“It is almost impossible to explain what it takes to keep a child alive who should be dead,” said Fabrello, whose son, Ysadore Maklakoff, experienced a rare brain condition called acute necrotizing encephalopathy at 9 months old.

Through North Carolina’s Medicaid program, Maklakoff qualifies for a large slate of medical care in the family’s home in Chapel Hill. Fabrello said she works with staffing agencies to arrange services. She also learned to give the care ordinarily performed by a doctor, skilled nurse, or highly trained therapist because she often can’t get help.

Now, broad cuts to North Carolina Medicaid will make finding and paying for care even more difficult.

Nationwide, states are scrambling to close budget shortfalls and are eyeing Medicaid, generally one of a state’s biggest costs — even before President Donald Trump’s hulking tax-and-spending law decreases federal spending on Medicaid by about $1 trillion over the next decade.

North Carolina and Idaho have already announced plans to cut Medicaid payments to health care providers, including hospitals, doctors, and caregivers.

In Michigan and Pennsylvania — where lawmakers have yet to pass budgets this year — spending on Medicaid is part of those debates. In Washington state, lawmakers approved cuts to the program that will not affect who is eligible, said Hayden Mackley, a spokesperson for the state’s Office of Financial Management.

Medicaid is government health insurance for people with low incomes or disabilities and both state and federal dollars pay for the program.

North Carolina’s Medicaid agency announced it will institute on Oct. 1 a minimum 3% reduction in pay for all providers who treat Medicaid patients. Primary care doctors face an 8% cut and specialty doctors a 10% drop in payments, according to the North Carolina Department of Health and Human Services.

Fabrello said her son’s dentist already called to say the office will not accept Medicaid patients come November. Fabrello fears dental work will become another service her son qualifies for but can’t get because there aren’t enough providers who accept Medicaid coverage.

Occupational and speech therapy, nursing care, and respite care are all difficult or impossible to get, she said. In a good week, her son will get 50 hours of skilled nursing care out of the 112 hours he qualifies for.

“When you say, ‘We’re just cutting provider rates,’ you’re actually cutting access for him for all his needs,” Fabrello said.

Shannon Dowler, former chief medical officer for North Carolina Medicaid, said that reduced payments to dentists and other providers will lower the number of providers in the state’s Medicaid network and result in “an immediate loss of access to care, worse outcomes, and cause higher downstream costs.”

The imminent cuts in North Carolina “don’t have anything to do” with the new federal law that cuts Medicaid funding, Dowler said.

“This is like the layers of the onion,” she said. “We are hurting ourselves in North Carolina way ahead of the game, way before we need to do this.” North Carolina alone is projected to lose about $23 billion in federal Medicaid dollars over the next decade.

More than 3 million North Carolinians are enrolled in Medicaid. Deadlocked state lawmakers agreed to a mini budget in July to continue funding state programs that gave the Medicaid agency $319 million less than it requested. Lawmakers can choose to reinstate funding for Medicaid this fiscal year, Dowler said.

“We all hope it changes,” Dowler said, adding that if it does not, “you’re going to see practices dropping coverage of Medicaid members.”

Each year since at least 2019, North Carolina’s Medicaid agency has asked for more money than it received from the state legislature. A variety of federal resources, including money provided to states during the covid-19 pandemic, helped bridge the gap.

But those funds are gone this year, leaving the agency with a choice: Eliminate some optional parts of the program or force every provider that accepts the public insurance to take a pay cut. The state opted mostly for the latter.

“It’s a difficult moment for North Carolina,” said Jay Ludlam, deputy secretary for North Carolina Medicaid. The cut in the budget is “absolutely the opposite direction of where we really want to go, need to go, have been headed as a state.”

For Anita Case, who leads a small group of health clinics in North Carolina, the cuts make it harder to take care of the “most vulnerable in our community.”

Western North Carolina Community Health Services’ three clinics serve about 15,000 patients in and around Asheville, including many non-English-speaking tourism workers. Case said she will look at staffing, services, and contracts to find places to trim.

Idaho has about 350,000 people enrolled in Medicaid. This month, state leaders there responded to an $80 million state budget shortfall by cutting Medicaid pay rates 4% across the board.

The broad cuts have raised backlash from nursing home operators and patient advocacy groups. Leaders of one nursing home company wrote in a recent op-ed in the Idaho Statesman newspaper that 75% to 100% of the funding at their facilities comes from Medicaid and the cuts will force them to “to reduce staff or accept fewer residents.”

Idaho Department of Health and Welfare spokesperson AJ McWhorter said the state faced tough choices. It forecasted 19% growth in Medicaid spending this year.

The Idaho Hospital Association’s Toni Lawson said the financial strain will be greatest at about two dozen small hospitals — ones with 25 or fewer beds — that dot the state. Lawson, the organization’s chief advocacy officer, said one hospital leader reported they had less than two days’ cash on hand to make payroll. Others reported 30 days’ cash or less, she said.

“Hopefully, none of them will close,” Lawson said, adding that she expects labor and delivery and behavioral health units, which often lose money, to be the first to go because of this latest state reduction in payments. Several hospitals in mostly rural areas of the state closed their labor and delivery units last year, she said.

Nationwide, Medicaid makes up an average of 19% of a state’s general fund spending, second only to K-12 spending, said Brian Sigritz, director of state fiscal studies for the National Association of State Budget Officers.

States generally had strong revenue growth in 2021 and 2022 because of economic growth, which included federal aid to stimulate the economy. Revenue growth has since slowed, and some states have cut income and property taxes.

Meanwhile, spending on Medicaid, housing, education, and disaster response has increased, Sigritz said.

In North Carolina, Fabrello has been unable to work outside of caring for her son. Her savings are almost exhausted, Fabrello said, and she was on the brink of financial ruin until North Carolina began allowing parents to be compensated for caregiving duties. She’s received that income for about a year, she said. Without it, she worried about losing her home.

Now, if the state reductions go through, she faces a salary cut.

“As parents, we are indispensable lifelines to our children, and we are struggling to fight for our own survival on top of it,” Fabrello said.

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Some children’s hospitals collectively stand to lose billions of dollars in revenue once Trump’s wide-ranging tax and spending law, which Republicans called the “One Big Beautiful Bill,” is fully enacted, according to the Children’s Hospital Association. Kids account for nearly half of enrollees in Medicaid, the state and federally financed health program for low-income and disabled people, and its related Children’s Health Insurance Program.

The law will cut federal Medicaid spending by about $900 billion over a decade.

The reduction “cannot be achieved without directly affecting coverage and care for Arizona’s kids, especially the most vulnerable among them,” said Robert Meyer, chief executive of Phoenix Children’s, a pediatric hospital system. About half of the system’s revenue comes from Medicaid.

Trump’s law locks into place much of his domestic agenda, including a massive expansion of immigration enforcement and an extension of tax cuts that largely benefit the wealthiest Americans. The cuts to Medicaid are expected to partially offset the cost of the president’s priorities, which will add more than $3 trillion to the nation’s deficit, according to the Congressional Budget Office. About 7.5 million Americans will lose Medicaid coverage by 2034 as a result, the CBO estimates.

Throughout debates over the measure, Republicans insisted the Medicaid cuts would affect only nondisabled adults enrolled in the program who don’t work and immigrants living in the U.S. without legal status. “Our legislation preserves Medicaid, strengthens Medicaid for the people who actually need it and deserve it,” House Speaker Mike Johnson said June 1 on NBC News’ “Meet the Press.” “And we’re going to get rid of the fraud, waste, and abuse.”

Meyer, though, warned that unless some cuts are reversed, Phoenix Children’s would lose about $172 million a year in payments that supplement the health system’s regular Medicaid revenue, for treating low-income children covered by the program. Medicaid typically pays lower rates for care than commercial insurance or Medicare, the federal program for people age 65 and older.

The supplemental payments, known as state-directed payments, are financed largely by federal taxpayers through complicated tax arrangements adopted by nearly all states. The payments have helped the Phoenix system open additional pediatric clinics, increase mental health staffing, and screen children for abuse and other trauma, Meyer said.

A provision of Trump’s law would cap the amount of directed payments states could make to any hospital, including those for children. But the cap, which doesn’t take effect until 2028, will be phased in over a decade — and hospitals are already lobbying to ensure that never happens. Days after voting for Trump’s law, Sen. Josh Hawley (R-Mo.) introduced legislation that would eliminate provisions of the measure cutting Medicaid payments to hospitals.

If the law isn’t changed, at least 29 states would need to reduce their payments, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

The extra Medicaid funds, on average, make up more than a third of children’s hospitals’ total Medicaid revenue and about 14% of their operating revenue overall, according to the Children’s Hospital Association.

Richard Park, a director at Fitch Ratings, a credit rating agency, said the Medicaid funding cuts present a “long-term headwind” for children’s hospitals. Hospital officials say that if the payments are cut and states don’t replace the funding, they could be forced to cut staff and services.

“Services the hospitals provide that require longer admissions or bring in less revenue are going to be in the crosshairs, for sure,” Park said.

Children’s hospitals are especially vulnerable to changes in Medicaid because they count on the program for about half their revenue — a much higher proportion than general acute-care hospitals do.

Most children’s hospitals are in good financial condition, however, because they face little competition — there are seldom more than one or two in a metropolitan area — and strong philanthropic support. And the funding cuts won’t affect all the nation’s approximately 200 children’s hospitals.

In 2023, Phoenix Children’s had a $163 million surplus on nearly $1.5 billion in revenue, according to its 2023 IRS tax return.

Under the law, the extra payments in the District of Columbia and 40 states that expanded Medicaid under the Affordable Care Act would be capped at Medicare payment rates. The 10 states that didn’t expand would be able to pay up to 110% of Medicare rates.

The Biden administration had allowed states to pay up to their average commercial insurance rates. That’s generally about 2.5 times the Medicare rate, according to KFF.

Medicaid’s traditionally low fees to health providers can make doctors, dentists, and other specialists reluctant to treat patients in the program.

Brian Blase, president of the conservative Paragon Health Institute and a key architect of Medicaid changes in the new law, said cutting state-directed payments is justified because states should not pay hospitals more to treat Medicaid patients than they do for Medicare patients. Unlike regular Medicaid payments for specific health services, hospitals are not always held accountable for how they spend the extra money, he said.

He said state-directed payments to children’s hospitals and other facilities amount to “corporate welfare,” often helping financially strong institutions get richer.

Blase said states have little incentive to pay hospitals less because the money from state-directed payments comes mostly from federal taxpayers.

In Norfolk, Virginia, Children’s Hospital of The King’s Daughters depends on more than $11 million annually in state-directed payments to make up for what it says is a shortfall between Medicaid’s low reimbursement rates and the cost of advanced care.

The cuts to Medicaid in Trump’s law “will have serious and far-reaching consequences to our services, programs, and patients,” spokesperson Alice Warchol told KFF Health News. “Medicaid supplemental funding helps us pay for the highly specialized pediatric medical, surgical, and psychiatric physicians that are needed to care for every child who needs our services.”

In fiscal 2023, King’s Daughters had a $24 million surplus on $646 million in revenue, according to its federal tax return.

King’s Daughters has used the extra Medicaid money to expand treatment for abused and neglected children and mental health services, Warchol said.

How states account for the extra payments made to hospitals varies. For instance, Utah Medicaid Director Jennifer Strohecker said her state does not track how the money gets spent.

Other states, such as Texas, use the money as an incentive for hospitals to improve their performance in treating patients. They track how well the facilities do each year and publish the findings in public reports.

Matthew Cook, president and chief executive of the Children’s Hospital Association, said that even with the extra funding, Medicaid doesn’t cover the full cost of treatment for its patients.

While some children’s hospitals have strong balance sheets, boosted by philanthropy, that is not the case for all, Cook said. And the Medicaid funding cuts come on top of reductions in other federal payments, including for training doctors and research, he said.

At Phoenix Children’s, Meyer said, the loss of extra funding would curtail expansions of care for children and growth of the hospital’s workforce. The hospital hopes Congress delays or reverses the cuts — but it’s not counting on it, he said.

“We see this grace period as a godsend to get ourselves ready to close the funding gap,” he said.

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The Centers for Medicare & Medicaid Services is scouring payments covering health care for immigrants without legal status to ensure there isn’t any waste, fraud, or abuse, according to public records obtained by KFF Health News and The Associated Press. While acknowledging that states can bill the federal government for Medicaid emergency and pregnancy care for immigrants without legal status, federal officials have sent letters notifying state health agencies in California, Colorado, Illinois, Minnesota, Oregon, and Washington that they are reviewing federal and state payments for medical services such as prescription drugs and specialty care.

The federal agency told the states it is reviewing claims as part of its commitment to maintain Medicaid’s fiscal integrity. California is the biggest target after the state self-reported overcharging the federal government for health care services delivered to immigrants without legal status, determined to be at least $500 million, spurring the threat of a lawsuit.

“If CMS determines that California is using federal money to pay for or subsidize healthcare for individuals without a satisfactory immigration status for which federal funding is prohibited by law,” according to a letter dated March 18, “CMS will diligently pursue all available enforcement strategies, including, consistent with applicable law, reductions in federal financial participation and possible referrals to the Attorney General of the United States for possible lawsuit against California.”

The investigations come as the White House and a Republican-controlled Congress slashed taxpayer spending on immigrant health care through cuts in President Donald Trump’s spending-and-tax law passed this summer. The administration is also pushing people living in the U.S. without authorization off Medicaid rolls. Health policy experts say these moves could hamper care and leave safety net hospitals, clinics, and other providers financially vulnerable. Some Democratic-led states — California, Illinois, and Minnesota — have already had to end or slim down their Medicaid programs for immigrants due to ballooning costs. Colorado is also considering cuts due to cost overruns.

At the same time, 20 states are pushing back on Trump’s immigration crackdown by suing the administration for handing over Medicaid data on millions of enrollees to deportation officials. A federal judge temporarily halted the move. California’s attorney general, Rob Bonta, who led that challenge, says the Trump administration is launching a political attack on states that embrace immigrants in Medicaid programs.

“The whole idea that there’s waste, fraud, and abuse is contrived,” Bonta said. “It’s manufactured. It’s invented. It’s a catchall phrase that they use to justify their predetermined anti-immigrant agenda.”

Trump Targets Immigrants

Immigrants lacking permanent legal status are not eligible to enroll in comprehensive Medicaid coverage. However, states bill the federal government for emergency and pregnancy care provided to anyone.

Fourteen states and Washington, D.C., expanded their Medicaid programs with their own funds to cover low-income children without legal status. Seven of those states, plus Washington, D.C., have also provided full-scope coverage to some adult immigrants living in the country without authorization.

The Trump administration appears to be targeting only states with full Medicaid coverage for both kids and adults without legal status. Utah, Massachusetts, and Connecticut, which provide Medicaid coverage only to immigrant children, have not received letters, for instance. CMS declined to provide a full list of states it is targeting.

Federal officials say it is their legal right and responsibility to scrutinize states for misspending on immigrant health coverage and are taking “decisive action to stop that.”

“It is a matter of national concern that some states have pushed the boundaries of Medicaid law to offer extensive benefits to individuals unlawfully present in the United States,” CMS spokesperson Catherine Howden said about the agency’s probe of selected states. The oversight is intended to “ensure federal funds are reserved for legally eligible individuals, not for political experiments that violate the law,” she said.

Health policy researchers and economists say providing Medicaid coverage to immigrants for preventive services and treatment of chronic health conditions staves off more costly care for patients down the road. It also tamps down insurance premium increases and the amount of uncompensated care for hospitals and clinics.

Francisco Silva, president and CEO of the California Primary Care Association, said the Trump administration is threatening to drive up health care costs and make it more difficult to access care.

“The impact is emergency rooms would get so crowded that ambulances have to be diverted away and people in a real emergency can’t get into the hospital, and public health threats like disease outbreaks,” Silva said.

California has taken a health-care-for-all approach, providing coverage to 1.6 million immigrants without legal status. The expansion, which was rolled out from 2016 to 2024, is estimated to cost $12.4 billion this year. Of that, $1.3 billion is paid by the federal government for emergency and pregnancy-related care.

As California rolled out its expansion, the state erroneously billed the federal government for care provided to immigrants without legal status — details that have not previously been reported and that former state officials shared with KFF Health News and the AP. The state improperly billed for services such as mental health and addiction services, prescription drugs, and dental care.

Jacey Cooper, who served as California’s Medicaid director from 2020 to 2023, said she discovered the error and reported it to federal regulators. Cooper said the state had been working to pay back at least $500 million identified by the federal government.

“Once I identified the problem, I thought it was really important to report it and we did,” Cooper said. “We take waste, fraud, and abuse very seriously.”

It’s not clear whether that money has been repaid. The state’s Medicaid agency says it does not know how CMS calculated the overpayments or “what is included in that amount, what time period it covers, and if or when it was collected,” said spokesperson Tony Cava.

California has an enormously complicated Medicaid program: It serves the largest population in the nation — nearly 15 million people — with a budget of nearly $200 billion this fiscal year.

Matt Salo, a national Medicaid expert, said these types of mistakes happen in states throughout the country because the program is rife with overlapping federal and state rules. Salo and other policy analysts agreed that states have the authority to administer their Medicaid programs as they see fit and root out misuse of federal funds.

And Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Trump administration’s actions “persecute a minority that’s unpopular with the powers that be.”

“The Trump administration cannot maintain that this effort has anything to do with maintaining the fiscal integrity of the Medicaid program,” Cannon said. “There are so much bigger threats to Medicaid’s fiscal integrity, that that argument just doesn’t wash.”

Immigrants’ Medicaid Under Attack

National Republicans have targeted health spending on immigrants in different ways. The GOP spending law, which Trump calls the “One Big Beautiful Bill,” will lower reimbursement to states around the country in October 2026. In California, for example, federal reimbursement for immigrants without legal status will go to 50% for emergency services, down from 90% for the Medicaid expansion population, according to Cava.

The Trump administration is also scaling back Medicaid coverage to immigrants with temporary legal status who were previously covered and announced in August that it would provide states with monthly reports pointing out enrollees whose legal status could not be confirmed by the Department of Homeland Security.

“Every dollar misspent is a dollar taken away from an eligible, vulnerable individual in need of Medicaid,” CMS Administrator Mehmet Oz said in a statement. “This action underscores our unwavering commitment to program integrity, safeguarding taxpayer dollars, and ensuring benefits are strictly reserved for those eligible under the law.”

States under review say they are following the law.

“Spending money on a congressionally authorized medical benefit program that helps people get emergency treatments for cancer, dialysis, and anti-rejection medications for organ transplants is decidedly not waste, fraud and abuse,” said Mike Faulk, deputy communications director for Washington state Attorney General Nick Brown.

Records show Washington Medicaid officials have been inundated with questions from CMS about federal payments covering emergency and pregnancy care for immigrants without legal status.

Emails show Illinois officials met with CMS and sought an extension to share its data. CMS denied that request and federal regulators told the state that its funding could be withheld.

“Thousands of Illinois residents rely on these programs to lawfully seek critical health care without fear of deportation,” said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services, noting that any federal cut would be “impossible” for the state to backfill.

Shastri reported from Milwaukee.

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

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As the Michigan state health director, he had spent the past year, and some $30 million in state tax dollars, trying to avoid that very thing.

Gordon was a Democrat, a veteran of the Obama administration, and he did not want people to lose the Medicaid coverage they had recently gained through the Affordable Care Act.

But Gordon and his boss, Democratic Gov. Gretchen Whitmer, had reluctantly inherited a law passed two years earlier, when Republicans led the state. And that law mandated that Michigan institute a work requirement for Medicaid on Jan. 1, 2020.

Gordon and his team determined that most enrollees were already meeting the law’s requirements, either because they were already working or had an exemption. Thousands more reported their status through the newly built phone and online systems.

But even so, estimates suggested 80,000 to 100,000 Michiganders were going to be booted off the rolls within the year.

“That’s the population of the city of Flint who were on track to lose their insurance,” said Gordon, who led the state health department until 2021. “We’re implementing this about as well as this thing can be implemented, and it is still going to be pretty catastrophic.”

The new tax-and-spending law signed by President Donald Trump in July mandates a vast expansion of Medicaid work requirements to most states.

These systems will lead to 5.3 million more people being uninsured in 2034, according to an estimate from the Congressional Budget Office.

The law applies to 40 states and Washington, D.C., because they expanded Medicaid in recent years to cover more working-age adults.

About 18 million people will be affected once the work mandate is fully implemented nationally, according to the CBO. Unless their state gets an exemption till 2028, by 2027, these enrollees will need to prove they’re working, volunteering, getting job training, or doing other qualifying activities at least 80 hours a month to keep their coverage.

Republicans say this is a commonsense way to weed out “freeloaders.” Democrats argue that’s just political cover for slashing a program that saved some 27,000 lives starting in 2010, when the Affordable Care Act was signed, through 2022.

The number of people who lose coverage, either temporarily or permanently, could vary widely by state, depending on how each state implements and maintains its reporting system.

Michigan’s experience illustrates how challenging it can be to stop large numbers of people from inadvertently losing coverage, even when leaders try their best to prevent that.

“We were very committed to implementing a law that we didn’t agree with, in a way that reduced the number of people who lost insurance just because the government screwed something up,” Gordon said.

A Year of High-Stakes Work

In 2013, then-Gov. Rick Snyder, a Republican, waged a fierce battle within his own party to expand Michigan’s Medicaid program.

To Snyder, it was an opportunity to simultaneously save money and expand access: By slashing the rate of uninsured Michiganders by almost half, the state could reduce the burden of uncompensated care on the health system and boost the economy by improving the physical health of the workforce.

But opponents saw it as an expansion of “Obamacare” that would shift massive new costs onto state and federal taxpayers. A work requirement became a point of compromise and a way for Snyder to mollify some of that opposition.

From a coverage perspective, Michigan’s expansion of Medicaid was a success. Low-income adults signed up, ballooning new enrollment beyond what even supporters had initially estimated.

By 2019, there were nearly 700,000 new Medicaid recipients in Michigan, and the state was responsible for an increasing share of their health care costs. (Medicaid is paid for jointly by states and the federal government.)

Fiscal hawks were worried. “It’s now become the largest budget problem in Michigan,” said Jarrett Skorup of the Mackinac Center for Public Policy, a free-market think tank

Snyder signed the bill creating the 80-hour-a-month work requirement in 2018, but it wouldn’t go into effect until 2020, after he left office.

That left newly elected Democratic governor Whitmer’s administration holding the bag. She tapped Gordon, who’d held senior roles in the federal Office of Management and Budget and Department of Education during the Obama administration, to lead the sprawling state health department.

Gordon was terrified that Michigan would become another Arkansas, which was the first state to implement a work requirement, in 2018. The change led more than 18,000 Arkansas residents to lose their coverage.

People in Arkansas were disenrolled “because computers went down, because forms weren’t clear, because they just never heard about it,” Gordon said. “Maybe they got sicker, maybe they died because of this decision.”

If Michiganders lost coverage at the same rate as Arkansans, as many as 160,000 people would have lost their health insurance within a year, according to one estimate.

Trying To Make Medicaid Work Requirements … Work

In some ways, Michigan was better positioned than other states to implement a work requirement, Gordon said: The unemployment rate was the lowest it had been in two decades and the state was already pretty good at collecting and tracking employment and wage data.

“If the state can figure out on its own, without having to ask you if you’re working, that’s great, because then you don’t have to do anything,” Gordon said. “You’re just exempted.”

Michigan eventually changed its law to allow people more time to report their work activities and to automatically determine their compliance or exemption by cross-checking data from other assistance programs, like food benefits.

To see if recipients were students or had health-related exemptions, Gordon and his team also tried to capture data from community college enrollment and medical insurance claims.

Dozens of staffers reprogrammed the state’s outdated benefits enrollment portal, created full-time call centers, set up audit and appeals processes, hired compliance review teams, and trained hundreds of local organizers to provide tech and enrollment assistance.

Forms and letters alerting hundreds of thousands of enrollees to the new policy were redesigned to be attention-grabbing and easier to understand.

The sheer amount of effort and time required meant other public health efforts had to take a back seat, Gordon said. “Your first job is going to suffer, and that is a consequence of work requirements.”

In Michigan, Black infant mortality rates were some of the highest in the nation. Thousands of people were still dying from overdoses.

Yet at the state health department, “all of the oxygen in the room was dedicated — almost all, I should say — to the work requirement implementation,” said Renuka Tipirneni, an internal medicine physician at the University of Michigan who studies Michigan’s Medicaid expansion.

Even after all that work, Gordon and his team had no illusions the system they’d spent $30 million creating was flawless.

“There was a real sense that everyone was doing everything they could,” he said. But they still worried that “huge numbers of people were going to fall through the cracks. Because that’s just what happens with systems like this.”

A “Waste” of $30 Million

By the time the work requirement went into effect on Jan. 1, 2020, the state had been able to determine that the vast majority of the nearly 700,000 Medicaid expansion recipients already met the work requirement or were exempt.

That left about 100,000 people whose status was unknown and who therefore still had to go through the reporting process. By March, around 80,000 of those had failed to report and were on track to lose coverage.

On the one hand, it was a lower rate of coverage loss than Arkansas had. But it was still “an enormous number of people” set to lose coverage, Gordon said.

Before that could happen, a federal judge issued a ruling on March 4, 2020, blocking Michigan’s policies from going forward. That same day, Gordon was scheduled to testify before a Republican-led subcommittee about how the rollout was going.

Instead, he found himself explaining to legislators that the state’s work requirement was essentially dead in the water, and that “we had, on the demand of the people holding the hearing, spent tens of millions of dollars for no purpose.”

Given how brief Michigan’s experiment with a Medicaid work requirement was — only about two months of the policy’s being in effect, with no one losing coverage in the end — the Mackinac Center’s Skorup doesn’t see a lot of takeaways about the real-life impacts of work requirements.

“If you have an administration that is not sold on these being necessary at all, then I think they’re more likely to drag their feet on implementing this, which is what I think they did,” Skorup said, referring to the Whitmer administration.

Skorup is concerned because Medicaid costs keep rising, with 2.6 million Michiganders (1 in 4 residents) now covered by the program or the related Children’s Health Insurance Program. Skorup believes Medicaid spending is “crowding out” teacher pay, pensions, and roads in the state budget.

Supporters of Medicaid expansion say the program’s growth has benefited Michigan, pointing to research that Medicaid expansion helped boost employment and school enrollment and was a net positive for the state financially.

Court Ruling Comes Days Before Covid Hits

Only days after the court ruling stopped the work requirement in Michigan, officials announced the state’s first cases of covid-19. The 80,000 Michiganders who might have lost Medicaid were spared, so their health coverage continued as the pandemic unfolded. Gordon continued as health director until 2021, when he resigned over “differences of opinion” with Whitmer about some pandemic restrictions.

These days, Gordon is experiencing a sense of déjà vu, with new predictions showing as many as 500,000 Michiganders could lose coverage within the first year of federally mandated work requirements, according to state estimates.

“We would have a more honest and more efficient policy if Republicans just kick people off Medicaid,” he said.

That would be “incredibly harmful,” he said. “But this thing they’re doing isn’t any less harmful. It’s just more wasteful administratively, and more confusing to everyone.”

This article is from a partnership that includes Michigan Public, NPR, and KFF Health News.

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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Estos estados brindan cobertura médica integral a inmigrantes pobres y con discapacidades que viven en el país sin estatus migratorio permanente.

Los Centros de Servicios de Medicare y Medicaid (CMS) están examinando los pagos que cubren atención médica para personas sin papeles, para asegurarse que no haya malgasto, fraude o abuso, según registros públicos obtenidos por KFF Health News y The Associated Press.

Si bien el gobierno federal permite que los estados facturen servicios de emergencia y atención relacionada con el embarazo para estos inmigrantes, funcionarios federales han enviado cartas a agencias estatales de salud en California, Colorado, Illinois, Minnesota, Oregon y Washington notificando que están revisando pagos estatales y federales por otros servicios médicos, como medicamentos recetados y atención especializada.

La agencia federal indicó a los estados que está revisando estos reclamos como parte de su compromiso por mantener la integridad financiera de Medicaid.

El principal objetivo es California, después que el propio estado informara haber cobrado de más al gobierno federal por servicios ofrecidos a inmigrantes sin estatus legal, por al menos $500 millones, lo que generó la amenaza de una demanda.

Según una carta con fecha del 18 de marzo, “si los CMS determinan que California está usando fondos federales para pagar o subsidiar atención médica para personas sin un estatus migratorio satisfactorio, para los cuales está prohibido por ley el financiamiento federal… los CMS aplicarán con diligencia todas las estrategias de cumplimiento disponibles, incluidas, de acuerdo con la ley aplicable, reducciones en la participación financiera federal y posibles derivaciones al fiscal general de Estados Unidos para una posible demanda contra California”.

Las investigaciones surgen mientras la Casa Blanca y el Congreso, controlado por los republicanos, recortan el gasto público en atención médica para inmigrantes, mediante los recortes de la ley fiscal y presupuestaria del presidente Donald Trump aprobada este verano. La administración también está impulsando que se elimine de Medicaid a las personas que viven en el país sin papeles.

Expertos en políticas de salud advierten que estas acciones podrían dificultar el acceso a atención médica y dejar vulnerables desde el punto de vista financiero a hospitales, clínicas y otros proveedores que forman parte de la red de seguridad.

Algunos estados liderados por demócratas —como California, Illinois y Minnesota— ya han tenido que reducir o finalizar sus programas de Medicaid para inmigrantes debido al aumento de los costos. Colorado también está considerando recortes por exceso de gastos.

Al mismo tiempo, 20 estados están demandando al gobierno federal por entregar datos de Medicaid de millones de beneficiarios a las autoridades migratorias. Un juez federal detuvo temporalmente esa acción. Rob Bonta, fiscal general de California, quien lidera este desafío, sostiene que la administración Trump está lanzando un ataque político contra los estados que incluyen a inmigrantes en sus programas de Medicaid.

“La idea de que hay malgasto, fraude y abuso es inventada”, dijo Bonta. “Es un pretexto. Es una frase genérica que usan para justificar su agenda antiinmigrante predeterminada”.

Grupo demográfico en la mira de Trump

Los inmigrantes sin estatus migratorio permanente no son elegibles para acceder a la cobertura médica completa de Medicaid. Sin embargo, los estados sí pueden facturar al gobierno federal por atención de emergencia y servicios relacionados con el embarazo que se ofrezcan a cualquier persona.

Catorce estados, y Washington, D.C., han ampliado sus programas de Medicaid con sus propios fondos para cubrir a niños de bajos recursos sin papeles. Siete de esos estados, además de D.C., también ofrecen cobertura integral a algunos adultos inmigrantes que viven en el país sin autorización.

La administración Trump parece estar enfocándose exclusivamente en los estados que ofrecen cobertura completa de Medicaid tanto a niños como a adultos sin papeles. Por ejemplo, Utah, Massachusetts y Connecticut, que sólo cubren a niños inmigrantes, no han recibido cartas. Los CMS se negaron a proporcionar una lista completa de los estados bajo investigación.

Funcionarios federales sostienen que es su derecho y responsabilidad legal examinar si los estados están usando mal los fondos de Medicaid para cubrir la atención médica de inmigrantes, y aseguran que están tomando “acciones decisivas para detenerlo”.

“Es un tema de interés nacional que algunos estados hayan sobrepasado los límites de la ley de Medicaid al ofrecer beneficios extensos a personas que se encuentran ilegalmente en Estados Unidos”, dijo Catherine Howden, vocera de los CMS, refiriéndose a la auditoría en estados específicos. Este escrutinio busca “asegurar que los fondos federales se reserven para personas legalmente elegibles, y no para experimentos políticos que violan la ley”, dijo.

Investigadores en políticas de salud y economistas afirman que ofrecer cobertura médica a inmigrantes para servicios preventivos y tratamiento de enfermedades crónicas puede evitar gastos mayores en el futuro. También ayuda a contener el aumento de las primas y reduce la atención no remunerada en hospitales y clínicas.

Francisco Silva, presidente y director ejecutivo de la  California Primary Care Association, advirtió que la administración Trump está poniendo en riesgo el acceso a servicios de salud, y elevando los costos.

“El impacto sería que las salas de emergencia se saturarían, las ambulancias tendrían que ser desviadas y personas con emergencias reales no podrían entrar al hospital, además de riesgos de salud pública como brotes de enfermedades”, expresó Silva.

California ha adoptado un enfoque de atención médica para todos, y ofrece cobertura de salud a 1.6 millones de inmigrantes sin estatus legal. La expansión, implementada entre 2016 y 2024, se estima que costará $12.400 millones este año. De ese total, $1.300 millones son financiados por el gobierno federal para servicios de emergencia y relacionados con el embarazo.

Durante la implementación de la expansión, California facturó erróneamente al gobierno federal por servicios ofrecidos a inmigrantes sin estatus legal, según detalles no informados previamente, que ex funcionarios federales compartieron con KFF Health News y The Associated Press. El estado cobró de forma incorrecta por servicios como atención de salud mental y adicciones, medicamentos recetados y atención dental.

Jacey Cooper, quien fue directora de Medicaid en California entre 2020 y 2023, dijo que detectó el error y lo reportó a los reguladores federales. Cooper aseguró que el estado ha estado trabajando para reembolsar al menos $500 millones identificados por el gobierno federal.

“Una vez que identifiqué el problema, creí que era muy importante reportarlo, y lo hicimos”, dijo Cooper. “Nos tomamos muy en serio el malgasto, fraude y abuso”.

No está claro si ese dinero ya se devolvió. La agencia estatal de Medicaid dice que no sabe cómo los CMS calcularon los pagos indebidos ni “qué se incluye en ese monto, qué período cubre y si ya fue devuelto o no”, indicó el vocero Tony Cava.

California tiene un programa de Medicaid extremadamente complejo: atiende a la población más grande del país —cerca de 15 millones de personas— con un presupuesto de casi $200.000 millones para este año fiscal.

Matt Salo, experto nacional en Medicaid, dijo que este tipo de errores ocurren en todo el país, ya que el programa está lleno de reglas superpuestas entre los gobiernos estatales y el federal. Salo y otros analistas coinciden en que los estados tienen la autoridad de administrar sus programas de Medicaid según lo consideren adecuado y corregir el uso indebido de fondos federales.

Por su parte, Michael Cannon, director de estudios de políticas de salud en el Instituto Cato —un centro de tendnecia libertaria— afirmó que las acciones de la administración Trump “persiguen a una minoría que es impopular para quienes están en el poder”.

“La administración Trump no puede sostener que este esfuerzo tiene que ver con mantener la integridad financiera del programa Medicaid”, dijo Cannon. “Hay amenazas mucho más grandes para la integridad financiera de Medicaid, por lo que ese argumento no se sostiene”.

Menos, o nada, de cobertura para inmigrantes

A nivel nacional, los republicanos han apuntado al gasto en salud para inmigrantes desde distintos frentes.

La ley de presupuesto del Partido Republicano, que Trump llama la “Grande y Hermosa Ley” (One Big Beautiful Bill), reducirá los reembolsos a los estados a partir de octubre de 2026. Por ejemplo, en California, el reembolso federal por servicios de emergencia para inmigrantes sin estatus legal pasará a ser del 50%, comparado con el 90% actual para la población cubierta por la expansión de Medicaid, según explicó Cava.

La administración Trump también está reduciendo la cobertura de Medicaid para inmigrantes con estatus legal temporal que antes estaban cubiertos, y anunció en agosto que enviará a los estados informes mensuales que destacan a beneficiarios cuyo estatus migratorio no ha sido confirmado por el Departamento de Seguridad Nacional.

“Cada dólar malgastado es un dólar que se le quita a una persona vulnerable y elegible que necesita Medicaid”, dijo en un comunicado Mehmet Oz, administrador de los CMS. “Esta acción subraya nuestro firme compromiso con la integridad del programa, la protección de los recursos públicos y la garantía de que los beneficios se otorguen exclusivamente a quienes son elegibles por ley”.

Los estados bajo revisión aseguran que están cumpliendo con la ley.

“Gastar dinero en un programa de beneficios médicos autorizado por el Congreso que ayuda a las personas a recibir tratamientos de emergencia para cáncer, diálisis y medicamentos antirrechazo para trasplantes de órganos no es, de ninguna manera, malgasto, fraude o abuso”, dijo Mike Faulk, subdirector de comunicaciones del fiscal general del estado de Washington, Nick Brown.

Los registros muestran que funcionarios de Medicaid en Washington han recibido muchas preguntas de los CMS sobre los pagos federales que cubren atención de emergencia y embarazo para inmigrantes sin papeles.

Correos electrónicos revelan que funcionarios de Illinois se reunieron con los CMS y pidieron una prórroga para compartir sus datos. La entidad les negó la solicitud y les advirtió que su financiación podría ser retenida.

“Miles de residentes de Illinois dependen de estos programas para recibir atención médica crítica sin temor a ser deportados”, dijo Melissa Kula, vocera del Departamento de Servicios de Salud y Atención Médica del estado, indicando que cualquier recorte federal sería “imposible” de compensar por parte del estado.

Shastri reportó desde Milwaukee.

El Departamento de Salud y Ciencia de The Associated Press recibe apoyo del Departamento de Educación Científica del Instituto Médico Howard Hughes y de la Fundación Robert Wood Johnson. AP es el único responsable de todo el contenido.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la 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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Wieder is a member of the Confederated Salish and Kootenai Tribes in Montana and can access some health services free of charge through her tribe’s health clinics. But funding is limited, so, like a lot of Native American people, she relied on Medicaid for herself and Oakleigh.

Months before Oakleigh’s 1st birthday, the date when Wieder’s postpartum coverage would come to an end, Wieder completed and returned paperwork to enroll her daughter in Healthy Montana Kids, the state’s version of the Children’s Health Insurance Program. But her paperwork, caught up in the lengthy delays and processing times for applications, did not go through.

“As soon as she turned 1, they cut her off completely,” Wieder said.

It took six months for Wieder to get Oakleigh covered again through Healthy Montana Kids. Before health workers in her tribe stepped in to help her resubmit her application, Wieder repeatedly called the state’s health department. She said she would dial the call center when she arrived at her job in the morning and go about her work while waiting on hold, only for the call to be dropped by the end of the day.

“Never did I talk to anybody,” she said.

Wieder and Oakleigh’s experience is an example of the chaos for eligible Medicaid beneficiaries caused by the process known as the “unwinding,” which led to millions of people in the U.S. losing coverage due to paperwork or other procedural issues. Now, tribal health leaders fear their communities will experience more health coverage disruptions when new federal Medicaid work and eligibility requirements are implemented by the start of 2027.

The tax-and-spending law that President Donald Trump signed this summer exempts Native Americans from the new requirement that some people work or do another qualifying activity a minimum number of hours each month to be eligible for Medicaid, as well as from more frequent eligibility checks. But as Wieder and her daughter’s experience shows, they are not exempt from getting caught up in procedural disenrollments that could reemerge as states implement the new rules.

“We also know from the unwinding that that just doesn’t always play out necessarily correctly in practice,” said Joan Alker, who leads Georgetown University’s Center for Children and Families. “There’s a lot to worry about.”

The new law is projected to increase the number of people who are uninsured by 10 million.

The lessons of the unwinding suggest that “deep trouble” lies ahead for Native Americans who rely on Medicaid, according to Alker.

Changes to Medicaid

Trump’s new law changes Medicaid rules to require some recipients ages 19 to 64 to log 80 hours of work or other qualifying activities per month. It also requires states to recheck those recipients’ eligibility every six months, instead of annually. Both of these changes will be effective by the end of next year.

The Congressional Budget Office estimated in July that the law would reduce federal Medicaid spending by more than $900 billion over a decade. In addition, more than 4 million people enrolled in health plans through the Affordable Care Act marketplace are projected to become uninsured if Congress allows pandemic-era enhanced premium tax credits to expire at the end of the year.

Wieder said she was lucky that the tribe covered costs and her daughter’s care wasn’t interrupted in the six months she didn’t have health insurance. Citizens of federally recognized tribes in the U.S. can access some free health services through the Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives.

But free care is limited because Congress has historically failed to fully fund the Indian Health Service. Tribal health systems rely heavily on Medicaid to fill that gap. Native Americans are enrolled in Medicaid at higher rates than the white population and have higher rates of chronic illnesses, die more from preventable diseases, and have less access to care.

Medicaid is the largest third-party payer to the Indian Health Service and other tribal health facilities and organizations. Accounting for about two-thirds of the outside revenue the Indian Health Service collects, it helps tribal health organizations pay their staff, maintain or expand services, and build infrastructure. Tribal leaders say protecting Medicaid for Indian Country is a responsibility Congress and the federal government must fulfill as part of their trust and treaty obligations to tribes.

Lessons Learned During the Unwinding

The Trump administration prevented states from disenrolling most Medicaid recipients for the duration of the public health emergency starting in 2020. After those eligibility checks resumed in 2023, nearly 27 million people nationwide were disenrolled from Medicaid during the unwinding, according to an analysis by the Government Accountability Office published in June. The majority of disenrollments — about 70% — occurred for procedural reasons, according to the federal Centers for Medicare & Medicaid Services.

CMS did not require state agencies to collect race and ethnicity data for their reporting during the unwinding, making it difficult to determine how many Native American and Alaska Native enrollees lost coverage.

The lack of data to show how the unwinding affected the population makes it difficult to identify disparities and create policies to address them, said Latoya Hill, senior policy manager with KFF’s Racial Equity and Health Policy program. KFF is a health information nonprofit that includes KFF Health News.

The National Council of Urban Indian Health, which advocates on public health issues for Native Americans living in urban parts of the nation, analyzed the Census Bureau’s 2022 American Community Survey and KFF data in an effort to understand how disenrollment affected tribes. The council estimated more than 850,000 Native Americans had lost coverage as of May 2024. About 2.7 million Native Americans and Alaska Natives were enrolled in Medicaid in 2022, according to the council.

The National Indian Health Board, a nonprofit that represents and advocates for federally recognized tribes, has been working with federal Medicaid officials to ensure that state agencies are prepared to implement the exemptions.

“We learned a lot of lessons about state capacity during the unwinding,” said Winn Davis, congressional relations director for the National Indian Health Board.

Nevada health officials say they plan to apply lessons learned during the unwinding and launch a public education campaign on the Medicaid changes in the new federal law. “A lot of this will depend on anticipated federal guidance regarding the implementation of those new rules,” said Stacie Weeks, director of the Nevada Health Authority.

Staff at the Fallon Tribal Health Center in Nevada have become authorized representatives for some of their patients. This means that tribal citizens’ Medicaid paperwork is sent to the health center, allowing staff to notify individuals and help them fill it out.

Davis said the unwinding process showed that Native American enrollees are uniquely vulnerable to procedural disenrollment. The new law’s exemption of Native Americans from work requirements and more frequent eligibility checks is the “bare minimum” to ensure unnecessary disenrollments are avoided as part of trust and treaty obligations, Davis said.

Eligibility Checks Are ‘Complex’ and ‘Vulnerable to Error’

The GAO said the process of determining whether individuals are eligible for Medicaid is “complex” and “vulnerable to error” in a 2024 report on the unwinding.

“The resumption of Medicaid eligibility redeterminations on such a large scale further compounded this complexity,” the report said.

It highlighted weaknesses across state systems. By April 2024, federal Medicaid officials had found nearly all states were out of compliance with redetermination requirements, according to the GAO. Eligible people lost their coverage, the accountability office said, highlighting the need to improve federal oversight.

In Texas, for example, federal Medicaid officials found that 100,000 eligible people had been disenrolled due to, for example, the state system’s failure to process their completed renewal forms or miscalculation of the length of women’s postpartum coverage.

Some states were not conducting ex parte renewals, in which a person’s Medicaid coverage is automatically renewed based on existing information available to the state. That reduces the chance that paperwork is sent to the wrong address, because the recipient doesn’t need to complete or return renewal forms.

But poorly conducted ex parte renewals can lead to procedural disenrollments, too. More than 100,000 people in Nevada were disenrolled by September 2023 through the ex parte process. The state had been conducting the ex parte renewals at the household level, rather than by individual beneficiary, resulting in the disenrollment of still-eligible children because their parents were no longer eligible. Ninety-three percent of disenrollments in the state were for procedural reasons — the highest in the nation, according to KFF.

Another issue the federal agency identified was that some state agencies were not giving enrollees the opportunity to submit their renewal paperwork through all means available, including mail, phone, online, and in person.

State agencies also identified challenges they faced during the unwinding, including an unprecedented volume of eligibility redeterminations, insufficient staffing and training, and a lack of response from enrollees who may not have been aware of the unwinding.

Native Americans and Alaska Natives have unique challenges in maintaining their coverage.

Communities in rural parts of the nation experience issues with receiving and sending mail. Some Native Americans on reservations may not have street addresses. Others may not have permanent housing or change addresses frequently. In Alaska, mail service is often disrupted by severe weather. Another issue is the lack of reliable internet service on remote reservations.

Tribal health leaders and patient benefit coordinators said some tribal citizens did not receive their redetermination paperwork or struggled to fill it out and send it back to their state Medicaid agency.

The Aftermath

Although the unwinding is over, many challenges persist.

Tribal health workers in Montana, Oklahoma, and South Dakota said some eligible patients who lost Medicaid during the unwinding had still not been reenrolled as of this spring.

“Even today, we’re still in the trenches of getting individuals that had been disenrolled back onto Medicaid,” said Rachel Arthur, executive director of the Indian Family Health Clinic in Great Falls, Montana, in May.

Arthur said staff at the clinic realized early in the unwinding that their patients were not receiving their redetermination notices in the mail. The clinic is identifying people who fell off Medicaid during the unwinding and helping them fill out applications.

Marlena Farnes, who was a patient benefit coordinator at the Indian Family Health Clinic during the Medicaid unwinding, said she tried for months to help an older patient with a chronic health condition get back on Medicaid. He had completed and returned his paperwork but still received a notice that his coverage had lapsed. After many calls to the state Medicaid office, Farnes said, state officials told her the patient’s application had been lost.

Another patient went to the emergency room multiple times while uninsured, Arthur said.

“I felt like if our patients weren’t helped with follow-up, and that advocacy piece, their applications were not being seen,” Farnes said. She is now the behavioral health director at the clinic.

Montana was one of five states where more than 50% of enrollees lost coverage during the unwinding, according to the GAO. The other states are Idaho, Oklahoma, Texas, and Utah. About 68% of Montanans who lost coverage were disenrolled for procedural reasons.

In Oklahoma, eligibility redeterminations remain challenging to process, said Yvonne Myers, a Medicaid and Affordable Care Act consultant for Citizen Potawatomi Nation Health Services. That’s causing more frequent coverage lapses, she said.

Myers said she thinks Republican claims of “waste, fraud, and abuse” are overstated.

“I challenge some of them to try to go through an eligibility process,” Myers said. “The way they’re going about it is making it for more hoops to jump through, which ultimately will cause people to fall off.”

The unwinding showed that state systems can struggle to respond quickly to changes in Medicaid, leading to preventable erroneous disenrollments. Individuals were often in the dark about their applications and struggled to reach state offices for answers. Tribal leaders and health experts are raising concerns that those issues will continue and worsen as states implement the requirements of the new law.

Georgia, the only state with an active Medicaid work requirement program, has shown that the changes can be difficult for individuals to navigate and costly for a state to implement. More than 100,000 people have applied for Georgia’s Pathways program, but only about 8,600 were enrolled as of the end of July.

Alker, of Georgetown, said Congress took the wrong lesson from the unwinding in adding more restrictions and red tape.

“It will make unwinding pale in comparison in terms of the number of folks that are going to lose coverage,” Alker said.

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

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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But amid the stark beauty in one of the state’s most productive agricultural regions, there was a sense of unease among the community’s leaders as Congress debated a budget bill that could radically reshape Medicaid, the government health program for low-income people.

“I’m trying to be worried and optimistic,” said Konnie Martin, CEO of San Luis Valley Health in Alamosa, Colorado, the hub for health care services for 50,000 people in six rural counties.

Martin said Medicaid is vital to rural health care.

“I think in Colorado right now, nearly 70% of rural hospitals are operating in a negative margin,” in the red, Martin said.

The health system’s annual budget is $140 million, and Medicaid revenue makes up nearly a third of that, according to Shane Mortensen, chief financial officer for SLV Health.

The operating margin is razor-thin, so federal cuts to Medicaid could force difficult cuts at SLV. “It will be devastating to us,” Mortensen said.

The region is one of the state’s poorest. In Alamosa County, 2 in 5 residents are enrolled in Health First Colorado, the state’s Medicaid program.

It’s a lifeline, especially for people who wouldn’t otherwise have easy access to health care. That includes low-income seniors who need supplemental coverage in addition to Medicare, and people of all ages with disabilities.

Envisioning a future with deep Medicaid cutbacks leaves many patients on edge.

“I looked into our insurance and, oh my goodness, it’s just going to take half my check to pay insurance,” said Julianna Mascarenas, a mother of six. She said Medicaid has helped her cover her family for years. Mascarenas works as a counselor treating people with substance use disorders. Her ex-husband farms — potatoes and cattle — for employers that don’t offer health insurance.

Across the state, Medicaid covers 1 in 5 Coloradans, more than a million people.

That includes children in foster care.

“We’ve had 13 kids in and out of our home, six of which have been born here at this hospital with drugs in their system,” foster parent Chance Padilla said, referring to SLV’s flagship hospital in Alamosa.

“Medicaid has played a huge part in just being able to give them the normal life that they deserve,” he said. “These kids require a lot of medical intervention.”

Chris Padilla, Chance’s husband, said: “At one point, we had a preteen that needed to be seen three times a week by a mental health professional. There’s no way that we could have done that without Medicaid.”

Staff and administrators at SLV Health wonder whether federal cuts will make it hard for the system to keep its cancer center running.

“It could be pretty dramatically affected,” said Carmelo Hernandez, SLV’s chief medical officer.

The hospital in Alamosa has its own labor and delivery unit, the type of service that other rural hospitals across the U.S. have struggled to keep open. About 85% of the hospital’s labor and delivery patients are covered by Medicaid, Hernandez said.

“If we don’t have obstetric services here, then where are they going to go?” said Hernandez, whose specialty is obstetrics and gynecology. “They’re going to travel an hour and 20 minutes north to Salida to get health care. Or they can travel to Pueblo, another two-hour drive over a mountain pass.”

Tiffany Martinez, 34, was recently forced to think about that possibility after giving birth to her fourth child.

Her pregnancy was high-risk, requiring twice-a-week ultrasounds and stress tests at the hospital. She’s enrolled in Medicaid.

“Everything down here is low-pay,” Martinez said. “It’s not like we have money to just be able to pay for the doctor. It’s not like we have money to travel often to go to the doctor. So it’s definitely beneficial.”

Providing Health Care — And Jobs

With 750 workers, the health system is the valley’s largest employer. Clint Sowards, a primary care physician, said having less Medicaid funds will make it harder to attract the next generation of doctors, nurses, and other health care workers.

Certain medical specialties might no longer be available, Sowards said. “People will have to leave. They will have to leave the San Luis Valley.”

Kristina Steinberg is a family medicine physician with Valley-Wide Health Systems, a network of small clinics serving thousands in the region. She said Medicaid covers most nursing home residents in the area. “If seniors lost access to Medicaid for long-term care, we would lose some nursing homes,” she said. “They would consolidate.”

Audrey Reich Loy, a licensed social worker and SLV Health’s director of programs, said the system utilizes Medicaid “as sort of the backbone of our infrastructure.”

“It doesn’t just support those that are recipients of Medicaid,” she said. “But as a result of what it brings to our community, it allows us to ensure that we have sort of a safety net of services that we can then expand upon and provide for the entire community.”

Seeking More Efficiency

Republicans in Congress who pushed for the big spending and tax law, which estimates suggest will result in large cuts to Medicaid, say they want to save money and make the government more efficient.

Many in the Alamosa County region voted for Donald Trump. “He’s potentially affecting his voter base pretty dramatically,” Hernandez said.

He said Medicaid cuts could give President Trump’s supporters second thoughts, but he noted that politics is a sensitive topic that he mostly doesn’t discuss with patients.

Sowards said he understands that some people believe the Medicaid system is ailing and costly. But he said he has grave doubts about the proposed cure.

“Losing Medicaid would have drastic repercussions that we can’t foresee,” Sowards said.

Cuts Would Create Ripple Effect

SLV Health’s regional economic impact is more than $100 million a year, with Medicaid accounting for a major part of that, Martin said.

Any Medicaid cuts would hit the health system hard, but they would also affect small businesses and their employees. The region is feeling economic stress from other changes, like recent cuts the Trump administration made to the federal workforce.

The San Luis Valley is home to the Monte Vista National Wildlife Refuge, Great Sand Dunes National Park, and other federally managed lands.

Joe Martinez, president of San Luis Valley Federal Bank, said that recently laid-off federal workers are already coming to banks saying: “‘Can I find a way to get my next two months’ mortgage payments forgiven? Or can we do an extension?’ Or: ‘I lost my job. What can we do to make sure that I don’t lose my vehicle?’”

Ty Coleman, Alamosa’s mayor, traveled to Washington, D.C., in April to talk to Colorado’s congressional delegation. He said his message about Medicaid cuts was straightforward: “It can have a devastating economic impact.” Coleman put together a long list of possible troubles: More chronic disease and higher mortality rates. Longer wait times for care. Medical debt and financial strain on families.

“It’s not just our rural community but the communities, rural communities, across Colorado as well, and the United States,” Coleman said. “And I don’t think people are getting it.”

This article is from a partnership that includes CPR News, NPR and KFF Health News.

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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Some states have already tried doing this, but Georgia is the only state that has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.

When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn’t opposed to work requirements — in principle.

But when she left her job at a faith-based nonprofit to start her own project, the Be Well Black Girl Initiative, she needed health coverage. She soon came face-to-face with how daunting it can be to prove you are meeting the state’s work requirements.

“I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I’m like, I know the process,” Corporal said. “I’ve been in human services.”

Corporal has been a social worker for more than two decades in Georgia and was familiar with the state’s social service programs. For years, it had been her job to help others access benefit programs.

But her challenges with paperwork and the process had only begun.

Health advocates point to Georgia’s system as a sign that the new law will lead to excessive red tape, improper denials, and lost health coverage.

Beginning in 2027, the law will require adults on Medicaid who are under 65 to report how they engaged in at least 80 hours per month of work, education, or volunteer activities. Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.

Most states will have to set up verification systems similar to Georgia’s, which can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data. More than $50 million of that was spent on building and operating the eligibility reporting system. Right now, just under 7,500 people are enrolled in Georgia.

For Corporal, 48, forgoing coverage wasn’t an option. She had been diagnosed with pre-diabetes and had other medical concerns.

“I have breast cancer in my family history,” she said. “So it was like, I gotta get my mammograms.”

On paper, it looked as if she qualified for Georgia’s program, called Georgia Pathways to Coverage.

It offers Medicaid to adults — who otherwise wouldn’t qualify for traditional Medicaid in Georgia — with incomes up to the federal poverty level ($15,650 per year for an individual, or $26,650 per year for a family of three), as long as they can show that for at least 80 hours a month they’re working, attending school, training for a job, or volunteering.

Corporal was eager to apply. She was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.

She gathered up the various documents and forms needed to verify her duties and volunteer hours, then submitted them through Georgia’s online portal.

“And we were denied. I was like, this makes no sense,” said Corporal, who has a master’s degree in social work. “I did everything right.”

In the end, it took eight months fighting to prove that she and her son, a full-time college student in Georgia, qualified for Medicaid. She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.

Corporal recently pulled up one of the denial notices on her cellphone to read aloud: “Your case was denied because you didn’t submit the correct documents. And you didn’t meet the qualifying activity requirement,” she read from the email.

When she tried to call the state Medicaid agency for answers, it was difficult reaching anyone who could explain what was wrong with her application paperwork, she said.

“Or, they’ll say they called you, and we look at our call log. Nobody called me,” she said. “And the letter will say, you missed your appointment, and it’ll come on the same day” as it was scheduled.

Corporal’s Pathways to Coverage application was finally approved in March after she spoke about her experience at a public hearing covered by Atlanta news outlets.

When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia’s Department of Human Services, emailed this statement: “Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case.”

Brown added that Georgia is implementing tech fixes to streamline the uploading and processing of participants’ documents. They include “rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents.”

Now that Corporal has coverage, she is having to recertify her volunteer hours every month using the same glitchy reporting system. It’s stressful, she said.

“It’s still a nightmare, even once I got through the red tape and got approved,” Corporal said. “Now maintaining it is bringing another level of anxiety.”

But she wonders how anyone without her professional background manages to get into the program at all.

“I think the system has to be simplified,” she said.

Because Georgia set up its work requirement before the recently passed law, it needed permission from the federal government through a special waiver.

It is now seeking an extension of that waiver to continue the Pathways program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to reverify their hours from once a month to once per year.

But for now, Corporal’s experience remains typical. And many health advocates fear it will be replicated under Trump’s budget law with its new national Medicaid work mandate. 

“In Georgia, we have seen that people just can’t get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn’t file their paperwork or there’s been some other glitch,” said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.

Another state, Arkansas, tried work requirements in 2018.

But it didn’t go any better there, said Joan Alker, who leads the Center for Children and Families at Georgetown University.

“A lot of the problems were similar to Georgia,” she said, “in terms of the website closed at night, people couldn’t get a hold of people.”

Some Republicans who backed the spending and tax legislation said the idea behind the national Medicaid work mandate was to ensure that as many people as possible who can work, do work. And to eliminate what the Trump administration deems waste, fraud, and abuse. 

“What we’re doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it,” U.S. House Speaker Mike Johnson said during a June appearance on “The Megyn Kelly Show.” “You’re talking about the elderly, disabled, you know, young single pregnant moms who are down on their luck, right? But it’s not being used for those purposes because it’s been expanded under the last two Democrat presidents and to cover everybody. So, you’ve got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we’re doing is restoring work requirements to Medicaid. OK, this is common sense.”

National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients ages 19-64 already have jobs. The remainder includes students, or those who are too sick or disabled to work.

“Work requirements don’t work, except to cut people off of health insurance,” she said.

The logistical steps required to report one’s activities assume that a recipient has reliable internet or transportation to travel to an agency — things that low-income Georgians may not have.

The paperwork requirements to gain coverage are time-consuming, said one Medicaid recipient, Paul Mikell.

Mikell is a licensed truck driver but does not have coverage through that job. He’s also an electrician who currently does property maintenance in exchange for free housing.

Mikell has had Medicaid through Pathways for nearly two years and has had problems navigating the Pathways web portal. 

“And I know it wasn’t my device because I would go to the library and use the computer, I would try different devices, and I’ve had the same issues,” he said. “Regardless of the device, it’s something with the website.”

Another time, he said, his attempt to recertify his work hours was delayed because of paperwork issues.

“They said I was ineligible for everything because of a typo in the system or something, I don’t know what it was. I eventually was able to speak to someone and she fixed it,” he said.

This article is from a partnership with WABE and NPR.

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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“For the first time, I’m having parents of newborns ask me if their baby will still be able to get vaccines,” Falusi said.

Throughout the country, pediatricians say anxious parents are concerned about access to routine childhood immunizations, especially those with children on Medicaid, the government insurance program for low-income families and people with disabilities. Medicaid covers 4 in 10 children in the U.S.

“It really became an issue when RFK Jr. stepped into the role of HHS secretary,” said Deborah Greenhouse, a pediatrician in South Carolina.

The concern accelerated after the shake-up of a key Centers for Disease Control and Prevention vaccine advisory body in June, raising fears that millions of American families could soon have to pay out-of-pocket for shots now covered by their health insurance.

Health and Human Services Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist, removed all 17 members of the CDC’s Advisory Committee on Immunization Practices, the panel responsible for recommending which shots are included in the nation’s adult and childhood immunization schedules.

Kennedy replaced the panelists with new members aligned with his views, prompting alarm among medical professionals and public health experts.

“People should be worried about what’s going to happen to the availability of vaccines for children,” said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a national health information nonprofit that includes KFF Health News.

Under the Affordable Care Act, health insurers are required to cover all ACIP-recommended vaccines. States and other jurisdictions use the childhood vaccine schedule to set immunization requirements for schoolchildren. ACIP’s recommendations also determine which vaccines get covered by the Vaccines for Children Program, a CDC-funded initiative that provides free immunizations to low-income and uninsured children. Half of children in the U.S. are eligible for the VFC program.

If the new ACIP members withdraw support for a particular vaccine and the CDC director agrees, Tolbert said, the consequences would be immediate. “It would automatically affect what is covered and therefore which vaccines are available to children on Medicaid,” she said.

Health insurance companies have not yet said how they would alter coverage, but Tolbert said such a move would open the door for private insurers to refuse to cover the vaccine.

Pediatricians worry about a future where parents might have to choose — pay hundreds of dollars out-of-pocket for shots or leave their kids unprotected.

The health insurance industry group AHIP said that health plans “continue to follow federal requirements related to coverage of ACIP-recommended vaccines and will continue to support broad access to critical preventive services, including immunizations.”

Pediatricians say news about President Donald Trump’s new budget law, which is expected to reduce Medicaid spending by about $1 trillion over the next decade, also prompted questions from parents.

While parents may be worried about losing their Medicaid, the law doesn’t mention vaccines or change eligibility or benefits for children’s Medicaid, Tolbert said. But less federal funding means states will have to make decisions about who is covered and which services are offered.

To raise the revenue needed to pay for Medicaid, states could raise taxes; move money earmarked for other spending, such as education or corrections; or, more likely, reduce Medicaid spending.

“And they may do that by cutting eligibility for optional populations or by cutting services that are optional, or by reducing payments to providers in the form of provider rates,” Tolbert said. “It’s unclear how this will play out, and it will likely look different across all states.”

In May, Kennedy announced in a post on X that the CDC is no longer recommending the covid-19 vaccine for healthy children and pregnant women. The move prompted a lawsuit by the American Academy of Pediatrics and other physician groups that seeks to freeze Kennedy’s directive.

In June, the new ACIP members appointed by Kennedy voted to recommend that adults and children no longer receive flu vaccines with thimerosal, a preservative rarely used in some flu vaccines. Anti-vaccine activists, including Kennedy, have rallied against thimerosal for decades, alleging links to autism despite no evidence of any association.

“There is no cause for concern,” Department of Health and Human Services spokesperson Emily Hilliard said in a statement. “As Secretary Kennedy has stated, no one will be denied access to a licensed vaccine if they choose to receive one.”

“When the ACIP committee met last month, they reaffirmed that flu vaccines will remain accessible and covered, and they emphasized safety by ensuring these vaccines are mercury-free,” Hilliard wrote. “The Vaccines for Children (VFC) program continues to provide COVID-19 vaccines at no cost for eligible children when the parent, provider, and patient decide vaccination is appropriate. Medicaid will continue to reimburse the administration fee.”

But the possibility that a vaccine could be restricted or no longer covered by insurance is already changing how parents approach immunization. In Falusi’s practice, parents are scheduling appointments to coincide precisely with their child’s eligibility, sometimes making appointments the same week as their birthdays.

Melissa Mason, a pediatrician in Albuquerque, New Mexico, has evaluated some patients who contracted measles during the multistate outbreak that started in neighboring Texas.

Last year, overall kindergarten vaccination rates fell in the U.S. At the same time, the number of children with a school vaccination exemption continued to rise.

Pertussis, or whooping cough — another disease that can be deadly to young children — is spreading. As of July 5, more than 15,100 cases had been identified in U.S. residents this year, according to the CDC.

Mason said pertussis is especially dangerous to babies too young to receive the vaccine.

For now, pediatricians are trying to maintain a sense of urgency without inciting panic.

In Columbia, South Carolina, Greenhouse used to offer families a flexible age range for routine vaccinations.

“I’m not saying that anymore,” the pediatrician said.

She now urges parents to get their children vaccinated as soon as they are eligible.

She described anxious parents asking whether the HPV vaccine, which helps prevent cervical cancer, can be administered to children younger than the recommended age of 9.

“I actually had two parents today ask if their 7- or 8-year-olds could get the HPV shot,” Greenhouse said. “I had to tell them it’s not allowed.”

With the vaccine requiring multiple doses months apart, Greenhouse fears time may run out for families to get the series covered by insurance. If they have to pay out-of-pocket, she’s afraid some families may choose not to get the second dose. A second dose could cost about $300 if no longer covered by insurance.

“I cannot be 100% sure what the future looks like for some of these vaccines,” Greenhouse said. “I can tell you it’s a very scary place to be.”

Kennedy’s newly appointed vaccine advisory committee is expected to hold its next public meeting as soon as August.

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

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KFF Health News’ Renuka Rayasam breaks down what you need to know about Medicaid work requirements.

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.

USE OUR CONTENT

This story can be republished for free (details).