SUITLAND, Md. — At a SuperSuds Laundromat just south of Washington, D.C., a steady stream of customers loaded clothes into washers and dryers on a recent Sunday morning, passing the time on their phones or watching television.

Amid the low hum of spinning clothes, Adrienne Jones made the rounds in a bright yellow sweatshirt, asking customers about their health needs. “Do you have health coverage?” Jones, an outreach manager for Fabric Health, asked Brendan Glover, 25, who was doing laundry with his toddler in tow.

Glover works in law enforcement, but he lost his coverage in 2024 when a job ended. “I am young, so I don’t think about it, but I know I will need it,” he said.

Jones collected his contact information, gave him a gift card for a future laundromat visit, and promised to help him find affordable coverage.

State Medicaid and Affordable Care Act coverage programs have long struggled to connect with lower-income Americans to help them access health care. They send letters and emails, place phone calls, and post on social media platforms such as Facebook and X.

Some of these state programs are trying an alternative approach: meeting people at the laundromat — where they regularly go and usually have time to chat.

Fabric Health, a Washington, D.C.-based startup, sends outreach workers into laundromats in Maryland, Pennsylvania, New Jersey, and — as of January — the District of Columbia, to help people get and use health coverage, including by helping schedule checkups or maternity care. The workers, many of whom are bilingual, visit the laundromats also to establish relationships, build trust, and connect people with government assistance.

Medicaid health plans including those run by CareFirst BlueCross BlueShield in Maryland, UPMC in Pittsburgh, and Jefferson Health in Philadelphia pay Fabric Health to connect with their enrollees. The company was paid by the Maryland Managed Care Organization Association, the state’s Medicaid health plan trade group, to help people recertify their Medicaid eligibility after covid pandemic-era coverage protections expired.

Since 2023, the company has connected with more than 20,000 people in Maryland and Pennsylvania alone, collecting contact information and data on their health and social needs, said Allister Chang, a co-founder and the chief operating officer. Chang also serves on the D.C. State Board of Education as Ward 2’s elected representative.

Fabric Health would not disclose its fees to KFF Health News. The company is structured as a public benefit corporation, meaning it is a for-profit business created to provide a social benefit and is not required to prioritize seeking profits for shareholders.

Pennie, Pennsylvania’s ACA marketplace, which opened in 2020, pays Fabric Health to talk to people in the Philadelphia and Pittsburgh areas about coverage options and enroll them.

A survey last year found that two-thirds of uninsured people in the state have never heard of Pennie, said Devon Trolley, Pennie’s executive director.

“Fabric’s approach is very novel and creative,” she said. “They go to where people are sitting with time on their hands and develop grassroots relationships and get the word out about Pennie.”

For enrollees, the laundromat chats can be easier and quicker than connecting with their health plans’ customer service. For the health plans, they can increase state performance payments, which are tied to enrollee satisfaction and effectiveness at getting them services such as cancer screenings.

“Our pitch is: People spend two hours a week waiting around in laundromats and that idle time can be incredibly productive,” said Courtney Bragg, a co-founder and the CEO of Fabric Health.

CareFirst began working with the company last year to help people in Maryland renew coverage, schedule checkups, and sign up for other benefits including energy assistance and food stamps.

Sheila Yahyazadeh, chief external operations officer for the CareFirst plan, said the initiative shows the importance of human interaction. “There is a misconception that technology will solve all, but a human face is absolutely fundamental to make this program successful because at the end of the day people want to talk to someone and feel seen and cared for,” she said.

On a previous visit to SuperSuds, Jones, the Fabric Health outreach worker, met Patti Hayes, 59, of Hyattsville, Maryland, who is enrolled in the Medicaid health plan operated by CareFirst but had not seen a primary care physician in over a year. She said she preferred to see a Black physician.

After they met at the laundromat, Jones helped her find a new doctor and schedule an appointment. She also helped her find a therapist in her plan’s network.

“This is helpful because it’s more of a personal touch,” Hayes said.

Fabric Health also texts people to stay in touch and tell them when the outreach workers will be back at their laundromat so they can meet again in person.

Paola Flores, 38, of Clinton, Maryland, told a Fabric Health worker she needed help switching Medicaid plans so she could get better care for her autistic child. Communicating with her in Spanish, the worker said she would help her, including by making an appointment with a pediatrician.

“Good help is hard to find,” Flores said.

Ryan Moran, Maryland’s Medicaid director, said Fabric Health helped keep people enrolled during the Medicaid “unwinding,” when everyone on the program had to get renewed after the expiration of pandemic-era coverage protections that lasted three years.

Outreach workers there focused on laundromats in towns that had high rates of people being disenrolled for paperwork reasons.

“There is no question about the value of human-to-human interaction and the ability to be on the ground where people are, that removes barriers and gets people to engage with us,” Moran said.

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En medio del suave zumbido de la ropa centrifugándose, Adrienne Jones inició su ronda vistiendo una remera amarilla, preguntando a los clientes sobre sus necesidades de salud. “¿Tiene cobertura médica?”, preguntaba Jones, gerenta de extensión de Fabric Health, a Brendan Glover, de 25 años, que estaba lavando la ropa con su niño pequeño a cuestas.

Glover trabaja en la policía, pero perdió su cobertura en 2024 cuando terminó un trabajo. “Soy joven, así que no pienso en eso, pero sé que lo necesitaré”, dijo.

Jones anotó su número, le dio una tarjeta de regalo para una futura visita a la lavandería y prometió ayudarlo a encontrar una cobertura asequible. Los programas estatales de cobertura de Medicaid y la Ley de Cuidado de Salud a Bajo Precio (ACA) han tenido dificultades durante mucho tiempo para conectarse con los estadounidenses de bajos ingresos para ayudarlos a acceder a la atención médica.

Envían cartas y correos electrónicos, hacen llamadas telefónicas y publican en plataformas de redes sociales como Facebook y X.

Ahora, algunos de estos programas estatales están probando un enfoque alternativo: reunirse con las personas en las lavanderías o “laundromats”, adonde van regularmente y en donde suelen tener tiempo para charlar.

Fabric Health, una empresa emergente con sede en Washington, D.C., envía trabajadores comunitarios a lavanderías en Maryland, Pennsylvania, Nueva Jersey y, desde enero, al Distrito de Columbia, para ayudar a las personas a obtener y utilizar la cobertura médica, incluso ayudando a programar controles o atención de maternidad.

Los trabajadores, muchos de los cuales son bilingües, también visitan las lavanderías para establecer relaciones, generar confianza y conectar a las personas con la asistencia del gobierno.

Los planes de salud de Medicaid, incluidos los administrados por CareFirst BlueCross BlueShield en Maryland, UPMC en Pittsburgh y Jefferson Health en Philadelphia, pagan a Fabric Health para que se conecte con sus afiliados.

La Asociación de Organizaciones de Atención Médica Administrada de Maryland, el grupo comercial de planes de salud de Medicaid del estado, le paga a Fabric health para ayudar a las personas a recertificar su elegibilidad para Medicaid después que expiraran las protecciones de cobertura promulgadas durante la pandemia de covid.

Desde 2023, la empresa se ha conectado con más de 20.000 personas solo en Maryland y Pennsylvania, recopilando información de contacto y datos sobre sus necesidades sociales y de salud, dijo Allister Chang, cofundador y director de operaciones. Chang también forma parte de la Junta de Educación de D.C. como representante electo del Distrito 2.

Fabric Health no reveló a KFF Health News lo que cobra. La empresa está estructurada como una corporación de beneficio público, lo que significa que es una empresa con fines de lucro creada para brindar un beneficio social y no está obligada a priorizar la búsqueda de ganancias para los accionistas.

Pennie, el mercado de ACA de Pennsylvania, que abrió en 2020, contrató a Fabric Health para que hable con personas en las áreas de Philadelphia y Pittsburgh sobre las opciones de cobertura, y las inscriba. Una encuesta realizada el año pasado reveló que dos tercios de las personas sin seguro en el estado nunca habían oído hablar de Pennie, dijo Devon Trolley, directora ejecutiva del mercado de seguros.

“El enfoque de Fabric es muy novedoso y creativo”, dijo. “Van a donde están las personas que tienen algo de tiempo, desarrollan relaciones de base y hacen correr la voz sobre Pennie”.

Para los afiliados, las charlas en las lavanderías pueden ser más fáciles y rápidas que conectarse con el servicio de atención al cliente de sus planes de salud. Para los planes, pueden aumentar los pagos de desempeño del estado, que están vinculados a la satisfacción de los afiliados, y la eficacia a la hora de acercar servicios como exámenes de detección de cáncer a sus clientes.

“Nuestro argumento es: la gente pasa dos horas a la semana esperando en las lavanderías y ese tiempo de inactividad puede ser increíblemente productivo”, dijo Courtney Bragg, cofundadora y directora ejecutiva de Fabric Health.

CareFirst comenzó a trabajar con la empresa el año pasado para ayudar a las personas en Maryland a renovar la cobertura, programar controles y registrarse para otros beneficios, como asistencia con los pagos de la luz y cupones de alimentos.

Sheila Yahyazadeh, directora de operaciones externas del plan CareFirst, dijo que la iniciativa muestra la importancia de la interacción humana. “Existe la idea errónea de que la tecnología resolverá todo, pero un rostro humano es absolutamente fundamental para que este programa sea exitoso porque, al final del día, la gente quiere hablar con alguien y sentirse que se la escucha y atiende”, dijo.

En una visita anterior a SuperSuds, Jones, la trabajadora social de Fabric Health, conoció a Patti Hayes, de 59 años, de Hyattsville, Maryland, que está inscrita en el plan de salud de Medicaid operado por CareFirst, pero que no había visto a un médico de atención primaria en más de un año. Dijo que prefería ver a un médico de raza negra.

Después de que se conocieron en la lavandería, Jones la ayudó a encontrar un nuevo médico y programar una cita. También la ayudó a encontrar un terapeuta en la red de su plan.

“Esto es útil porque es más un toque personal”, dijo Hayes.

Fabric Health también envía mensajes de texto a las personas para que se mantengan en contacto y les digan cuándo volverán a la lavandería para encontrarse de nuevo en persona

Paola Flores, de 38 años, de Clinton, Maryland, le dijo a una trabajadora de Fabric Health que necesitaba ayuda para cambiar de plan de Medicaid para poder recibir una mejor atención para su hijo autista. Al comunicarse con ella en español, la trabajadora le dijo que la ayudaría, incluso concertando una cita con un pediatra.

“Es difícil encontrar buena ayuda”, dijo Flores.

Ryan Moran, director del Medicaid de Maryland, dijo que Fabric Health ayudó a mantener a las personas inscritas durante el proceso de desafiliación de Medicaid, cuando todos los que estaban en el programa tuvieron que renovar su inscripción después que expiraran las protecciones de la pandemia, que duraron tres años.

Los trabajadores comunitarios se centraron en las lavanderías de las ciudades que tenían altas tasas de personas que eran dadas de baja por razones de papeleo.

“No hay duda sobre el valor de la interacción entre humanos y la capacidad de estar en donde están las personas, lo que elimina barreras y hace que las personas se relacionen con nosotros”, dijo Moran.

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Robert F. Kennedy Jr., the anti-vaccine activist President Donald Trump nominated to lead the nation’s top health agency, did little to win over his critics at two Senate confirmation hearings this week. 

Democrats argued he’s not qualified for the job. And by botching answers to basic questions about health policy, Kennedy supplied some evidence. 

It’s uncertain whether Kennedy will get enough votes in the Senate to be confirmed as the secretary of Health and Human Services. Every Democrat and independent is expected to vote against him, meaning he can afford to lose only three GOP votes. 

Sen. Bill Cassidy (R-La.), a physician who sits on the Finance Committee and chairs the Senate Health, Education, Labor and Pensions Committee, known as HELP, is seen as the crucial vote. 

He made a point of highlighting the successes of vaccination and questioned whether Kennedy, as HHS secretary, would champion the lifesaving medicines he has spent years attacking. 

Kennedy, 71, appeared before Finance on Wednesday, backed by dozens of supporters wearing “Make America Healthy Again” shirts and hats. Advocates also cheered him on at Thursday’s hearing of Cassidy’s HELP Committee. 

Over 3½ hours at Finance, Kennedy confused Medicare and Medicaid, the two largest government health insurance programs, which together cover more than a third of Americans but operate very differently. He also mistakenly said that Medicaid is funded solely by the federal government. In fact, nearly a third of costs are paid by the states. 

Kennedy, as recently as last year a supporter of abortion rights, said he agreed with Trump that “every abortion is a tragedy.” 

Kennedy also said he didn’t think HHS had “a law enforcement branch.” The agency can issue fines and penalties against health providers who break the law. 

He didn’t do much better Thursday at HELP, where he couldn’t correctly answer a question from Sen. Maggie Hassan (D-N.H.) about how Medicare works. 

Kennedy got kid-glove treatment from most Republicans on both Senate panels, with several seeking (and receiving) assurances that he would prioritize rural health care or leave alone federal policies that affect farmworkers. 

But Cassidy was an exception. At the Finance hearing, he unsuccessfully pressed Kennedy to say how he would improve care for people enrolled in Medicare and Medicaid, often called dual eligibles, for whom the government has struggled to coordinate care and control costs. 

Opening the HELP hearing, Cassidy made clear to Kennedy that he supports vaccines and that he expects the U.S. health secretary to support them as well, yet he couldn’t persuade the nominee to disavow debunked conspiracies that childhood vaccines cause autism. 

The Finance Committee plans a vote next week; HELP does not vote on HHS nominees. 

At the close of Thursday’s hearing, Cassidy said he would take the weekend to consider his vote. “Will you continue what you have been, or will you overturn a new leaf at age 70?” Cassidy said. 

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By midmorning Tuesday, state officials around the country reported they had been shut out of a critical online portal that allows states to access federal Medicaid funding.

Sen. Ron Wyden of Oregon, the top Democrat on the Senate Finance Committee, said on the social media site Bluesky that the portals were down in all 50 states following the Trump administration’s order.

“This is a blatant attempt to rip away health care from millions of Americans overnight and will get people killed,” he wrote.

Around midday Tuesday, as state health officials pressed the federal government for clarity, the White House Office of Management and Budget — which issued the Monday memo — put out new guidance clarifying that “mandatory programs like Medicaid” were not included in the freeze.

Karoline Leavitt, the White House press secretary, declined to confirm that Medicaid was exempt when pressed by reporters during an early afternoon briefing.

But she later said in a post on the social platform X that “no payments have been affected” by what she described as a “portal outage.”

The possibility that federal Medicaid funding would be shut off overnight spooked advocates already on edge about the program’s future. President Donald Trump vowed on the campaign trail not to seek cuts for Medicare or Social Security, the nation’s major entitlement programs serving mostly retired people. But he did not make the same promise about Medicaid, which pays for health care for primarily low-income and disabled people — approximately 1 in 5 Americans.

On Wednesday, after a federal judge temporarily blocked the administration from proceeding with the freeze, OMB withdrew its memo altogether. But Leavitt said in another post on X that a series of orders Trump has issued on federal funding “remain in full force and effect, and will be rigorously implemented.”

Kate McEvoy, executive director of the National Association of Medicaid Directors, said Wednesday morning that access to the Medicaid portals had been restored.

Separate from the freeze, congressional Republicans are discussing cutting the nearly $900 billion program, arguing costs have ballooned with enrollment, notably including the program’s expansion to cover more low-income adults. Lawmakers are also eyeing ways to save money for Trump’s other legislative priorities — in particular, extending the tax cuts from his first term that expire at the end of this year.

The federal government pays most costs for Medicaid, which is operated by states. Medicaid pays for most long-term care for Americans and for about 40% of all U.S. births, and together with the related Children’s Health Insurance Program covers about 38 million children.

Federal funding for Medicaid does not go directly to individual enrollees but to the states, which then distribute it to providers, health plans, and other entities that serve Medicaid enrollees.

State officials can access that funding through internet portals.

Joan Alker, who is executive director of the Center for Children and Families at the Georgetown McCourt School of Public Policy, said on X Tuesday that the portal lockout is “a major crisis.”

She pointed out that many states access their federal funding at the end of the month — “i.e. this week,” she wrote.

The original freeze order came in the form of a vaguely worded two-page memo from OMB to all federal agencies directing them to “temporarily pause all activities related to obligation or disbursement of all Federal financial assistance.”

“This temporary pause will provide the Administration time to review agency programs and determine the best uses of the funding for those programs consistent with the law and the President’s priorities,” the memo said. The only programs explicitly noted as exceptions were Medicare and Social Security, which left it unclear how states would continue to pay doctors, hospitals, nursing homes, and private health plans to manage Medicaid.

Around the nation, health officials scrambled to make sense of the order, which was scheduled to take effect at 5 p.m. ET Tuesday.

Even as OMB clarified that Medicaid was not included, the immediate impacts to other critical health programs were becoming clear, especially for community health centers and medical research centers.

Democrats in Congress expressed outrage at the Trump administration for pausing federal funding not only to Medicaid but also to numerous other programs, including the Supplemental Nutrition Assistance Program, also known as food stamps, the WIC nutrition program for pregnant and postpartum women and infants, and school meal programs for low-income students.

“The Trump Administration’s action last night to suspend all federal grants and loans will have a devastating impact on the health and well-being of millions of children, seniors on fixed incomes, and the most vulnerable people in our country,” Sen. Bernie Sanders (I-Vt.) said in a statement Tuesday. “It is a dangerous move towards authoritarianism and it is blatantly unconstitutional.”

The National Association of Medicaid Directors and the major nursing home associations were among those seeking clarification from the White House on Tuesday about the order’s impact on Medicaid funding.

Numerous state officials and groups said they were considering or had already filed litigation challenging the order. One lawsuit was filed Tuesday against OMB in federal court in Washington, D.C., by the National Council of Nonprofits and the American Public Health Association, seeking a temporary restraining order to “maintain the status quo until the Court has an opportunity to more fully consider the illegality of OMB’s actions.”

Attorneys general in California, New York, and four other states announced Tuesday afternoon a joint lawsuit against the Trump administration over the order, which they said had already frozen systems for Medicaid, Head Start, and even child support enforcement across multiple states.

“There is no question this policy is reckless, dangerous, illegal, and unconstitutional,” said New York Attorney General Letitia James. She added that she and other Democratic attorneys general would seek a temporary restraining order to halt the OMB policy from going into effect.

Leavitt defended the freeze during her White House briefing — the first of the new administration — saying it was critical to ensuring that federal funding was being used appropriately.

“This is a very responsible measure,” she said.

Reporting contributed by Bram Sable-Smith, Jordan Rau, Renuka Rayasam, Brett Kelman, and Christine Mai-Duc.

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The introduction of the continuous glucose monitor (CGM) made that unnecessary. The small device, typically attached to the arm, has a sensor under the skin that sends readings to an app on a phone or other wireless device. The app shows blood sugar levels at a glance and sounds an alarm when they move out of a normal range.

Blood sugar that’s too high could call for a dose of insulin — delivered by injection or the touch of a button on an insulin pump — to stave off potentially life-threatening complications including loss of consciousness, while a sip of juice could remedy blood sugar that’s too low, preventing problems such as dizziness and seizures.

Schools around the country say teachers listen for CGM alarms from students’ phones in the classroom. Yet many parents say that there’s no guarantee a teacher will hear an alarm in a busy classroom and that it falls to them to ensure their child is safe when out of a teacher’s earshot by monitoring the app themselves, though they may not be able to quickly contact their child.

Parents say school nurses or administrative staff should remotely monitor CGM apps, making sure someone is paying attention even when a student is outside the classroom — such as at recess, in a noisy lunchroom, or on a field trip.

But many schools have resisted, citing staff shortages and concerns about internet reliability and technical problems with the devices. About one-third of schools do not have a full-time nurse, according to a 2021 survey by the National Association of School Nurses, though other staffers can be trained to monitor CGMs.

Caring for children with Type 1 diabetes is nothing new for schools. Before CGMs, there was no alarm that signaled a problem; instead, it was caught with a time-consuming finger-prick test, or when the problem had progressed and the child showed symptoms of complications.

With the proliferation of insulin pumps, many kids can respond to problems themselves, reducing the need for schools to provide injections as well.

Parents say they are not asking schools to continuously monitor their child’s readings, but rather to ensure that an adult at the school checks that the child responds appropriately.

“People at the [school] district don’t understand the illness, and they don’t understand the urgency,” said Julie Calidonio of Lutz, Florida.

Calidonio’s son Luke, 12, uses a CGM but has received little support from his school, she said. Relying on school staff to hear the alarms led to instances in which no one was nearby to intervene if his blood sugar dropped to critical levels.

“Why have this technology that is meant to prevent harms, and we are not acting on it,” she said.

Corey Dierdorff, a spokesperson for the Pasco County School District, where Luke attends school, said in a statement to KFF Health News that staff members react when they hear a student’s CGM sound an alert. Asked why the district won’t agree to have staff remotely monitor the alarms, he noted concerns about internet reliability.

In September, Calidonio filed a complaint with the U.S. Justice Department against the district, saying its inability to monitor the devices violates the Americans with Disabilities Act, which requires schools to make accommodations for students with diabetes, among other conditions. She is still awaiting a decision.

The complaint comes about four years after the Connecticut U.S. attorney’s office determined that having school staffers monitor a student’s CGM was a “reasonable accommodation” under the ADA. That determination was made after four students filed complaints against four Connecticut school districts.

“We fought this fight and won this fight,” said Jonathan Chappell, one of two attorneys who filed the complaints in Connecticut. But the decision has yet to affect students outside the state, he said.

Chappell and Bonnie Roswig, an attorney and director of the nonprofit Center for Children’s Advocacy Disability Rights Project, both said they have heard from parents in 40 states having trouble getting their children’s CGMs remotely monitored in school. Parents in 10 states have filed similar complaints, they said.

CGMs today are used by most of the estimated 300,000 people in the U.S. with Type 1 diabetes under age 20, health experts say. Also known as juvenile diabetes, it is an autoimmune disease typically diagnosed in early childhood and treated with daily insulin to help regulate blood sugar. It affects about 1 in 400 people under 20, according to the American Academy of Pediatrics.

(CGMs are also used by those with Type 2 diabetes, a different disease tied to risk factors such as diet and exercise that affects tens of millions of people — including a growing number of children, though it is usually not diagnosed until the early teens. Most people with Type 2 diabetes do not take insulin.)

Students with diabetes or another disease or disability typically have a health care plan, developed by their doctor, that works with a school-approved plan to get the support they need. It details necessary accommodations to attend school, such as allowing a child to eat in class or ensuring staff members are trained to check blood glucose or give a shot of insulin.

For children with Type 1 diabetes, the plan usually includes monitoring CGMs several times a day and responding to alarms, Roswig said.

Lynn Nelson, president-elect of the National Association of School Nurses, said when doctors and parents deem a student needs their CGM remotely monitored, the school is obligated under the ADA to meet that need. “It is legally required and the right thing to do.”

Nelson, who also manages school nurse programs in Washington state, said schools often must balance the students’ needs with having enough administrative staff.

“There are real workforce challenges, but that means schools have to go above and beyond for an individual student,” she said.

Henry Rodriguez, a pediatric endocrinologist at the University of South Florida and a spokesperson for the American Diabetes Association, said remote monitoring can be challenging for schools. While they advocate for giving every child what they need to manage their diabetes at school, he said, schools can be limited by a lack of support staff, including nurses.

The association last year updated its policy around CGMs, stating: “School districts should remove barriers to remote monitoring by school nurses or trained school staff if this is medically necessary for the student.”

In San Diego, Taylor Inman, a pediatric pulmonologist, said her daughter, Ruby, 8, received little help from her public school after being diagnosed with Type 1 diabetes and starting to use a CGM.

She said alerts from Ruby’s phone often went unheard outside the classroom, and she could not always reach someone at the school to make sure Ruby was reacting when her blood sugar levels moved into the abnormal range.

“We kept asking for the school to follow my daughter’s CGM and were told they were not allowed to,” she said.

In a 2020 memo to school nurses that remains in effect, Howard Taras, the San Diego Unified School District’s medical adviser, said if a student’s doctor recommends remote monitoring, it should be done by their parents or doctor’s office staff.

CGM alarms can be “disruptive to the student’s education, to classmates and to staff members with other responsibilities,” Taras wrote.

“Alarms are closely monitored, even those that occur outside of the classroom,” Susan Barndollar, the district’s executive director of nursing and wellness, said in a statement. Trained adults, including teachers and aides, listen for the alarms when in class, at recess, at gym class, or during a field trip, she said.

She said the problem with remote monitoring is that staff in the school office doing the monitoring may not know where the student is to tend to them quickly.

Inman said last year they paid $20,000 for a diabetes support dog trained to detect high or low blood sugar and later transferred Ruby to a private school that remotely tracks her CGM.

“Her blood sugar is better controlled, and she is not scared and stressed anymore and can focus on learning,” she said. “She is happy to go to school and is thriving.”

Some schools have changed their policies. For more than a year, several parents lobbied Loudoun County Public Schools in Northern Virginia to have school nurses follow CGM alerts from their own wireless devices.

The district board approved the change, which took effect in August and affects about 100 of the district’s more than 80,000 students.

Before, Lauren Valentine would get alerts from 8-year-old son Leo’s CGM and call the school he attends in Loudoun County, not knowing if anyone was taking action. Valentine said the school nurse now tracks Leo’s blood sugar from an iPad in the clinic.

“It takes the responsibility off my son and the pressure off the teacher,” she said. “And it gives us peace of mind that the school clinic nurses know what is happening.”

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La llegada del monitor continuo de glucosa (MCG) hizo que eso ya no fuera necesario. El pequeño dispositivo, que normalmente se coloca en el brazo, tiene un sensor bajo la piel que envía lecturas a una aplicación en un teléfono u otro dispositivo inalámbrico. La aplicación muestra los niveles de azúcar en sangre en un instante, y emite una alarma cuando están fuera del rango normal.

Un nivel de azúcar en sangre demasiado alto podría requerir una dosis de insulina —con una inyección o solo tocando un botón en una bomba de insulina— para evitar complicaciones potencialmente mortales, como la pérdida del conocimiento. Un sorbo de jugo podría solucionar un nivel muy bajo de azúcar en sangre, previniendo problemas como mareos y convulsiones.

En las escuelas, los maestros están atentos a las alarmas de los MCG de los teléfonos de los alumnos. Sin embargo, muchos dicen que no hay garantía de que un maestro escuche una alarma en un aula ruidosa, y que les corresponde a ellos como padres garantizar la seguridad de sus hijos, supervisando ellos mismos la aplicación, aunque no puedan ponerse en contacto rápidamente.

Los padres dicen que las enfermeras escolares y el personal administrativo deberían supervisar de forma remota las aplicaciones de MCG, asegurándose de que alguien esté atento incluso cuando el estudiante esté fuera del aula, en el recreo, en un comedor ruidoso o en una excursión.

Pero muchas escuelas se han resistido, argumentando escasez de personal y preocupación por la fiabilidad de internet y los problemas técnicos con los dispositivos.

“La gente del distrito [escolar] no entiende la enfermedad, y no entiende la urgencia”, dijo Julie Calidonio, de Lutz, Florida.

El hijo de Calidonio, Luke, de 12 años, usa un MCG, pero ha recibido poco apoyo de su escuela, según la madre: nadie escuchaba la alarma o intervenía si su nivel de azúcar en sangre bajaba a niveles críticos.

“¿Por qué tenemos esta tecnología que está diseñada para prevenir daños y no la utilizamos?”, preguntó.

Corey Dierdorff, vocera del Distrito Escolar del condado de Pasco, donde Luke va a la escuela, dijo a KFF Health News que el personal reacciona cuando escuchan que el MCG de un estudiante emite una alerta. Cuando se le preguntó por qué el distrito no acepta que el personal supervise las alarmas de forma remota, dijo que duda de la eficacia de internet.

En septiembre, Calidonio presentó una denuncia ante el Departamento de Justicia contra el distrito, alegando que su incapacidad para supervisar los dispositivos viola la Ley de Estadounidenses con Discapacidades (ADA), que exige a las escuelas adaptarse para ayudar a los estudiantes que viven con diabetes, entre otras afecciones. Todavía está a la espera de una decisión.

La denuncia ocurrió unos cuatro años después que la fiscalía federal de Connecticut determinara que supervisar el MCG de un alumno en la escuela era una “adaptación razonable” bajo ADA. Esa determinación se tomó después que cuatro estudiantes presentaran denuncias contra cuatro distritos escolares de Connecticut.

“Luchamos y ganamos esta batalla”, dijo Jonathan Chappell, uno de los dos abogados que presentaron las denuncias en Connecticut. Pero la decisión aún no ha impactado en estudiantes en otros estados, agregó.

Chappell y Bonnie Roswig, abogada y directora de la organización sin fines de lucro Center for Children’s Advocacy Disability Rights Project, explicaron que han escuchado de padres en 40 estados que tienen problemas para que las escuelas monitoreen de manera remota los MCG de sus hijos.

Expertos en salud afirman que, en la actualidad, la mayoría de las aproximadamente 300.000 personas menores de 20 años con diabetes tipo 1 en Estados Unidos utilizan MCG. También conocida como diabetes juvenil, es una enfermedad autoinmune que suele diagnosticarse en la primera infancia y que se trata con insulina diaria para ayudar a regular el azúcar en sangre.

(Los MCG también se utilizan en casos de diabetes tipo 2, una afección diferente vinculada a factores de riesgo como la dieta y el ejercicio que afecta a millones de personas, incluyendo un número creciente de niños, aunque por lo general no se diagnostica hasta principios de la adolescencia. La mayoría de las personas con diabetes tipo 2 no utilizan insulina).

Los estudiantes que viven con diabetes, u otra afección o discapacidad, suelen tener un plan de salud desarrollado por su médico, que funciona con otro aprobado por la escuela para tener el apoyo que necesitan. Detalla adaptaciones necesarias, como permitir que un niño coma en el aula o asegurarse que el personal esté capacitado para controlar la glucosa o administrar una inyección de insulina.

Para los niños con diabetes tipo 1, el plan suele incluir monitorear los MCG varias veces al día y responder a las alarmas, indicó Roswig.

Lynn Nelson, presidenta electa de la National Association of School Nurses, dijo que cuando los médicos y los padres consideran que un estudiante necesita que su MCG sea monitoreado de forma remota, la escuela está obligada, bajo ADA, a satisfacer esa necesidad. “Es un requisito legal y es lo correcto”.

Nelson, que también gestiona programas de enfermería escolar en el estado de Washington, señaló que las escuelas a menudo deben equilibrar las necesidades de los estudiantes con la disponibilidad de personal.

“Hay verdaderos desafíos en materia de personal, pero eso significa que las escuelas tienen que hacer todo lo posible, y más, por ayudar a cada estudiante”, afirmó.

Henry Rodríguez, endocrinólogo pediátrico de la Universidad del Sur de Florida y vocero de la American Diabetes Association, dijo que este monitoreo puede ser un reto para las escuelas. Aunque abogan para que cada niño reciba lo que necesita para controlar su diabetes en la escuela, según Rodríguez, las escuelas pueden verse limitadas por la falta de personal de apoyo, incluidas enfermeras.

El año pasado, la asociación actualizó su política sobre los MCG estableciendo que “los distritos escolares deben eliminar las barreras para que las enfermeras escolares o el personal escolar capacitado monitoree los MCG de manera remota, si esto es médicamente necesario para el estudiante”.

En San Diego, Taylor Inman, neumonóloga infantil, dijo que su hija Ruby, de 8 años, recibió poca ayuda de su escuela pública después que le diagnosticaran diabetes tipo 1 y empezara a usar uno de estos dispositivos.

Contó que las alertas del teléfono de Ruby a menudo no se escuchaban fuera del aula, y que no siempre podía comunicarse con alguien para asegurarse de que Ruby reaccionaba cuando sus niveles de azúcar en sangre se volvían anormales.

“Seguimos pidiendo a la escuela que siguiera el MCG de mi hija y nos dijeron que no estaban autorizados a hacerlo”, afirmó.

En un memorando de 2020 enviado a las enfermeras escolares, que sigue vigente, Howard Taras, asesor médico del Distrito Escolar Unificado de San Diego, comunicó que si el médico de un estudiante recomienda el monitoreo remoto, debe hacerlo un padre o personal del consultorio del médico.

Las alarmas del MCG pueden ser “perturbadoras para la educación del estudiante, para los compañeros de clase y para los miembros del personal con otras responsabilidades”, escribió Taras.

Susan Barndollar, directora ejecutiva de enfermería y bienestar del distrito aseguró en un comunicado que el problema con la supervisión remota es que el personal de la oficina de la escuela que la realiza puede no saber dónde está el estudiante para asistirlo rápidamente.

Inman dijo que el año pasado pagaron $20.000 por un perro de apoyo para la diabetes entrenado para detectar niveles altos o bajos de azúcar en sangre y luego transfirieron a Ruby a una escuela privada que rastrea de forma remota su MCG.

“Su nivel de azúcar en sangre está mejor controlado, ya no está asustada ni estresada y puede concentrarse en aprender”, dijo Inman. “Está feliz de ir a la escuela y está progresando mucho”.

Algunas escuelas han cambiado sus políticas. Durante más de un año, varios padres presionaron a las escuelas públicas del condado de Loudoun, en el norte de Virginia, para que las enfermeras escolares siguieran las alertas del MCG desde sus propios dispositivos inalámbricos.

La junta del distrito aprobó el cambio, que entró en vigencia en agosto y afecta a cerca de 100 de los más de 80.000 estudiantes del distrito.

Antes, Lauren Valentine recibía alertas del MCG de su hijo Leo, de 8 años, y llamaba su escuela, en el condado de Loudoun, sin saber si alguien estaba tomando medidas. Valentine dijo que la enfermera del colegio ahora controla el azúcar en sangre de Leo desde un iPad en la clínica.

“Le quita la responsabilidad a mi hijo y la presión al maestro”, afirmó. “Y nos da tranquilidad que las enfermeras de la clínica escolar sepan lo que está pasando”.

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Donald Trump’s return to the White House — along with a GOP-controlled Senate and House of Representatives — is expected to change that.

Republicans in Washington say they plan to use funding cuts and regulatory changes to dramatically shrink Medicaid, the nearly $900-billion-a-year government health insurance program that, along with the related Children’s Health Insurance Program, serves about 79 million mostly low-income or disabled Americans.

The proposals include rolling back the Affordable Care Act’s expansion of Medicaid, which over the last 11 years added about 20 million low-income adults to its rolls. Trump has said he wants to drastically cut government spending, which may be necessary for Republicans to extend 2017 tax cuts that expire at the end of this year.

Trump made little mention of Medicaid during the 2024 campaign. The first Trump administration approved work requirements in several states, though only Arkansas implemented theirs before a federal judge said it violated the law. The first Trump administration also sought to block-grant funding to states.

House Budget Committee Chair Jodey Arrington (R-Texas) told KFF Health News that Medicaid and other federal entitlement programs need major changes to help cut the federal debt. “Without them, we will watch this country sadly enter into fiscal collapse.”

Rep. Chip Roy (R-Texas), a member of the Budget Committee, said Congress needs to explore cutting federal spending on Medicaid.

“You need wholesale reform on the health care front, which can include undoing a lot of the damage being done by the ACA and Obamacare,” Roy said. “Frankly, we could end up providing better service if we do it the right way.”

Advocates for poor people fear GOP funding cuts will leave more Americans without insurance, making it harder for them to get care.

“Medicaid is an obvious target for huge cuts,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “An existential fight about Medicaid’s future likely lies ahead.”

Medicaid, which turns 60 in July, is nearing the end of a disruptive period, after covid pandemic-era coverage protections expired in 2023 and all enrollees had to prove they still qualified. More than 25 million people lost coverage over the 18 months after the “unwinding” began, though it has not notably increased the number of people without insurance, according to the latest census data.

The unwinding’s disruptions could pale in comparison to what happens in the next four years, said Matt Salo, former executive director and founder of the National Association of Medicaid Directors. “What we are going to see is an even bigger seismic shift in who Medicaid covers and how it operates,” he said.

But Salo said any efforts to shrink the program will face pushback.

“A lot of powerful entities — state governments, managed-care organizations, long-term care providers, and everyone under the sun who wants to do well by doing good — wants to see Medicaid work efficiently and be adequately funded,” he said. “And they will be highly motivated to push back on something they see as draconian cuts, because it could affect their business model.”

The GOP is looking at several tactics to reduce the size of Medicaid:

• Shifting to block grants. Switching to annual block grants could lower federal funding for states to operate the program while giving states more discretion over how to spend the money. Currently, the government matches a certain percentage of state spending each year with no cap. Republican presidents since Ronald Reagan have sought to block-grant Medicaid with no success. Arrington said he favors ending the open-ended federal funding to states and replacing it with a set annual amount based on how many people each state has in the program.
• Cutting ACA Medicaid funding. The ACA provided financing to cover, through Medicaid, Americans with incomes up to 138% of the federal poverty level, or $20,783 for an individual last year. The federal government pays 90% of the cost for adults covered through the law’s Medicaid expansion, which 40 states and Washington, D.C., have adopted. The GOP may try to lower that funding to the same match rate the feds pay states for everyone else in the program, which averages about 60%. “We should absolutely note that we are subsidizing the healthy, able-bodied Medicaid expansion population at a higher rate than we do the poorest and sickest among us, which was the original intent of the program,” Arrington said. “That’s not right.”
• Lowering federal matching funds. Since Medicaid began, the federal match rate has been based on the relative wealth of a state’s population, with poorer states receiving a higher rate and no state receiving less than a 50% match. Ten states get the base rate — all but two are Democratic-run states, including New York and California. The GOP may seek to cut the base rate to 40% or less.
• Adding work requirements. During the first Trump term, federal courts ruled that Medicaid law doesn’t allow coverage to be conditioned on enrollees’ working or seeking jobs. But the GOP may try again. “If we can get strict work requirements on able-bodied adults, that can be a huge cost savings by itself,” Rep. Tom McClintock (R-Calif.) told KFF Health News. Because most Medicaid enrollees already work, go to school, or serve as caregivers, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
• Placing enrollment hurdles. About 10 states offer some populations what’s called continuous eligibility, whereby people stay enrolled for years without having to renew their coverage. That policy’s been shown to prevent enrollees from falling out of the program for short periods because of hardships or paperwork problems, which can lead to surprise medical bills and debt. The Trump administration could seek to repeal waivers that allow states to grant multiyear continuous eligibility, which would require people in those states to reapply for coverage annually.

If the GOP’s plans to shrink Medicaid are realized, Democrats and health experts say, low-income people forced to buy private insurance would face challenges paying monthly premiums and the large copayments and deductibles common to commercial plans that typically don’t exist in Medicaid.

The Paragon Health Institute, a leading conservative think tank run by former Trump adviser Brian Blase, has issued reports saying the billions in extra money states took to expand Medicaid under the ACA has been a boon to private insurers that manage the program and relatively wealthier people it says shouldn’t be enrolled.

Josh Archambault, a senior fellow with the conservative Cicero Institute, said he hopes the Trump administration holds states accountable for overpaying providers and enrolling people in Medicaid who are not eligible. Conservatives have cited CMS reports saying states improperly pay Medicaid providers billions of dollars a year, though the federal government notes that is mostly due to lack of documentation.

He said the GOP will look to scale back Medicaid to its “traditional” populations of children, pregnant women, and people with disabilities. “We need to rebalance the program that most people think is underperforming,” he said. Most Americans, including large majorities of both Republicans and Democrats, view the program favorably, according to polls.

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Pero se espera que el regreso de Donald Trump a la Casa Blanca, junto con un Senado y una Cámara de Representantes controlados por republicanos, cambie esta situación.

Los republicanos en Washington afirman que planean utilizar recortes de financiamiento y cambios regulatorios para reducir drásticamente Medicaid, el programa de salud federal gerenciado por los estados que cuesta casi $900.000 millones al año y que, junto con el Programa de Seguro Médico Infantil (CHIP), ofrece atención a unos 79 millones de estadounidenses, en su mayoría de bajos ingresos o con discapacidades.

Las propuestas incluyen revertir la expansión de Medicaid impulsada por la Ley de Cuidado de Salud a Bajo Precio (ACA), que en los últimos 11 años sumó cerca de 20 millones de adultos de bajos ingresos al programa.

Trump ha dicho que quiere recortar drásticamente el gasto del gobierno, lo que podría ser necesario para que los republicanos extiendan los recortes de impuestos de 2017 que vencen a finales de este año.

Trump no habló demasiado sobre Medicaid durante su campaña de 2024. Su primera administración aprobó requisitos de trabajo en varios estados, aunque solo Arkansas los implementó antes de que un juez federal determinara que violaban los principios de ACA. También intentó otorgar financiamiento en bloque a los estados.

El presidente del Comité de Presupuesto de la Cámara, Jodey Arrington (republicano de Texas), dijo a KFF Health News que Medicaid y otros programas federales de beneficencia necesitan cambios importantes para ayudar a reducir la deuda federal. “Sin esos cambios, veremos con pesar cómo este país sufre un colapso fiscal”.

El representante Chip Roy (republicano de Texas), miembro del Comité de Presupuesto, indicó que el Congreso necesita explorar recortes al gasto federal en Medicaid.

“Es necesaria una reforma integral en el sector de salud, que podría incluir deshacer gran parte del daño causado por ACA y Obamacare”, dijo Roy. “Francamente, podríamos terminar proporcionando un mejor servicio si lo hacemos de la manera correcta”.

Defensores de las personas de bajos ingresos temen que los recortes que buscan los republicanos dejen a más estadounidenses sin seguro, dificultándoles el acceso a la atención médica.

“Medicaid es un objetivo obvio para recortes enormes”, dijo Joan Alker, directora ejecutiva del Centro para Niños y Familias de la Universidad Georgetown. “Probablemente se avecina una lucha existencial sobre el futuro de Medicaid”.

El programa, que cumplirá 60 años en julio, está llegando al final de una gran crisis, después que las protecciones de cobertura implementadas durante la pandemia de covid-19 expiraran en 2023, y todos los inscriptos tuvieran que demostrar que seguían siendo elegibles.

Más de 25 millones de personas perdieron su cobertura durante los 18 meses posteriores al inicio del proceso de “desafiliación”, aunque no ha aumentado notablemente el número de personas sin seguro, según los datos más recientes del censo.

Pero este número podría ser insignificante comparado con lo que ocurra en los próximos cuatro años, dijo Matt Salo, ex director ejecutivo y fundador de la Asociación Nacional de Directores de Medicaid. “Lo que vamos a ver es un cambio dramático aún mayor en quiénes estarán cubiertos por Medicaid y cómo operará el programa”, aseguró.

Sin embargo, Salo señaló que cualquier esfuerzo por reducir el programa enfrentará resistencia.

“Muchas entidades poderosas —gobiernos estatales, organizaciones de atención administrada, proveedores de atención de largo plazo y todos aquellos interesados en que Medicaid funcione de manera eficiente— estarán altamente motivadas para resistirse a recortes que consideren draconianos, ya que podrían afectar sus modelos de negocio”, afirmó.

Algunas de las estrategias del partido republicano para reducir el tamaño de Medicaid son:

1. Cambio a financiamiento en bloque. Actualmente, el gobierno federal iguala un porcentaje del gasto estatal anual en Medicaid, sin un límite específico. Los republicanos quieren cambiar a pagos fijos anuales, lo que impactaría en la cantidad de dinero federal que algunos estados reciben. Desde Ronald Reagan, los presidentes republicanos han intentado sin éxito imponer una suma fija de financiación para Medicaid.
2. Recortes a la financiación de ACA para Medicaid. ACA financió la cobertura para estadounidenses con ingresos de hasta el 138% del nivel federal de pobreza ($20.783 de ingresos anuales para un individuo en 2024). Los republicanos podrían intentar reducir ese financiamiento al mismo porcentaje que el gobierno federal paga por el resto de los inscritos en el programa, que promedia un 60%. “Debemos tener en cuenta que estamos subsidiando a la población sana y apta para trabajar que se beneficia de la expansión de Medicaid a un ritmo mayor que el que subsidiamos a los más pobres y enfermos, que era la intención original del programa”, dijo Arrington. “Eso no está bien”.
3. Reducción de fondos federales. Desde su inicio, la tasa de contribución federal varía según la riqueza relativa de la población del estado. Los estados más pobres reciben una tasa más alta y ningún estado recibe menos del 50% en contrapartida. Los republicanos podrían buscar reducir la tasa base del 50% a menos del 40%.
4. Agregar requisitos de trabajo. Aunque los tribunales federales han dictaminado que no se puede condicionar la cobertura a trabajar o a estar buscando trabajo, el Partido Republicano podría intentarlo nuevamente. “Si podemos lograr que los adultos sanos tengan requisitos de trabajo estrictos, eso puede suponer un enorme ahorro de costos”, dijo el representante Tom McClintock (republicano de California) a KFF Health News. Como la mayoría de los inscriptos en Medicaid ya trabajan, van a la escuela o son cuidadores, los críticos dicen que un requisito de ese tipo simplemente agregaría burocracia a la obtención de cobertura, con poco impacto en el empleo.
5. Imponer barreras a la inscripción. Unos 10 estados ofrecen a algunas poblaciones lo que se denomina elegibilidad continua, mediante la cual las personas permanecen inscriptas durante años sin tener que renovar su cobertura. Se ha demostrado que esa política evita que los beneficiarios abandonen el programa durante períodos cortos por dificultades o problemas con el papeleo, lo que puede generar facturas médicas inesperadas y deuda. La administración Trump podría intentar derogar las exenciones que permiten a los estados otorgar elegibilidad continua, lo que obligaría a las personas en esos estados a tener que volver a solicitar cobertura cada año.

Si los planes de los republicanos para reducir Medicaid se concretan, expertos dicen que las personas de bajos ingresos que se vean obligadas a comprar seguros privados enfrentarán dificultades para pagar las primas y copagos comunes en estos planes comerciales, que no suelen existir en Medicaid.

El Paragon Health Institute, un centro de estudios conservador dirigido por Brian Blasé, ex asesor de Trump, ha publicado informes que dicen que los miles de millones de dólares adicionales que los estados recibieron para ampliar Medicaid bajo ACA han sido una bendición para las aseguradoras privadas que administran el programa y para las personas relativamente más ricas que, según la organización, no deberían estar inscriptas.

Josh Archambault, miembro senior del conservador Cicero Institute, dijo que espera que la administración Trump haga responsables a los estados por pagar miles de millones de más a los proveedores, y por inscribir en Medicaid a personas que no son elegibles.

Archambault agregó que el Partido Republicano buscará reducir Medicaid a sus poblaciones “tradicionales”: niños, embarazadas y personas con discapacidades.

“Necesitamos reequilibrar el programa que la mayoría de la gente piensa que tiene un bajo rendimiento”, apuntó. La mayoría de los estadounidenses, incluidas grandes mayorías tanto de republicanos como de demócratas, ven el programa de manera favorable, según encuestas.

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But nearly a year since the Food and Drug Administration green-lit the state’s importation strategy, Florida has no planned date to begin bringing drugs over the border, according to a state official familiar with the program who asked not to be identified because they weren’t authorized to speak publicly.

Florida is the first and only state that has been approved to import drugs from Canada — a strategy for which politicians ranging from conservatives such as DeSantis to progressives such as Sen. Bernie Sanders (I-Vermont) have long pushed.

Drug companies say importation would increase the risk of counterfeit drugs appearing on U.S. pharmacy shelves, while Ottawa has warned it won’t allow medicines to be exported if Canadians could experience shortages as a result.

The Trump administration gave states the option to apply to bring medicines over the border in 2020, a move Trump touted in an interview published in October by AARP. He vowed to continue his “efforts to protect Americans from unaffordable drug prices” in a second term.

Colorado has an importation plan pending with the FDA.

Floridians would not directly benefit, as the program is geared toward lowering costs for the state Medicaid program and for the corrections and health departments.

LifeScience Logistics — a Dallas-based company whose board includes Alex Azar, secretary of the Department of Health and Human Services for most of the first Trump administration — has already received $50 million from Florida to set up its program, including warehousing its medicines.

Azar said he wasn’t authorized to speak about the program, and DeSantis administration officials refused for months to answer questions about it.

After KFF Health News reported in November that Florida had not set a date to start its program, Alecia Collins, deputy chief of staff for the Florida Agency for Health Care Administration, said the state is “awaiting feedback from the FDA on the last of the [pharmaceutical] labels so we can move forward with the next steps for launching the program.”

After Florida applied to create an importation program in November 2020, DeSantis filed suit against the FDA in 2022 for what he called a “reckless delay.”

Camm Epstein, a health policy analyst in Saratoga Springs, New York, said drug importation is a seemingly simple concept that resonates. “It riles up the crowd,” he said. “Who doesn’t want to pay lower drug costs?”

But it is complicated because of the FDA’s many requirements, including finding companies to work with — a Canadian exporter and a U.S. importer — and following a process that ensures the drugs are authentic, Epstein said.

“This was, at best, a boondoggle,” he said.

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More than 3 million adults in nine states would be at immediate risk of losing their health coverage should the GOP reduce the extra federal Medicaid funding that’s enabled states to widen eligibility, according to KFF, a health information nonprofit that includes KFF Health News, and the Georgetown University Center for Children and Families. That’s because the states have trigger laws that would swiftly end their Medicaid expansions if federal funding falls.

The states are Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia.

The 2010 Affordable Care Act encouraged states to expand Medicaid programs to cover more low-income Americans who didn’t get health insurance through their jobs. Forty states and the District of Columbia agreed, extending health insurance since 2014 to an estimated 21 million people and helping drive the U.S. uninsured rate to record lows.

In exchange, the federal government pays 90% of the cost to cover the expanded population. That’s far higher than the federal match for other Medicaid beneficiaries, which averages about 57% nationwide.

Conservative policy groups, which generally have opposed the ACA, say the program costs too much and covers too many people. Democrats say the Medicaid expansion has saved lives and helped communities by widening coverage to people who could not afford private insurance.

If Congress cuts federal funding, Medicaid expansion would be at risk in all states that have opted into it — even those without trigger laws — because state legislatures would be forced to make up the difference, said Renuka Tipirneni, an associate professor at the University of Michigan’s School of Public Health.

Decisions to keep or roll back the expansion “would depend on the politics at the state level,” Tipirneni said.

For instance, Michigan approved a trigger as part of its Medicaid expansion in 2013, when it was controlled by a Republican governor and legislature. Last year, with the government controlled by Democrats, the state eliminated its funding trigger.

Six of the nine states with trigger laws — Arizona, Arkansas, Indiana, Montana, North Carolina, and Utah — went for Trump in the 2024 election.

Most of the nine states’ triggers kick in if federal funding falls below the 90% threshold. Arizona’s trigger would eliminate its expansion if funding falls below 80%.

Montana’s law rolls back expansion below 90% funding but allows it to continue if lawmakers identify additional funding. Under state law, Montana lawmakers must reauthorize its Medicaid expansion in 2025 or the expansion will end.

Across the states with triggers, between 3.1 million and 3.7 million people would swiftly lose their coverage, researchers at KFF and the Georgetown center estimate. The difference depends on how states treat people who were added to Medicaid before the ACA expansion; they may continue to qualify even if the expansion ends.

Three other states — Iowa, Idaho, and New Mexico— have laws that require their governments to mitigate the financial impact of losing federal Medicaid expansion funding but would not automatically end expansions. With those three states included, about 4.3 million Medicaid expansion enrollees would be at risk of losing coverage, according to KFF.

The ACA allowed Medicaid expansions to adults with incomes up to 138% of the federal poverty level, or about $20,783 for an individual in 2024.

Nearly a quarter of the 81 million people enrolled in Medicaid nationally are in the program due to expansions.

“With a reduction in the expansion match rate, it is likely that all states would need to evaluate whether to continue expansion coverage because it would require a significant increase in state spending,” said Robin Rudowitz, vice president and director of the Program on Medicaid and the Uninsured at KFF. “If states drop coverage, it is likely that there would be an increase in the number of uninsured, and that would limit access to care across red and blue states that have adopted expansion.”

States rarely cut eligibility for social programs such as Medicaid once it’s been granted.

The triggers make it politically easier for state lawmakers to end Medicaid expansion because they would not have to take any new action to cut coverage, said Edwin Park, a research professor at the Georgetown University Center for Children and Families.

To see the impact of trigger laws, consider what happened after the Supreme Court in 2022 struck down Roe v. Wade and, with it, the constitutional right to an abortion. Conservative lawmakers in 13 states had crafted trigger laws that would automatically implement bans in the event a national right to abortion were struck down. Those state laws resulted in restrictions taking effect immediately after the court ruling, or shortly thereafter.

States adopted triggers as part of Medicaid expansion to win over lawmakers skeptical of putting state dollars on the hook for a federal program unpopular with most Republicans.

It’s unclear what Trump and congressional Republicans will do with Medicaid after he takes office in January, but one indicator could be a recent recommendation from the Paragon Health Institute, a leading conservative policy organization led by former Trump health adviser Brian Blase.

Paragon has proposed that starting in 2026 the federal government would phase down the 90% federal match for expansion until 2034, when it would reach parity with each state’s federal match for its traditional enrollees. Under that plan, states could still get ACA Medicaid expansion funding but restrict coverage to enrollees with incomes up to the federal poverty level. Currently, to receive expansion funding, states must offer coverage to everyone up to 138% of the poverty level.

Daniel Derksen, director of the Center for Rural Health at the University of Arizona, said it’s unlikely Arizona would move to eliminate its trigger and make up for lost federal funds. “It would be a tough sell right now as it would put a big strain on the budget,” he said.

Medicaid has been in the crosshairs of Republicans in Washington before. Republican congressional leaders in 2017 proposed legislation to cut federal expansion funding, a move that would have shifted billions in costs to states. That plan, part of a strategy to repeal Obamacare, ultimately failed.

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