitalarias en estados y ciudades que han sido objeto de operativos del ICE. Muchos se negaron a comentar si, luego del fallo judicial, habían actualizado sus políticas de divulgación.

De los que respondieron, ninguno dijo que estuviera advirtiendo directamente a los pacientes que su información personal podía ser compartida con el ICE si solicitaban cobertura de Medicaid.

“No ofrecemos asesoramiento legal sobre el intercambio de datos entre agencias del gobierno federal”, escribió por correo electrónico Aimee Jordon, vocera del sistema hospitalario M Health Fairview, con sede en Minneapolis. “Recomendamos a los pacientes que tengan preguntas sobre prestaciones o inquietudes relacionadas con temas migratorios que busquen orientación en los recursos estatales adecuados y con asesores legales calificados”.

Información sobre las solicitudes

En algunos estados, las solicitudes de Medicaid de Emergencia  preguntan específicamente por el estatus migratorio del paciente, pero aseguran a las personas que su información se mantendrá protegida y fuera del alcance de los funcionarios de inmigración.

Por ejemplo, hasta el 3 de febrero, la solicitud de California aún incluía un texto en el que se informaba a los solicitantes que su información migratoria era “confidencial”.

“Solo la usamos para determinar si califica para un seguro médico”, explica el formulario de 44 páginas que el programa estatal de Medicaid, conocido como Medi-Cal, publicó en redes sociales en enero.

Anthony Cava, vocero del Departamento de Servicios de Atención Médica de California, dijo en una declaración que la agencia, que supervisa Medi-Cal, se asegurará de que los californianos tengan información precisa sobre la privacidad de sus datos, “incluyendo, si es necesario, la revisión de otras publicaciones”.

Hasta finales de enero, el sitio web de Medicaid en Utah también aseguraba que el programa de Medicaid de Emergencia no compartía información con funcionarios migratorios. Después de que KFF Health News contactara a la agencia estatal, la vocera Kolbi Young anunció el 23 de enero que esa información sería retirada de inmediato. Fue eliminada ese mismo día.

El sistema hospitalario Oregon Health & Science University, con sede en Portland, ofrece a pacientes inmigrantes un documento de preguntas y respuestas desarrollado por el programa estatal de Medicaid para quienes tienen dudas sobre el uso de su información. El documento no indica de manera explícita que la información de quienes se inscriben en Medicaid será compartida con el ICE.

Los hospitales dependen del Medicaid de Emergencia para que les reembolsen el tratamiento de personas que cumplirían con los requisitos para Medicaid si no fuera por su estatus migratorio, ya sea que estén en el país sin papeles o dispongan de una presencia legal temporal, como visas de estudiante o de trabajo. Esta cobertura solo paga por atención médica de urgencia y servicios relacionados con el embarazo. Por lo general, representantes del hospital ayudan a los pacientes a presentar la solicitud mientras están en el hospital.

El programa principal de Medicaid, que cubre una gama mucho más amplia de servicios para más de 77 millones de personas con bajos ingresos o discapacidades, no cubre a quienes están en el país sin autorización.

Por lo tanto, examinar los registros de inscripción en el Medicaid de Emergencia es la forma más efectiva que tienen los funcionarios de deportación para identificar a los inmigrantes, incluidos aquellos que podrían no residir legalmente en los Estados Unidos.

Rich Danker, vocero del Departamento de Salud y Servicios Humanos, dijo por correo electrónico que los CMS —que supervisa Medicaid, un programa conjunto federal y estatal— están compartiendo datos con el ICE tras la decisión del juez. Pero no explicó cómo se asegura de compartir solo información sobre personas sin residencia legal, como exige el fallo judicial.

Dado que el ICE ahora tiene acceso directo a la información personal de millones de personas inscritas en Medicaid, los hospitales —aunque “están en una posición muy difícil”— deberían ser transparentes sobre los cambios, dijo Sarah Grusin, abogada del National Health Law Program, un grupo de defensa legal.

“Deben decirle a la gente que el juez ha autorizado compartir la información —incluida sus direcciones— en el caso de quienes no residen legalmente en el país”, afirmó. “Una vez enviada, esa información ya no puede protegerse para evitar que sea divulgada”.

Grusin dijo que recomienda a las familias que midan la importancia de buscar atención médica frente al riesgo de que sus datos sean compartidos con el ICE.

“Queremos dar información sincera y honesta, incluso si eso significa que las personas se vayan a ver obligadas a tomar decisiones muy difíciles”, destacó.

Quienes se hayan inscrito anteriormente en Medicaid o cuya dirección pueda encontrarse fácilmente en internet deben asumir que los funcionarios de inmigración ya conocen esos datos, agregó.

Medicaid de Emergencia

La cobertura de Medicaid de Emergencia se estableció a mediados de la década de 1980, cuando una ley federal comenzó a exigir que los hospitales atendieran y estabilizaran a cualquier persona que llegara con una condición que pusiera en riesgo su vida.

En 2023, el gasto del gobierno federal en Medicaid de Emergencia fue de casi $4.000 millones, lo que representa aproximadamente el 0,4% del gasto total federal en Medicaid.

Los estados envían informes mensuales al gobierno federal con información detallada sobre quiénes se inscriben en Medicaid y qué servicios reciben.

El fallo judicial de diciembre limitó lo que los CMS pueden compartir con el ICE a datos básicos, incluyendo direcciones, de los afiliados a Medicaid en los 22 estados que llevaron a la Justicia el acuerdo de intercambio de datos. El ICE no tiene permitido acceder a información sobre los servicios médicos que reciben las personas, según la orden del juez.

El juez también prohibió a la agencia compartir los datos de ciudadanos estadounidenses o inmigrantes con residencia legal en esos estados.

En los otros 28 estados, los funcionarios de deportación tienen acceso a la información personal de los inscritos en Medicaid.

La agencia federal de salud no ha aclarado cómo garantiza que la información sobre ciudadanos y residentes legales de ciertos estados no sea compartida con el ICE. Pero expertos en Medicaid dicen que sería casi imposible separar esos datos, lo que genera dudas sobre si el gobierno de Trump está cumpliendo con la orden judicial.

Los esfuerzos de la administración Trump por deportar a inmigrantes que viven en el país sin autorización han afectado a familias inmigrantes que buscan atención de salud.

Cerca de un tercio de los adultos nacidos fuera de los Estados Unidos dijeron haber evitado o pospuesto atención médica en el último año, según una encuesta de KFF y The New York Times publicada en noviembre. (KFF es una organización sin fines de lucro dedicada a la información sobre salud, que incluye a KFF Health News).

Bethany Pray, directora legal y de políticas del Colorado Center on Law and Policy, advirtió que el hecho de compartir datos de Medicaid con funcionarios de deportación obligará a muchas familias a tomar decisiones aún más difíciles.

“Esto es muy preocupante”, opinó Pray. “La gente no debería tener que elegir entre dar a luz en un hospital y preguntarse si eso significa correr el riesgo de enfrentar la deportación”.

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Warning patients could deter them from signing up for a program called Emergency Medicaid, through which the government reimburses hospitals for the cost of emergency treatment for immigrants who are ineligible for standard Medicaid coverage.

But if hospitals don’t disclose that the patients’ information is shared with federal law enforcement, they might not know that their medical coverage puts them at risk of being located by Immigration and Customs Enforcement.

“If hospitals tell people that their Emergency Medicaid information will be shared with ICE, it is foreseeable that many immigrants would simply stop getting emergency medical treatment,” said Leonardo Cuello, a research professor at Georgetown University’s Center for Children and Families. “Half of the Emergency Medicaid cases are for the delivery of U.S. citizen babies. Do we want these mothers avoiding the hospital when they go into labor?”

For more than a decade, hospitals and states have assured patients that their personal information, including their home addresses and immigration status, would not be shared with immigration enforcement officials when they apply for federal health care coverage. A 2013 ICE policy memo guaranteed the agency would not use information from health coverage applications for enforcement activities.

But that changed last year, after President Donald Trump returned to the White House and ordered one of the most aggressive immigration crackdowns in recent history. His administration began funneling data from a variety of government agencies to the Department of Homeland Security, including tax information filed with the IRS.

The Centers for Medicare & Medicaid Services, part of the Department of Health and Human Services, agreed last spring to give ICE officials direct access to a Medicaid database that includes enrollees’ addresses and citizenship status.

Twenty-two states, all but one led by Democratic governors, sued to block the Medicaid data-sharing agreement, which the administration did not formally announce until a federal judge ordered it to do so last summer. The judge ruled in December that in those states, ICE could access information in the Medicaid database only about people in the country unlawfully. KFF Health News contacted more than a dozen hospitals and hospital associations in states and cities that have been targets of ICE sweeps. Many declined to comment on whether they’ve updated their disclosure policies after the ruling.

Of those that responded, none said they are directly warning patients that their personal information may be shared with ICE when they apply for Medicaid coverage.

“We do not provide legal advice about federal government data-sharing between agencies,” Aimee Jordon, a spokesperson for M Health Fairview, a Minneapolis-based hospital system, said in an email to KFF Health News. “We encourage patients with questions about benefits or immigration-related concerns to seek guidance from appropriate state resources and qualified legal counsel.”

Information on Applications

Some states’ Emergency Medicaid applications specifically ask for a patient’s immigration status — and still assure people that their information will be kept secure and out of the hands of immigration enforcement officials.

For example, as of Feb. 3, California’s application still included language advising applicants that their immigration information is “confidential.”

“We only use it to see if you qualify for health insurance,” states the 44-page form, which the state’s Medicaid program, known as Medi-Cal, posted on social media in January.

California Department of Health Care Services spokesperson Anthony Cava said in a statement that the agency, which oversees Medi-Cal, will “ensure that Californians have accurate information on the privacy of their data, including by revising additional publications as necessary.”

Until late January, Utah’s Medicaid website also claimed its Emergency Medicaid program did not share its information with immigration officials. After KFF Health News contacted the state agency, Kolbi Young, a spokesperson, said Jan. 23 that the language would be taken down immediately. It was removed that day.

Oregon Health & Science University, a hospital system based in Portland, offers immigrant patients a Q&A document developed by the state Medicaid program for those with concerns about how their information might be used. The document does not directly say that Medicaid enrollees’ information is shared with ICE officials.

Hospitals rely on Emergency Medicaid to reimburse them for treating people who would qualify for Medicaid if not for their citizenship status — those in the country illegally and lawfully present immigrants, such as those with a student or work visa. The coverage pays only for emergency medical and pregnancy care. Typically, hospital representatives help patients apply while they are still in the medical facility.

The main Medicaid program, which covers a much broader range of services for over 77 million low-income and disabled people, does not cover people living in the country illegally.

Examining Emergency Medicaid enrollment is the most obvious way, then, for deportation officials to identify immigrants, including those who might not reside in the U.S. lawfully.

HHS spokesperson Rich Danker said in an email that CMS — which oversees Medicaid, a joint state-federal program — is sharing data with ICE after the judge’s ruling. But he would not answer how the agency is ensuring it is sharing information only on people who are not lawfully present, as the judge required.

With ICE now getting direct access to the personal information of millions of Medicaid enrollees, hospitals — while “definitely in a tough position” — should be up-front about the changes, said Sarah Grusin, an attorney at the National Health Law Program, an advocacy group.

“They need to be telling people that the judge has permitted sharing of information, including their address, for people who are not lawfully residing,” she said. “Once this information is submitted, you can’t protect it from disclosure at this point.”

Grusin said she advises families to weigh the importance of seeking medical care against the risk of having their information shared with ICE.

“We want to give candid, honest information even if it means the decision people have to make is really hard,” she said.

Those who have previously enrolled in Medicaid or can easily search their address online should assume that immigration officials already have their information, she added.

Emergency Medicaid

Emergency Medicaid coverage was established in the mid-1980s, when a federal law began requiring hospitals to treat and stabilize all patients who show up at their doors with a life-threatening condition.

Federal government spending on Emergency Medicaid accounted for nearly $4 billion in 2023, or about 0.4% of total federal spending on Medicaid.

States send monthly reports to the federal government with detailed information about who enrolls in Medicaid and what services they receive. The judge’s ruling in December limited what CMS can share with ICE to only basic information, including addresses, about Medicaid enrollees in the 22 states that sued over the data-sharing arrangement. ICE officials are not supposed to access information about the medical services people receive, per the judge’s order.

The judge also prohibited the agency from sharing the data of U.S. citizens or lawfully present immigrants from those states.

Deportation officials have access to personal Medicaid information of all enrollees in the remaining 28 states.

The federal health agency has not clarified how it is ensuring that certain states’ information on citizens and legal residents is not shared with ICE. But Medicaid experts say it would be nearly impossible for the agency to separate the data, raising questions about whether the Trump administration is complying with the judge’s order.

The Trump administration’s efforts to deport immigrants living in the country illegally have had implications on immigrant families seeking care. About a third of adult immigrants reported skipping or postponing health care in the past year, according to a KFF/New York Times poll released in November. (KFF is a health information nonprofit that includes KFF Health News.)

Bethany Pray, the chief legal and policy officer at the Colorado Center on Law and Policy, warned that sharing Medicaid data directly with deportation officials will force even tougher decisions upon some families.

“This is very concerning,” Pray said. “People should not have to choose between giving birth in a hospital and wondering if that means they risk deportation.”

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Those same dollars can’t be used, though, to pay for most baby formulas, toothbrushes — or insurance premiums.

President Donald Trump and some Republicans are pitching the accounts as an alternative to expiring enhanced federal subsidies that have lowered insurance premium payments for most Americans with Affordable Care Act coverage. But legal limits on how HSAs can and can’t be used are prompting doubts that expanding their use would benefit the predominantly low-income people who rely on ACA plans.

The Republican proposals come on the heels of a White House-led change to extend HSA eligibility to more ACA enrollees. One group that would almost certainly benefit: a slew of companies selling expensive wellness items that can be purchased with tax-free dollars from the accounts.

There is also deep skepticism, even among conservatives who support the proposals, that the federal government can pull off such a major policy shift in just a few weeks. The enhanced ACA subsidies expire at the end of the year, and Republicans are still debating among themselves whether to simply extend them.

“The plans have been designed. The premiums have been set. Many people have already enrolled and made their selections,” Douglas Holtz-Eakin, the president of the American Action Forum, a conservative think tank, warned senators on Nov. 19. “There’s very little that this Congress can do to change the outlook.”

Cassidy’s Plan

With health savings accounts, people who pay high out-of-pocket costs for health insurance are able to set aside money, without paying taxes, for medical expenses.

For decades, Republicans have promoted these accounts as a way for people to save money for major or emergent medical expenses without spending more federal tax dollars on health care.

The latest GOP proposals would build on a change included in Republicans’ One Big Beautiful Bill Act, which makes millions more ACA enrollees eligible for health savings accounts. Starting Jan. 1, those enrolled in Obamacare’s cheapest coverage may open and contribute to HSAs.

Now Republicans are making the case that, in lieu of the pandemic-era enhanced ACA subsidies, patients would be better off being given money to cover some health costs — specifically through deposits to HSAs.

The White House has yet to release a formal proposal, though early reports suggested it could include HSA contributions as well as temporary, more restrictive premium subsidies.

Sen. Bill Cassidy — a Louisiana Republican who chairs the Senate Health, Education, Labor, and Pensions Committee and is facing a potentially tough reelection fight next year — has proposed loading HSAs with federal dollars sent directly to some ACA enrollees.

“The American people want something to pass, so let’s find something to pass,” Cassidy said on Dec. 3, pitching his plan for HSAs again. “Let’s give power to the patient, not profit to the insurance company.”

He has promised a deal can be struck in time for 2026 coverage.

Democrats, whose support Republicans will likely need to pass any health care measure, have widely panned the GOP’s ideas. They are calling instead for an extension of the enhanced subsidies to control premium costs for most of the nearly 24 million Americans enrolled in the ACA marketplace, a larger pool than the 7.3 million people the Trump administration estimates soon will be eligible for HSAs.

HSAs “can be a useful tool for very wealthy people,” said Sen. Ron Wyden of Oregon, the top Democrat on the Senate Finance Committee. “But I don’t see it as a comprehensive health insurance opportunity.”

Who Can Use HSAs?

The IRS sets restrictions on the use of HSAs, which are typically managed by banks or health insurance companies. For starters, on the ACA marketplace, they are available only to those with the highest-deductible health insurance plans — the bronze and catastrophic plans.

There are limits on how much can be deposited into an account each year. In 2026 it will be $4,400 for a single person and $8,750 for a family.

Flexible spending accounts, or FSAs — which are typically offered through employer coverage — work similarly but have lower savings limits and cannot be rolled over from year to year.

The law that established HSAs prohibits the accounts from being used to pay insurance premiums, meaning that without an overhaul, the GOP’s proposals are unlikely to alleviate the problem at hand: skyrocketing premium payments. Obamacare enrollees who receive subsidies are projected to pay 114% more out-of-pocket for their premiums next year on average, absent congressional action.

Even with the promise of the government depositing cash into an HSA, people may still opt to go without coverage next year once they see those premium costs, said Tom Buchmueller, an economics professor at the University of Michigan who worked in the Biden administration.

“For people who stay in the marketplace, they’re going to be paying a lot more money every month,” he said. “It doesn’t help them pay that monthly premium.”

Others, Buchmueller noted, might be pushed into skimpier insurance coverage. Obamacare bronze plans come with the highest out-of-pocket costs.

An HHS Official’s Interest

Health savings accounts can be used to pay for many routine medical supplies and services, such as medical and dental exams, as well as emergency room visits. In recent years, the government has expanded the list of applicable purchases to include over-the-counter products such as Tylenol and tampons.

Purchases for “general health” are not permissible, such as fees for dance or swim lessons. Food, gym memberships, or supplements are not allowed unless prescribed by a doctor for a medical condition or need.

Americans are investing more into these accounts as their insurance deductibles rise, according to Morningstar. The investment research firm found that assets in HSAs grew from $5 billion 20 years ago to $146 billion last year. President George W. Bush signed the law establishing health savings accounts in 2003, with the White House promising at the time that they would “help more American families get the health care they need at a price they can afford.”

Since then, the accounts have become most common for wealthier, white Americans who are healthy and have employer-sponsored health insurance, according to a report released by the nonpartisan Government Accountability Office in September.

Now, even more money is expected to flow into these accounts, because of the One Big Beautiful Bill Act. Companies are taking notice of the growing market for HSA-approved products, with major retailers such as Amazon, Walmart, and Target developing online storefronts dedicated to devices, medications, and supplies eligible to be purchased with money in the accounts.

Startups have popped up in recent years dedicated to helping people get quick approval from medical providers for various — and sometimes expensive — items, memberships, or fitness or health services.

Truemed — a company co-founded in 2022 by Calley Means, a close ally of Health and Human Services Secretary Robert F. Kennedy Jr. — has emerged as one of the biggest players in this niche space.

A $9,000 red cedar ice bath and a $2,000 hemlock sauna, for example, are available for purchase with HSA funds through Truemed. So, too, is the $1,700 bassinet, designed to automatically respond to the cries of a newborn by gently rocking the baby back to sleep.

Truemed’s executives say its most popular products are its smaller-dollar fitness offerings, which include kettlebells, supplements, treadmills, and gym memberships.

“What we’ve seen at Truemed is that, when given the choice, Americans choose to invest their health care dollars in these kinds of proven lifestyle interventions,” Truemed CEO Justin Mares told KFF Health News.

Means joined the Department of Health and Human Services in November after a stint earlier this year at the White House, where he worked when Trump signed the One Big Beautiful Bill Act into law in July. Truemed’s general counsel, Joe Vladeck, said Means left the company in August.

Asked about Means’ potential to benefit from the law’s expansion of HSAs, HHS spokeswoman Emily Hilliard said in a statement that “Calley Means will not personally benefit financially from this proposal as he will be divesting from his company since he has been hired at HHS as a senior advisor supporting food and nutrition policy.”

Truemed is privately held, not publicly traded, and details of how Means will go about divesting have not been disclosed.

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“Este país quiere que seamos máquinas de parir, pero están recortando los pocos recursos que existen”, dijo Olcott, de 20 años. “¿Y un bono de $1.000 por tener un bebé? ‘¿De verdad?’  Eso ni siquiera cubre un mes de renta”.

El gobierno quiere que los estadounidenses tengan más hijos y está impulsando políticas públicas para revertir la caída en la tasa de natalidad en el país.

A mediados de octubre, la Casa Blanca presentó un plan para ampliar el acceso a tratamientos de fertilización in vitro. El presidente  Trump ha promocionado estas iniciativas, y se ha llamado a sí mismo “el presidente de la fertilización”.

Sin embargo, grupos de derechos reproductivos y otras organizaciones de defensa afirman que estos esfuerzos por aumentar la natalidad no compensan el rumbo general del gobierno, que apunta a recortar planes federales como Medicaid, el Programa de Seguro de Salud Infantil (CHIP) y otras iniciativas que apoyan a mujeres y niños.

Según estos grupos, el enfoque “pro familia” no se limita a fomentar que las personas tengan más hijos. Más bien, afirman, ese discurso se está utilizando como herramienta para impulsar una agenda conservadora que amenaza la salud de las mujeres, los derechos reproductivos y la participación femenina en el mercado laboral.

Algunos expertos pronostican que estas políticas podrían desalentar la maternidad y aumentar la mortalidad materna.

“La derecha religiosa quiere más bebés blancos cristianos y está tratando de restringir la libertad reproductiva de las mujeres para lograrlo”, dijo Marian Starkey, vocera de Population Connection, una organización sin fines de lucro que promueve la estabilización demográfica mediante el acceso a anticonceptivos y el aborto. “El verdadero peligro es el recorte constante de los derechos reproductivos”, afirmó.

La Casa Blanca no respondió a múltiples solicitudes de entrevista.

Un paquete de programas federales que por años han apoyado a mujeres y niños también está en la mira de Trump y de miembros de su gabinete, que dicen impulsar políticas pro natalidad.

Por ejemplo, los requisitos laborales para acceder a Medicaid, establecidos por la ley de presupuesto de los republicanos, One Big Beautiful Bill Act, aprobada en julio, exigirán más trámites y más requisitos que, según la Oficina de Presupuesto del Congreso, harán que millones de beneficiarios que ahora califican pierdan su cobertura. Medicaid cubre más del 40% de los nacimientos.

Esa misma ley también recorta fondos federales para un programa nacional que proporciona beneficios mensuales en alimentos. Casi el 40% de quienes recibieron esa ayuda en el año fiscal 2023 fueron niños.

Los recortes presupuestarios y el congelamiento de contrataciones promovidos por los republicanos han afectado al programa Head Start, una iniciativa educativa federal que ofrece guardería y preescolar a niños pequeños de familias de bajos ingresos, en momentos en que adultos en todo el país piden al gobierno que reduzca los crecientes costos del cuidado infantil.

Además, los republicanos suspendieron por un año el financiamiento de Medicaid para Planned Parenthood of America debido a que ofrece servicios de aborto, lo que obligó al cierre de unas 50 clínicas en todo el país desde comienzos de 2025.

Planned Parenthood brinda una amplia gama de servicios de salud para mujeres, que incluyen exámenes médicos generales, pruebas para detección de cáncer de mama y atención prenatal inicial.

Grupos que abogan por la salud y los derechos reproductivos de las mujeres sostienen que las acciones de la administración y del Congreso republicano están dificultando que las familias accedan al apoyo y atención médica que necesitan.

“Se habla mucho sobre quiénes ‘merecen’ recibir asistencia pública y, para muchos legisladores, no son las madres solteras”, señaló Allyson Crays, analista en derecho y políticas de salud pública de la Escuela de Salud Pública del Instituto Milken de la Universidad George Washington.

La perspectiva pro natalidad, en general, promueve que el gobierno intervenga para fomentar la procreación, a partir de la creencia de que la cultura moderna ha dejado de valorar la célula familiar. Sus defensores también afirman que estas políticas son necesarias desde el punto de vista económico.

Menos nacimientos

La tasa de natalidad nacional ha mostrado una tendencia en baja desde 2007.

Entre 2015 y 2020, el número de nacimientos disminuyó en promedio un 2% anual, según los Centros para el Control y Prevención de Enfermedades (CDC, por sus siglas en inglés), aunque desde entonces hubo fluctuaciones.

Las ideas centrales de este movimiento están plasmadas en el Proyecto 2025, una iniciativa política liderada por la organización conservadora Heritage Foundation, cuyas propuestas han sido adoptadas en gran parte por el gobierno de Trump. El documento afirma que los niños se desarrollan mejor en un “matrimonio heterosexual y estable”.

“Los hombres y mujeres casados representan la estructura familiar ideal y natural, porque todos los niños tienen derecho a ser criados por el hombre y la mujer que los concibieron”, indica el texto

El Proyecto 2025 también propone medidas que, según los críticos, son perjudiciales para la salud de las mujeres. Por ejemplo, busca eliminar el acceso a la mifepristona, un medicamento utilizado habitualmente tanto para realizar abortos como para el manejo de abortos espontáneos. También alienta a los estados a impedir que clínicas de Planned Parenthood reciban fondos de Medicaid.

El lema “más bebés” se ha adoptado en los más altos niveles del gobierno federal. “No recuerdo otra administración tan alineada con el movimiento pro natalidad”, dijo Brian Dixon, vicepresidente senior de asuntos gubernamentales y políticos de Population Connection.

Días después de asumir el cargo, el vicepresidente JD Vance declaró: “Quiero más bebés en Estados Unidos”. También ha criticado las decisiones de hombres y mujeres que han optado por no tener hijos.

En octubre, la Casa Blanca anunció descuentos en ciertos medicamentos utilizados en tratamientos de fertilización in vitro a través de TrumpRx.gov, un sitio web del gobierno, aún no lanzado, que busca conectar a los consumidores con medicamentos a más bajo precio.

Mehmet Oz, actual director de Medicare y Medicaid, celebró la posible llegada de “bebés Trump” gracias a los fármacos de fertilidad más baratos.

La administración también anunció que animaría a los empleadores a ofrecer beneficios en las prestaciones por fertilidad como una opción independiente en la que los empleados puedan inscribirse.

Pero esa medida está lejos de la promesa anterior de Trump de hacer que los tratamientos de fertilización sean gratuitos y puede que no sea suficiente para contrarrestar otras preocupaciones financieras a largo plazo que a menudo influyen en la decisión de tener hijos.

Angel Albring, quien tiene seis hijos, dice que su sueño de tener una familia numerosa siempre dependió de poder trabajar y evitar los costos del cuidado de los niños. Su carrera como escritora freelance le permitió contribuir al ingreso familiar trabajando durante las siestas de sus hijos o por la noche, cuando el resto de la familia dormía.

“La frase ‘duerme cuando el bebé duerma’ nunca aplicó en mi caso”, comentó.

Pero dijo que algunas de sus amigas no tienen esa misma suerte. Temen no poder tener hijos por el alto costo del cuidado, además de los alimentos y de la vivienda.

Mientras tanto, la administración Trump ha impulsado otra política que busca dar a los pequeños un respaldo financiero futuro.

La ley de presupuesto creó una “Cuenta Trump”, financiada inicialmente con $1.000 del gobierno federal —lo que se conoce popularmente como “bono por bebé”— para cada niño estadounidense que cumpla con los requisitos.

Los primeros depósitos están previstos para 2026, y el gobierno abrirá automáticamente una cuenta para niños nacidos entre el 1 de enero de 2025 y el 31 de diciembre de 2028.

Los padres podrán aportar hasta $5.000 anuales a la cuenta y los empleadores hasta $2.500. Se prevé que estas cuentas funcionen como un ahorro a largo plazo, con restricciones para retirar los fondos antes de que el niño cumpla 18 años. Después de eso, se convertirían probablemente en cuentas de jubilación tipo IRA.

Esta tendencia pro natalidad también ha llegado a otras agencias del gobierno federal.

El secretario de Transporte, Sean Duffy —padre de nueve hijos—, ordenó a su departamento priorizar fondos federales para comunidades con altas tasas de matrimonios y nacimientos, aunque aún no se han anunciado proyectos directamente vinculados a la iniciativa. Durante un tiempo, la administración incluso consideró entregar medallas nacionales a madres con seis o más hijos.

Sin embargo, hay un problema: los datos indican que las políticas y programas propuestos por el gobierno de Trump no necesariamente funcionarán.

Otros países han implementado planes más sólidos para fomentar la natalidad y apoyar la crianza, sin lograr que suban sus tasas de nacimientos, explicó Michael Geruso, economista de la Universidad de Texas-Austin, quien es partidario de que crezca la población global.

Por ejemplo, Israel ha ofrecido tratamientos gratuitos de fertilización in vitro por casi tres décadas, y aun así su tasa de natalidad se ha mantenido estancada, con menos de tres hijos por mujer, explicó Geruso.

Francia y Suecia tienen redes de apoyo social para familias muy extendidas —incluyendo licencias de maternidad y paternidad pagas, así como cuidado infantil y atención de la salud subsidiados—, pero sus tasas de natalidad también están disminuyendo, señaló Peggy O’Donnell Heffington, profesora adjunta de Historia en la Universidad de Chicago y autora de un libro sobre la decisión de no ser madre.

“Nadie ha descubierto aún cómo evitar que la población siga disminuyendo”, explicó Geruso.

Algunos proponen una solución distinta para revertir la caída poblacional en el país: aumentar la inmigración para asegurar una fuerza laboral joven y una base tributaria más sólida.

Sin embargo, la administración Trump está haciendo lo contrario, revocando visas y creando un ambiente en el que incluso los inmigrantes que están legalmente en el país se sienten cada vez más inseguros.

En 2025, la población inmigrante del país cayó por primera vez desde la década de 1960, según un análisis del Pew Research Center.

Mientras tanto, según los críticos del gobierno, el énfasis en promover los nacimientos le sirve a la administración Trump y a los republicanos para dar la impresión de que realmente ayudan a las familias.

“No estamos viendo políticas que realmente apoyen a las familias con hijos”, opinó Amy Matsui, vicepresidenta de seguridad económica y cuidado infantil del Centro Nacional de Leyes para la Mujer (National Women’s Law Center), una organización sin fines de lucro enfocada en los derechos de género. “Lo que se está promoviendo es un matrimonio blanco, heterosexual, cristiano fundamentalista y con dos padres”.

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“Our country wants us to be birthing machines, but they’re cutting what resources there already are,” said Olcott, 20. “And a $1,000 baby bonus? It’s low-key like, what, bro? That wouldn’t even cover my month’s rent.”

The Trump administration wants Americans to have more babies, and the federal government is debuting policy initiatives to reverse the falling U.S. fertility rate. In mid-October, the White House unveiled a plan to increase access to in vitro fertilization treatment. President Donald Trump has heralded such initiatives, calling himself “the fertilization president.”

But reproductive rights groups and other advocacy organizations say these efforts to buttress the birth rate don’t make up for broader administration priorities aimed at cutting federal programs such as Medicaid, its related Children’s Health Insurance Program, and other initiatives that support women and children. The pro-family focus, they say, isn’t just about boosting procreation. Instead, they say, it’s being weaponized to push a conservative agenda that threatens women’s health, reproductive rights, and labor force participation.

Some predict these efforts could deter parenthood and lead to increases in maternal mortality.

“The religious right wants more white Christian babies and is trying to curtail women’s reproductive freedom in order to achieve that aim,” said Marian Starkey, a spokesperson for Population Connection, a nonprofit that promotes population stabilization through increased access to birth control and abortion. “The real danger is the constant whittling down of reproductive rights.”

The White House did not respond to repeated interview requests.

A slate of federal programs that have long helped women and children are also being targeted by Trump and Cabinet members who say they champion pronatalist policies.

Medicaid work requirements, for instance, put in place by the Republicans’ One Big Beautiful Bill Act, a budget law enacted in July, will lead to extra paperwork and other requirements that, according to the Congressional Budget Office, will cause millions of eligible enrollees to lose coverage. Medicaid covers more than 4 in 10 births in the U.S.

The measure also cuts federal funding for a national program that provides monthly food benefits. Almost 40% of recipients in fiscal 2023 were children.

GOP spending cuts and staffing freezes have hampered Head Start, a federal education program that provides day care and preschool for young, low-income children, even as U.S. adults implore the government to curtail ballooning child care costs.

And the GOP halted Medicaid funding to Planned Parenthood of America for one year because it provides abortion services, forcing roughly 50 clinics around the country to close since the beginning of 2025. Planned Parenthood provides a wide range of women’s health services, from wellness exams to breast cancer screenings and initial prenatal care.

Groups that advocate for women’s health and reproductive rights say the actions by the administration and congressional Republicans to attack these programs are making it harder for families to get the support and medical care they need.

“There is a lot of rhetoric about who is worthy of public assistance, and to many policymakers, it’s not the single mother,” said Allyson Crays, a public health law and policy analyst at the Milken Institute School of Public Health at George Washington University.

The pronatalist perspective generally supports government intervention to encourage procreation and is rooted in a belief that modern culture has failed to celebrate the nuclear family. The movement’s supporters also say policies to encourage childbearing are an economic necessity.

A Declining Birth Rate

The national birth rate has largely been on a downward trajectory since 2007, with the number of births declining by an average 2% per year from 2015 through 2020, according to the Centers for Disease Control and Prevention, although the rate has fluctuated since.

The concepts that shape the movement can be found in Project 2025, a political initiative led by the conservative Heritage Foundation that has seen many of its proposals adopted by Trump. The document asserts that children fare best in a “heterosexual, intact marriage.”

“Married men and women are the ideal, natural family structure because all children have a right to be raised by the men and women who conceived them,” it says.

Project 2025 also includes many proposals that critics say aren’t friendly toward women’s health. For instance, it calls for eliminating access to mifepristone, a drug commonly used in abortions as well as in the management of miscarriages, and encourages states to block Planned Parenthood facilities from receiving Medicaid funding.

The “more babies” mantra is being embraced at the highest levels of the federal government.

“I can’t remember any other administration being so tied to the pronatalist movement,” said Brian Dixon, Population Connection’s senior vice president for government and political affairs.

Just days after he was sworn in, Vice President JD Vance declared, “I want more babies in the United States of America.” He has also criticized the decision-making of women and men who opt not to start families.

The White House in October did announce a discount on certain drugs used in IVF treatments through TrumpRx, a yet-to-debut government website that aims to connect consumers with lower-priced drugs. Mehmet Oz, who heads Medicare and Medicaid, heralded a possible future of “Trump babies,” resulting from the lower-priced infertility drugs.

The administration also announced it would encourage employers to move to a new model for offering fertility benefits as a stand-alone option in which employees can enroll. But that is far from Trump’s earlier pledge to make infertility treatments free and may not be enough to overcome other long-term financial worries that often guide decisions about whether to have children.

Angel Albring, a mother of six, says her dream of having a big family always hinged on her ability to work and avoid child care costs. Her career as a freelance writer enabled her to do so while still contributing to the family’s income, working during nap times and at night, while the rest of her household slept.

“The whole thing of ‘sleep when the baby sleeps’ never applied to me,” Albring said.

Some of her friends, though, aren’t so fortunate. They fear they cannot afford children because of climbing costs for day care, groceries, and housing, she said.

Delivering on ‘Baby Bonuses’?

The Trump administration, meanwhile, has advanced another policy aimed at giving children a future financial boost.

The One Big Beautiful Bill Act establishes a tax-advantaged “Trump account” seeded with $1,000 in federal funds — often called a “baby bonus” — on behalf of every eligible American child. The initial deposits are scheduled to start in 2026 with the federal government automatically opening an account for children born after Dec. 31, 2024, and before Jan. 1, 2029.

Parents could contribute up to $5,000 a year initially to the account, with employers able to annually contribute up to $2,500 of that amount. The accounts reportedly would be vehicles for long-term savings. Details are still being ironed out, but funds could not be withdrawn before the child turns 18. After that, the accounts would likely become traditional IRAs.

On Tuesday, billionaires Michael and Susan Dell of Dell computer fame said they would give $250 to 25 million children age 10 and under in the U.S. The donations will be aimed at encouraging participation in the Trump accounts.

Pronatalism extends to other parts of the federal government, too.

Transportation Secretary Sean Duffy, who has nine children, instructed his department to prioritize federal funds for communities with high marriage and birth rates, though it has not yet announced any projects directly related to the initiative. For a time, the administration considered bestowing national medals on mothers with six or more children.

Except there’s one hitch: Data suggests the policies and programs the Trump administration has proposed won’t necessarily work.

Other countries have offered more robust programs to encourage childbearing and ease parenting but haven’t seen their birth rates go up, noted Michael Geruso, an economist for the University of Texas-Austin who hopes to see the global population increase. Israel, for example, has offered free IVF treatment for roughly three decades, yet its birth rates have stayed statistically stagnant, at just under three children for every woman, he said.

France and Sweden have extensive social safety-net programs to support families, including paid time off and paid paternity and maternity leave, and subsidized child care and health care, but their fertility rates are also falling, said Peggy O’Donnell Heffington, a University of Chicago assistant senior instructional professor in the history department who wrote a book on non-motherhood.

“Nobody yet knows how to avoid depopulation,” Geruso said.

Some point to a different solution to reverse the United States’ declining population: boost immigration to ensure a younger labor force and stronger tax base. The Trump administration, however, is doing the opposite — revoking visas and creating an environment in which immigrants who are in the U.S. legally feel increasingly uncomfortable because of heavy-handed policies, analysts say.

The country’s immigrant population this year fell for the first time since the 1960s, according to a Pew Research Center analysis.

Meanwhile, to critics of the administration, the focus on encouraging childbirth allows the Trump administration and Republicans to sound as if they support families.

“You’re not seeing policies that support families with children,” said Amy Matsui, vice president of income security and child care at the National Women’s Law Center, a nonprofit focused on gender rights. “It’s a white, heterosexual, fundamentalist Christian, two-parent marriage that’s being held up.”

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Seitz noted that the plan — which has not been formally unveiled — could extend the expiring, more generous subsidies that help many Americans pay their share of Affordable Care Act premiums. But that extension would likely impose limitations sought by Republicans, including changes to eligibility for the enhanced assistance, she said.

She recently explored the expiration of the enhanced ACA premium tax credits in her articles “Farmers, Barbers, and GOP Lawmakers Grapple With the Fate of ACA Tax Credits” and, with KFF Health News’ Julie Appleby, “A Ticking Clock: How States Are Preparing for a Last-Minute Obamacare Deal.”

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Esta directiva, incluida en un cable enviado por el Departamento de Estado a funcionarios de embajadas y consulados —y revisada por KFF Health News— indica a los oficiales encargados de los visados declarar a los solicitantes “no elegibles” para ingresar a Estados Unidos por nuevas razones, entre ellas la edad o la probabilidad de que fueran a depender de beneficios públicos.

También dice que estas personas podrían convertirse en una “carga pública”, es decir, representar un posible gasto para los recursos del país debido a sus problemas de salud o a su edad.

Si bien la evaluación del estado de salud de potenciales inmigrantes ha sido parte del proceso de solicitud de una visa durante años —incluyendo pruebas para detectar enfermedades transmisibles como la tuberculosis y la revisión del historial de vacunas—, expertos dijeron que las nuevas directrices amplían considerablemente la lista de afecciones médicas a considerar. Y otorgan a los oficiales más poder para tomar decisiones sobre inmigración basadas en la salud del solicitante.

La directiva forma parte de la campaña divisiva y agresiva de la administración Trump para deportar a personas que viven en el país sin papeles y desalentar a otros a emigrar.

La ofensiva del gobierno para restringir la inmigración ha incluido arrestos masivos a diario, prohibiciones para refugiados de ciertos países y planes para limitar drásticamente la cantidad total de inmigrantes permitidos en el país.

Las nuevas directrices exigen que la salud de los inmigrantes sea un tema central en el proceso de solicitud.

Aunque se aplican a casi todos los solicitantes de visa, probablemente se utilicen sobre todo en los casos de personas que quieran residir en el país de manera permanente, explicó Charles Wheeler, abogado principal de Catholic Legal Immigration Network, una organización sin fines de lucro que ofrece asistencia legal.

“Se debe considerar la salud del solicitante”, dice el cable. “Ciertas afecciones médicas —incluyendo, pero no limitándose, a enfermedades cardiovasculares y respiratorias, cáncer, diabetes, enfermedades metabólicas, enfermedades neurológicas y trastornos de salud mental— pueden requerir atención médica que cuesta cientos de miles de dólares”.

Cerca del 10% de la población mundial vive con diabetes. Las enfermedades cardiovasculares también son comunes y son la principal causa de muerte a nivel global.

El cable también anima a los oficiales encargados de las visas a considerar otras afecciones como la obesidad, que se destaca que puede causar asma, apnea del sueño e hipertensión, al evaluar si una persona podría convertirse en una carga pública. Si se concluye que esto pudiera ocurrir, podría negársele la entrada a Estados Unidos.

“Todas estas [afecciones] pueden requerir atención médica costosa y a largo plazo”, afirma el cable. Los voceros del Departamento de Estado no respondieron de inmediato a una solicitud de comentarios.

Los oficiales también deben determinar si los solicitantes cuentan con medios económicos suficientes para cubrir el costo de su atención médica sin ayuda del gobierno de Estados Unidos.

“El solicitante, ¿cuenta con recursos financieros adecuados para cubrir esos gastos durante toda su vida, sin recurrir a asistencia económica pública o sin requerir institucionalización a largo plazo a expensas del gobierno?”, dice el cable.

Según Wheeler, el lenguaje del cable parece contradecir al propio Manual de Asuntos Exteriores del Departamento de Estado, que indica que los oficiales no pueden rechazar una solicitud basándose en escenarios hipotéticos.

La directiva dirige a los oficiales a “desarrollar sus propias opiniones sobre lo que podría derivar en una emergencia médica o en costos médicos futuros”, dijo. “Eso es preocupante porque no tienen formación médica, no tienen experiencia en este ámbito y no deberían hacer proyecciones basadas en su conocimiento personal o en prejuicios”.

La guía también pide a los oficiales considerar la salud de los familiares del solicitante, incluidos hijos o padres mayores.

“¿Alguno de los dependientes tiene discapacidades, enfermedades crónicas u otras necesidades especiales que requieran atención al grado de impedir que el solicitante mantenga un empleo?”, dice una pregunta del cable.

Actualmente, los inmigrantes ya deben someterse a un examen médico realizado por un doctor aprobado por una embajada estadounidense.

Se les evalúa para detectar enfermedades transmisibles, como tuberculosis, y se les pide llenar un formulario donde informen si han tenido antecedentes de consumo de drogas o alcohol, afecciones de salud mental o episodios de violencia. También deben tener una serie de vacunas contra enfermedades infecciosas como el sarampión, la polio y la hepatitis B.

Pero esta nueva directiva va más allá, al recalcar que se deben tomar en cuenta las afecciones crónicas, explicó Sophia Genovese, abogada de inmigración en la Universidad de Georgetown. También señaló que el lenguaje de la directiva alienta a los oficiales y a los médicos encargados de examinar a los solicitantes a especular sobre el costo de su atención médica y su capacidad de obtener empleo en Estados Unidos, dadas sus condiciones de salud.

“Tomar en cuenta los antecedentes de diabetes o de enfermedades cardíacas, eso es bastante amplio”, dijo Genovese. “Ya existe cierto grado de evaluación, pero no tan amplio como para opinar sobre, por ejemplo, ‘¿Qué pasa si alguien sufre un shock diabético?’ Si este cambio se aplica de inmediato, obviamente causará muchos problemas cuando las personas se presenten a entrevistas consulares”.

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The guidance, issued in a cable the State Department sent to embassy and consular officials and examined by KFF Health News, directs visa officers to deem applicants ineligible to enter the U.S. for several new reasons, including age or the likelihood they might rely on public benefits. The guidance says that such people could become a “public charge” — a potential drain on U.S. resources — because of their health issues or age.

While assessing the health of potential immigrants has been part of the visa application process for years, including screening for communicable diseases like tuberculosis and obtaining vaccine history, experts said the new guidelines greatly expand the list of medical conditions to be considered and give visa officers more power to make decisions about immigration based on an applicant’s health status.

The directive is part of the Trump administration’s divisive and aggressive campaign to deport immigrants living without authorization in the U.S. and dissuade others from immigrating into the country. The White House’s crusade to push out immigrants has included daily mass arrests, bans on refugees from certain countries, and plans to severely restrict the total number permitted into the U.S.

The new guidelines mandate that immigrants’ health be a focus in the application process. The guidance applies to nearly all visa applicants but is likely to be used only in cases in which people seek to permanently reside in the U.S., said Charles Wheeler, a senior attorney for the Catholic Legal Immigration Network, a nonprofit legal aid group.

“You must consider an applicant’s health,” the cable reads. “Certain medical conditions – including, but not limited to, cardiovascular diseases, respiratory diseases, cancers, diabetes, metabolic diseases, neurological diseases, and mental health conditions – can require hundreds of thousands of dollars’ worth of care.”

About 10% of the world’s population has diabetes. Cardiovascular diseases are also common; they are the globe’s leading killer.

The cable also encourages visa officers to consider other conditions, like obesity, which it notes can cause asthma, sleep apnea, and high blood pressure, in their assessment of whether an immigrant could become a public charge and therefore should be denied entry into the U.S.

“All of these can require expensive, long-term care,” the cable reads. Spokespeople for the State Department did not immediately respond to a request for comment on the cable.

Visa officers were also directed to determine if applicants have the means to pay for medical treatment without help from the U.S. government.

“Does the applicant have adequate financial resources to cover the costs of such care over his entire expected lifespan without seeking public cash assistance or long-term institutionalization at government expense?” the cable reads.

The cable’s language appears at odds with the Foreign Affairs Manual, the State Department’s own handbook, which says that visa officers cannot reject an application based on “what if” scenarios, Wheeler said.

The guidance directs visa officers to develop “their own thoughts about what could lead to some sort of medical emergency or sort of medical costs in the future,” he said. “That’s troubling because they’re not medically trained, they have no experience in this area, and they shouldn’t be making projections based on their own personal knowledge or bias.”

The guidance also directs visa officers to consider the health of family members, including children or older parents.

“Do any of the dependents have disabilities, chronic medical conditions, or other special needs and require care such that the applicant cannot maintain employment?” the cable asks.

Immigrants already undergo a medical exam by a physician who’s been approved by a U.S. embassy.

They are screened for communicable diseases, like tuberculosis, and asked to fill out a form that asks them to disclose any history of drug or alcohol use, mental health conditions, or violence. They’re also required to have a number of vaccinations to guard against infectious diseases like measles, polio, and hepatitis B.

But the new guidance goes further, emphasizing that chronic diseases should be considered, said Sophia Genovese, an immigration lawyer at Georgetown University. She also noted that the language of the directive encourages visa officers and the doctors who examine people seeking to immigrate to speculate on the cost of applicants’ medical care and their ability to get employment in the U.S., considering their medical history.

“Taking into consideration one’s diabetic history or heart health history — that’s quite expansive,” Genovese said. “There is a degree of this assessment already, just not quite expansive as opining over, ‘What if someone goes into diabetic shock?’ If this change is going to happen immediately, that’s obviously going to cause a myriad of issues when people are going into their consular interviews.”

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He hasn’t forgotten the pile of hospital bills that awaited him after he had a seizure while tending to customers in his Austin, Texas, barbershop four years ago. Once doctors hurriedly removed the dangerous tumor growing on his brain, a weeklong hospital stay, months of therapy, and nearly $250,000 worth of medical expenses followed.

The coverage he has purchased for years through the Affordable Care Act marketplace covered most of those bills.

“That saved my ass,” said Cleveland, who owns three barbershops across the city.

Even with Cleveland’s monthly premiums expected to soar next year — from $560 to about $682 — he will still sign up for a plan that requires him to shell out $70 if he sees a doctor and 50% of the cost for any emergency room visits. Still, Cleveland is most worried about some of his employees, who might risk going without insurance once they see the high prices.

Small-business owners are among those who stand to lose the most should Congress let the additional, generous federal subsidies put in place during the covid-19 pandemic lapse. The looming change threatens not only their own coverage but also that of their employees, who often depend on marketplace coverage.

Whether to extend the enhanced ACA subsidies that cost taxpayers billions of dollars yearly poses a serious political conundrum for Republicans. After years of unified opposition to Obamacare, the party now faces pressure from one of its most loyal constituencies, small-business owners, who will bear the brunt of rising premiums if the subsidies disappear.

Most of the roughly 20 employees who work on Justin Miller’s 113-year-old family fruit farm in rural Northern California purchase coverage through the Obamacare marketplace.

He’s agonizing over what it could mean if health insurance through the marketplace becomes unaffordable for his employees. He fears they might consider leaving his farm for a job that comes with health coverage.

“Being a small-business owner, especially in a field like ours, where it is tough work and we really understand how hard everybody works, we have to look everybody in the eyes every day,” Miller said. “Knowing that they’re going to have to pay $4,000 or $5,000 more a year to stay on their insurance is a tough pill to swallow.”

Miller says he already pays a minimum wage of $22.50 and provides sick leave, vacation, retirement, and employee housing benefits.

Adding health insurance for his employees, he said, would be too costly to keep his farm in business.

GOP Pollsters Issue ACA Caution

About half of the 24 million people enrolled in Obamacare coverage are, or are employed by, small-business owners — a group that is more likely to vote Republican and overwhelmingly backed President Donald Trump in last year’s election. Farmers, dentists, real estate agents, and chiropractors are among the professions most represented among enrollees.

Even Trump’s own pollsters have found deep support for the Obamacare subsidies, warning that failing to extend them could cost Republicans in next year’s midterms.

A poll conducted last month by Republican pollster John McLaughlin found that a majority of independent voters would be less likely to vote for politicians who voted to let the enhanced tax credits expire.

Given that “approximately 4 million” people would lose coverage and premiums would “skyrocket by an average of 75%,” the poll also concluded that: “A candidate for congress who let the healthcare tax cuts expire would also be vulnerable to more pointed messages.”

Red States Benefited From the Subsidies

Some red states have seen Obamacare enrollment balloon since the federal government began offering extra help paying premiums in the form of more generous subsidies.

Texas and Florida have added 2.8 million enrollees each since 2020, far outpacing growth in most other states. Together, the two states now account for more than a third of marketplace enrollment nationally.

A small chorus of Republican lawmakers — up for reelection next year, mostly in competitive races — have proposed an extension of the subsidies, urging Democrats to vote to reopen the government while simultaneously pleading with House Speaker Mike Johnson to work out a bipartisan deal that doesn’t allow them to simply lapse.

At Cleveland’s barbershops in Austin, about a third of his 18 employees rely on Obamacare coverage. He’s talked to them about their health insurance options for next year but said many hadn’t started thinking about open enrollment, which began Nov. 1.

He’s worried they’ll be baffled once they see the new prices, which currently reflect what customers will pay next year without an extension of the extra subsidies.

“There’s a couple of my barbers that are going to go without, because they’re healthy and young, but I thought I was too when everything happened to me,” said Cleveland, now 47.

Republicans, meanwhile, remain wary of voting to extend the additional Obamacare subsidies, said Rodney Whitlock, a vice president at the McDermott+ consultancy who was a longtime congressional staffer and advises on health care policy.

No Republican voted for the extra subsidies when they were introduced in 2021 or continued in 2022. Approving them now, he said, is viewed by many as a band-aid that would temporarily help a program GOP leaders have long lambasted as problematic and too costly.

But, Whitlock noted, many in the party are coming to terms with how the subsidies might affect their changing constituencies. Nearly 6 in 10 Obamacare enrollees live in a Republican-held congressional district.

“Republicans are slowly starting to grasp that the lower third of income earners are their voters,” he said. “For the first time, I think they’re getting there. That battleship turns slowly.”

Rep. Marjorie Taylor Greene, a Georgia Republican who has firmly backed Trump, broke with her party last month, calling on the GOP to extend the subsidies. Greene said in an interview that rising health care costs are the “No. 1 issue” she hears about from people living in her district.

“I know a lot of small-business owners, like a family of four, and they’re paying $2,000 a month,” Greene said during the television interview, adding that rising deductibles make the insurance hardly functional for anything other than catastrophes.

She warned in another TV interview that “ignoring” the issue could be “very bad for midterms” next year.

Miller, the farmer who lives in a conservative district in Northern California, expects monthly health insurance premiums for himself, his wife, and two of his children to jump from $264 to $600. His deductibles and copayments are going up, too. He expects all these new expenses will still be on his mind when he goes to vote in the midterm elections next year, he said. Describing himself as an independent, Miller said he is frustrated that few American politicians talk about the type of universal health care coverage that’s available in other countries.

“I’m definitely voting for those that will protect the working American, regardless of party,” he 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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