The day after Trump’s inauguration, South Carolina GOP Gov. Henry McMaster asked federal officials to approve a work requirement plan. Ohio Republican Gov. Mike DeWine plans to soon follow suit. Republicans in Congress are eyeing Medicaid work requirements as they seek to slash billions from the federal budget.

But, just as a second Trump administration reignites interest in work requirements, Georgia is proposing to scale back key parts of the nation’s only active program. And Arkansas announced an effort to revive — with fundamental changes — a program that ended after a legal judgment in 2019.

The Georgia and Arkansas proposals, from the only two states to have implemented Medicaid work requirements, reveal the disconnect between rhetoric behind such programs and the realities of running them, said consumer advocates and health policy researchers.

“They recognize that what they did the first time didn’t work,” said Ben Sommers, a Harvard professor and a former health official in the Biden and Obama administrations. “It should be a signal to federal policymakers: Don’t point to Georgia and Arkansas and say, ‘Let’s do that.’”

More than a dozen states had Medicaid work requirement programs approved during Trump’s first administration.

After an expensive and bumpy rollout, Georgia in January posted a draft renewal plan for its Georgia Pathways to Coverage program. The plan removes the requirement to document work every month and to pay premiums. Those key elements — which supporters have argued promote employment and personal responsibility — were never implemented, the state said.

Enrollees would still have to meet the work requirement when they first apply and when they renew each year. The draft plan also expands the group of people who can opt out of work reporting to include parents of children under age 6. A public comment period on the plan is open through Feb. 20.

Arkansas’ latest request to federal officials doesn’t require enrollees to report their work hours. Instead, it proposes checking whether people are working, caregiving, or fulfilling other qualifying activities by using data, which could include income, job history, educational status, whether a child lives at home, and other criteria, said Gavin Lesnick, a spokesperson for the state’s Medicaid agency.

People deemed “not on track towards meeting their personal health and economic goals” won’t be disenrolled but can participate in a “success coaching” program to maintain coverage, according to the state’s proposal. A public comment period on Arkansas’ program runs through March 3.

‘Fundamentally Flawed’

More than 90% of U.S. adults eligible for Medicaid expansion are already working or could be exempt from requirements, according to KFF. Still, several states are quickly moving to restart Medicaid work requirements.

Besides the three states of Arkansas, Ohio, and South Carolina, Iowa and South Dakota are considering similar proposals. Lawmakers in Montana are weighing them as they debate renewing the state’s Medicaid expansion.

This week, House Republicans floated a budget proposal to cut $880 billion from the Energy and Commerce Committee, which oversees Medicaid, the state-federal health insurance program for people with low incomes or disabilities. Before the release of that plan, Speaker Mike Johnson said Republicans were discussing changes to Medicaid that include imposing work requirements.

Supporters of such requirements say Medicaid should be reserved for people who are working.

Right now, it “disincentivizes many low-income families from earning additional income” because they would lose health coverage if they make too much money, said South Carolina Gov. McMaster in his January letter to federal officials. He has argued that a work-reporting requirement is “fiscally responsible” and “will incentivize employment.”

There is no evidence showing such programs improve economic outcomes for people; the requirements don’t help people find jobs, but not having health insurance can keep them from working, health policy researchers say.

The goal of Ohio’s plan is to focus “resources and efforts on those who are engaged with their health choices and independence,” said the state. The plan doesn’t require most individuals to regularly “report activities, fill out forms, or take any action” beyond what is generally required for Medicaid enrollment. Ohio estimates that more than 61,000 people, or 8% of enrollees subject to its measure, would lose Medicaid eligibility in the first year.

Consumer advocates, health policy analysts, and researchers said the scaling back seen in recent work requirement proposals speaks to the challenges of mandating them for public benefits — and could serve as a cautionary tale for Republicans in Washington, D.C., and across the country. The programs can eliminate people from the Medicaid rolls or suppress enrollment, while adding costly layers of bureaucracy, they said.

“As a matter of health policy, work-reporting requirements in Medicaid are fundamentally flawed,” said Leo Cuello, a researcher at the Georgetown Center for Children and Families.

Lessons Learned?

Arkansas got its initial program off the ground in 2018 before a federal judge said it was illegal. Unlike Georgia, the state had already expanded Medicaid. That work-reporting requirement led to more than 18,000 people losing coverage, in part because enrollees were unaware or confused about how to report they were working.

In his ruling that ended the program, Judge James Boasberg said its approval was “arbitrary and capricious” because it failed to address a core goal of Medicaid: “the provision of medical coverage to the needy.”

Arkansas’ latest proposal tries to address a potential legal challenge by suspending, rather than terminating, health coverage through the end of the calendar year for people who don’t meet requirements.

“We have worked to design this amendment taking into account lessons learned from previous work requirements,” said Arkansas Medicaid Director Janet Mann at a press conference in late January announcing the new proposal.

But the requirements are “subjective,” and the difference between suspension and termination isn’t meaningful, said Camille Richoux, health policy director of Arkansas Advocates for Children and Families.

“The impact is the same: You can’t go to the doctor,” she said. “You can’t get your prescriptions filled.”

In Georgia, the Pathways program, launched in 2023, has offered coverage to a small portion of those who would qualify for Medicaid if the state had fully expanded it to all low-income adults, as 40 others have done. With the proposed changes, the state estimates enrollment in Pathways would grow to as many as 30,000 people in the final year of the pilot. The state currently estimates at least 246,000 would become eligible for Medicaid under a full expansion.

About 6,500 people were enrolled in Pathways as of late January, said Grant Thomas, the state’s deputy Medicaid commissioner, in a legislative hearing. According to state officials, the program has cost more than $57 million in state and federal funds through December, with most of that money going toward program administration, not benefits.

“Pathways is doing what it is designed to do: increase access to affordable health care coverage while lowering the uninsured rate across Georgia,” said Russel Carlson, who oversees the state’s Medicaid program as commissioner of the Department of Community Health. The changes to Pathways are an attempt to “improve the member experience” while finding ways “to make government more efficient and accessible,” he added.

Pathways requires that enrollees regularly submit documentation to prove they are working, but the program doesn’t include meaningful measures to help people find work, critics said. People who could be eligible for Pathways have said the whole process is time-consuming due to lengthy questionnaires, a glitchy system for uploading documents, and confusing technical language on the website, according to those working with potential enrollees.

“There’s stuff that sounds good on paper, but when you go to implement it in real life, it’s costly and burdensome,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.

So far, Pathways has cost state and federal taxpayers nearly $9,000 per enrollee, largely back-end costs to run the program. States that have expanded Medicaid spent about $6,500 per enrollee in that group in 2021, according to KFF researchers.

Georgia GOP Gov. Brian Kemp has said he’s committed to his signature health program, but some Republican state lawmakers have shown an openness to consider full expansion.

A group of Democratic senators cited KFF Health News’ reporting last year when they asked the federal government’s top watchdog to investigate Pathways spending.

Even with the proposed changes, some people, including those who work in the informal or gig economy, may not have official records and may be locked out of health coverage, said Laura Colbert, executive director of Georgians for a Healthy Future, a nonprofit consumer health advocacy organization. People caring for older children or aging relatives, older adults who struggle to find work, and those with medical conditions that prevent them from working still wouldn’t qualify for health coverage, she said.

“The Pathways program just doesn’t reflect the reality of how people are working,” Colbert said. “Pathways is a program that has clearly been developed by people who have had salaried jobs with predictable incomes.”

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).

Fisher’s son Raleigh, 12, lives with a congenital heart condition, which has left him with a weakened immune system. For his protection, Raleigh has received all the recommended vaccines for a child his age. But even with his vaccinations, a virus that might only sideline another child could sicken him and land him in the emergency room, Fisher said.

“We want everyone to be vaccinated so that illnesses like measles and things that have basically been eradicated don’t come back,” Fisher said. “Those can certainly have a very adverse effect on Raleigh.”

For much of Raleigh’s life, Fisher could take comfort in the high childhood vaccination rate in Tennessee — a public health bright spot in a conservative state with poor health outcomes and one of the shortest life expectancies in the nation.

Mississippi and West Virginia, two similarly conservative states with poor health outcomes and short life expectancies, also have some of the highest vaccination rates for kindergartners in the nation — a seeming contradiction that stems from the fact that childhood vaccination requirements don’t always align with states’ other characteristics, said James Colgrove, a Columbia University professor who studies factors that influence public health.

“The kinds of policies that states have don’t map neatly on to ‘red’ versus ‘blue’ or one region or another,” Colgrove said.

Advocates, doctors, public health officials, and researchers worry such public health bright spots in some states are fading: Many states have recently reported an increase in people opting out of vaccines for their kids as Americans’ views shift.

During the 2023-24 school year, the percentage of kindergartners exempted from one or more vaccinations rose to 3.3%, the highest ever reported, with increases in 40 states and Washington, D.C., according to Centers for Disease Control and Prevention data. Tennessee and Mississippi were among those with increases. Nearly all exemptions nationally were for nonmedical reasons.

Vaccine proponents worry anti-vaccine messaging could accelerate a growing “health freedom” movement that has been pushed by leaders in states such as Florida. Momentum against vaccines is likely to continue to grow with the election of Donald Trump as president and his proposed nomination of anti-vaccine activist Robert F. Kennedy Jr. as secretary of the Department of Health and Human Services.

Pediatricians in states with high exemption rates, such as Florida and Georgia, say they’re concerned by what they see — declining immunization levels for kindergartners, which could lead to a resurgence in vaccine-preventable diseases such as measles. The Florida Department of Health reported nonmedical exemption rates as high as 50% for children in some areas.

“The religious exemption is huge,” said Brandon Chatani, a pediatric infectious disease doctor in Orlando. “That has allowed for an easy way for these kids to enter schools without vaccines.”

In many states, it’s easier to get a religious exemption than a medical one, which often requires signoff from a doctor.

Over the past decade, California, Connecticut, Maine, and New York have removed religious and philosophical exemptions from school vaccination requirements. West Virginia has not had them.

Idaho, Alaska, and Utah had the highest exemption rates for the 2023-24 school year, according to the CDC. Those states allow parents or legal guardians to exempt their children for religious reasons by submitting a notarized form or a signed statement.

Florida and Georgia, with some of the lowest reported minimum vaccination rates for kindergartners, allow parents to exempt their children by submitting a form with the child’s school or day care.

Both states have reported declines in uptake of the measles, mumps, and rubella vaccine, which is one of the most common childhood shots. In Georgia, MMR coverage for kindergartners dropped to 88.4% in the 2023-24 school year from 93.1% in 2019-20, according to the CDC. Florida dropped to 88.1% from 93.5% during the same period.

Andi Shane, a pediatric infectious disease specialist in Atlanta, traces Georgia’s declining rates to families who lack access to a pediatrician. State policies on exemptions are also key, she said.

“There’s lots of data to support the fact that when personal belief exemptions are not permitted, that vaccination rates are higher,” she said.

In December, Georgia public health officials put out an advisory saying the state had recorded significantly more whooping cough cases than in the prior year. According to CDC data, Georgia reported 280 cases in 2024 compared with 96 the year before.

Until 2023, Mississippi was one of the few states that allowed parents to opt out of vaccinating their kids only for medical reasons — and only with the approval of a doctor. That gave it among the highest vaccination rates in the nation as of the 2023-24 school year.

“It’s one of the few things Mississippi has done well,” said Anita Henderson, a pediatrician who has practiced in the southern part of the state for nearly 30 years. In terms of health, she said, childhood vaccination rates were the state’s one “shining star.”

But that changed in April 2023 when a federal judge ordered state officials to start allowing religious exemptions. The ruling has emboldened many families, Henderson said.

“We are seeing more and more skepticism, more and more vaccine hesitancy, and a lack of confidence because of this ruling,” she said.

State officials have granted more than 5,000 religious exemptions since the court order allowing them, according to the state health department. Daniel Edney, the state health officer, said most of the requests have come from “more affluent” residents in “pockets” of the state.

“Most people listen to the expert opinions of their pediatricians and family medicine doctors to stay on the vaccine schedule, because it’s what is best to protect their children,” he said.

West Virginia’s vaccine law — which hasn’t allowed nonmedical exemptions — also could soon change, Matthew Christiansen said in December before he resigned as the state’s health officer.

A bill that would have broadened exemptions made it through the legislature last year but was vetoed by outgoing Republican Gov. Jim Justice. The new governor, Republican Pat Morrisey, has been a vocal critic of vaccine mandates. And just a day after being inaugurated, he issued an executive order to propose provisions by Feb. 1 that could allow religious and conscientious exemptions.

“I want to send a message that if you have a religious belief, then we’re going to have an exception,” he said at a Jan. 14 press conference. “We’re not going to be the outlier.”

People asserting their personal freedoms to decline vaccines for their kids can ultimately curtail the ability of others to live full lives, Christiansen said. “Kids getting measles and mumps and polio and being paralyzed for their whole life is an impediment on personal freedom and autonomy for those kids,” he said.

Since the covid pandemic, anti-vaccine sentiment has been growing in Tennessee. One organization, Stand for Health Freedom, drafted a letter for constituents to send to their state lawmakers calling for the resignation of the medical director of Tennessee’s Vaccine-Preventable Diseases and Immunization Program. The group said she demonstrated a “lack of respect for the informed consent rights” of the people.

“They feel emboldened by the idea that this presidential administration seems to feel very strongly that a lot of these issues should be taken back to the states,” said Emily Delikat, director of Tennessee Families for Vaccines, a pro-vaccine group.

Ultimately, like many effective public health interventions, vaccines are a victim of their own success, said Henderson, the Mississippi pediatrician. Most people haven’t seen outbreaks of measles or polio, so they forget how dangerous the diseases are, she said.

“It may unfortunately take a resurgence of those diseases to raise awareness to the fact that these are dangerous, these are deadly, these are preventable,” she said. “I hope it doesn’t come to that.”

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).

El hijo de Fisher, Raleigh, de 12 años, vive con una afección cardíaca congénita que ha debilitado su sistema inmune. Ha recibido todas las vacunas recomendadas a su edad, para su protección. Pero incluso con estas vacunas, un virus que para otro niño significaría estar en cama un par de días, para Raleigh podría transformarse en una enfermedad grave, terminando en una sala de emergencias, explicó Fisher.

“Queremos que todos estén vacunados para que enfermedades como el sarampión y cosas que básicamente han sido erradicadas no regresen”, dijo Fisher. “Esas pueden definitivamente tener un efecto muy adverso en Raleigh”.

Durante gran parte de la vida de Raleigh, Fisher podía estar tranquila gracias a la alta tasa de vacunación infantil en Tennessee, un punto positivo de salud pública en un estado conservador con resultados de salud deficientes y una de las expectativas de vida más cortas del país.

Mississippi y West Virginia, dos estados también conservadores, con malos resultados de salud y baja expectativa de vida, también tienen algunas de las tasas de vacunación más altas para niños de kinder en el país.

Esta aparente contradicción se debe a que los requisitos de vacunación infantil no siempre se alinean con otras características de los estados, dijo James Colgrove, profesor de la Universidad Columbia que estudia los factores que influyen en la salud pública.

“Los tipos de políticas que tienen los estados no encajan perfectamente en la categoría de ‘rojo’ o ‘azul’ o en una región u otra”, dijo Colgrove.

Defensores, médicos, investigadores, y funcionarios de salud pública temen que estos puntos positivos de salud pública en algunos estados estén desapareciendo: muchos han informado recientemente un aumento en las personas que optan por no vacunar a sus hijos, a medida que cambian las opiniones de los estadounidenses.

Durante el año escolar 2023-24, el porcentaje de niños de kinder exentos de una o más vacunas aumentó al 3.3%, el más alto jamás reportado, con aumentos en 40 estados y Washington, DC, según datos de los Centros para el Control y Prevención de Enfermedades (CDC). Tennessee y Mississippi estuvieron entre los estados con aumentos. Casi todas las exenciones a nivel nacional fueron por razones no médicas.

Los defensores de la vacunación temen que los mensajes antivacunas puedan acelerar un creciente movimiento de “libertad sanitaria” impulsado por líderes en estados como Florida.

Este impulso contra las vacunas probablemente continuará creciendo con la elección de Donald Trump como presidente y su propuesta de nominar al activista antivacunas Robert F. Kennedy Jr. como secretario del Departamento de Salud y Servicios Humanos (HHS).

Pediatras en estados con altas tasas de exenciones, como Florida y Georgia, dicen estar preocupados por lo que observan: niveles decrecientes de inmunización entre niños de kinder, lo que podría llevar a un resurgimiento de enfermedades prevenibles por vacunación, como el sarampión. En algunas áreas, el Departamento de Salud de Florida reportó tasas de exenciones no médicas de hasta un 50% para niños.

“La exención religiosa es enorme”, dijo Brandon Chatani, especialista en enfermedades infecciosas pediátricas en Orlando. “Eso ha permitido una forma fácil para que estos niños vayan a las escuelas sin vacunas”.

En muchos estados, es más fácil obtener una exención religiosa que una médica, que a menudo requiere la aprobación de un médico.

En la última década, California, Connecticut, Maine y Nueva York han eliminado las exenciones religiosas y filosóficas de los requisitos de vacunación escolar. West Virginia no las ha tenido.

Idaho, Alaska y Utah tuvieron las tasas de exención más altas durante el año escolar 2023-24, según los CDC. Estos estados permiten que los padres o tutores legales eximan a sus hijos por razones religiosas presentando un formulario notarizado o una declaración firmada.

Florida y Georgia, con algunas de las tasas reportadas más bajas de vacunación para niños de kinder, permiten que los padres eximan a sus hijos presentando un formulario en la escuela o guardería.

Ambos estados han informado disminuciones en la aplicación de la vacuna contra el sarampión, las paperas y la rubéola (conocida como MMR), una de las vacunas infantiles más comunes. En Georgia, la cobertura de la MMR para niños de kinder cayó de 93.1% en el año escolar 2019-20 al 88.4% en el año escolar 2023-24, según los CDC. En Florida, en el mismo período, bajó de 93.5% al 88.1%.

Andi Shane, especialista en enfermedades infecciosas pediátricas en Atlanta, atribuye las tasas decrecientes en Georgia a familias que no tienen acceso a un pediatra. Las políticas estatales sobre exenciones también son clave, dijo.

“Hay muchos datos que respaldan el hecho de que cuando no se permiten exenciones por creencias personales, las tasas de vacunación son más altas”, aseguró Shane.

En diciembre, funcionarios de salud pública de Georgia lanzaron un aviso diciendo que el estado había registrado significativamente más casos de tos ferina que el año anterior. Según datos de los CDC, Georgia reportó 280 casos en 2024 en comparación con 96 el año anterior.

Hasta 2023, Mississippi era uno de los pocos estados que permitía a los padres optar por no vacunar a sus hijos solo por razones médicas, y únicamente con la aprobación de un médico. Eso hizo que tuviera una de las tasas de vacunación más altas del país hasta el año escolar 2023-24.

“Es una de las pocas cosas que Mississippi ha hecho bien”, dijo Anita Henderson, pediatra que ha ejercido en la parte sur del estado durante casi 30 años. Aseguró que, en términos de salud, las tasas de vacunación infantil eran el único “rayo de luz” del estado.

Pero eso cambió en abril de 2023 cuando un juez federal ordenó a los funcionarios estatales comenzar a permitir exenciones religiosas. Según Henderson, el fallo ha alentado a muchas familias.

“Estamos viendo cada vez más escepticismo, más dudas sobre las vacunas y una falta de confianza debido a este fallo”, dijo.

Desde la orden judicial que permite las exenciones religiosas, los funcionarios estatales han otorgado más de 5.000, según el departamento de salud estatal. Daniel Edney, oficial de salud del estado, dijo que la mayoría de las solicitudes provienen de residentes “más pudientes” en bolsones de riqueza del estado.

“La mayoría de las personas escuchan las opiniones de los expertos, como sus pediatras y médicos de familia, para mantenerse al día con el calendario de vacunación porque es lo mejor para proteger a sus hijos”, dijo.

La ley de vacunación de West Virginia —que no permite exenciones no médicas— también podría cambiar pronto, dijo Matthew Christiansen, quien fue oficial de salud del estado hasta que renunció en diciembre.

El año pasado, un proyecto de ley que habría ampliado las exenciones avanzó en la Legislatura, pero fue vetado por el gobernador saliente republicano Jim Justice. El gobernador entrante, el republicano Pat Morrisey, ha sido un crítico abierto de los mandatos de vacunación: emitió una orden ejecutiva vigente a partir del 1 de febrero para proponer disposiciones que permitan las exenciones de vacunación por motivos religiosos y de conciencia.

“Quiero enviar un mensaje de que si tienes una creencia religiosa, entonces vamos a tener una excepción”, dijo en una conferencia de prensa el 14 de enero. “No vamos a ser la excepción.

Las personas que usan como argumento sus libertades personales para rechazar vacunas para sus hijos pueden, en última instancia, limitar la capacidad de otros para vivir plenamente, dijo Christiansen. “Que los niños contraigan sarampión, paperas y polio, y queden paralizados de por vida, es un impedimento para la libertad y autonomía personal de esos niños”, enfatizó.

Desde la pandemia de covid, el sentimiento antivacunas ha ido en aumento en Tennessee. La organización Stand for Health Freedom redactó una carta para que los ciudadanos enviaran a sus legisladores estatales pidiendo la renuncia de la directora médica del Programa de Vacunas y Enfermedades Prevenibles por Vacunación de Tennessee. El grupo dijo que la directora había demostrado una “falta de respeto por los derechos de consentimiento informado” de las personas.

“Se sienten empoderados por la idea de que esta administración presidencial parece creer firmemente que muchos de estos temas deberían ser devueltos a los estados”, dijo Emily Delikat, directora de Tennessee Families for Vaccines, un grupo pro-vacunación.

En última instancia, como muchas intervenciones efectivas de salud pública, las vacunas son víctimas de su propio éxito, dijo Henderson, la pediatra de Mississippi. La mayoría de las personas no han presenciado brotes de sarampión o polio, por lo que olvidan lo peligrosas que son estas enfermedades, agregó.

“Desafortunadamente, puede que se necesite un resurgimiento de esas enfermedades para crear conciencia sobre el hecho de que son mortales y prevenibles”, dijo. “Espero que no se tenga que llegar a eso”.

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).

The program, called “Georgia Pathways to Coverage,” is the nation’s only active Medicaid work requirement.

Pathways has cost tens of millions in federal and state dollars on administration and consulting fees while enrolling 5,542 people as of Nov. 1, according to KFF Health News’ reporting. The congressional letter cited the reporting in its request to the Government Accountability Office.

“Republicans are hell-bent on putting mountains of red tape between Americans and their health care,” Sen. Ron Wyden (D-Ore.), head of the Senate Finance Committee, said in a statement about the letter he co-wrote. “Taxpayers deserve to hear from an independent watchdog about the true costs of the Republican health care agenda.”

Georgia Sens. Jon Ossoff and Raphael Warnock co-signed the request.

The Democrats’ letter asks the GAO to prepare a summary of the costs to run the program — and detail how much of that has been picked up by the feds, break down the cost of the program per person, and assess how Georgia has used contractors to run the program and how federal officials have overseen it.

The request comes as President-elect Donald Trump, who supported work requirements in his first administration, is set to take office and potentially transform how people qualify for Medicaid, the joint federal-state health insurance program for people who are disabled or have low incomes.

Many GOP-led states have pushed for work requirements in public benefits programs such as Medicaid, arguing that they promote employment. Georgia’s Pathways program requires some Medicaid applicants to prove they are working, volunteering, or studying for 80 hours a month.

The first Trump administration approved work requirements in 13 states. Only Georgia’s program, which started on July 1, 2023, is in effect. A Medicaid work requirement launched in Arkansas was halted by a court order in 2019.

In November, South Dakota voters gave lawmakers a green light to seek a work requirement for some Medicaid enrollees. In 2023, North Carolina lawmakers directed the state to seek work requirements if the federal government would approve such a waiver. And some GOP-led states have indicated they might also seek work requirements.

Georgia’s program has been a priority of Republican Gov. Brian Kemp, and his team defended the program.

“The Senators should be more focused on examining the failures of the federal government to adequately provide the services they’re required to administer than looking for every opportunity to criticize states that are taking innovative approaches,” Garrison Douglas, a Kemp spokesperson, said in an emailed statement.

Enrollment in the program, which as of Dec. 13 was 5,903, has fallen far short of the state’s initial projection of more than 25,000 in the first year.

The program has cost more than $40 million in state and federal funds, largely administrative costs and not medical care for enrollees, Georgia officials have said. KFF Health News reported in March that Georgia officials estimated the program’s administrative costs could increase to $122 million over four years.

A spokesperson for Georgia’s Medicaid agency, Fiona Roberts, said the costs “increased significantly” because of the program’s delayed launch. While it was approved by the Trump administration, the Biden administration attempted to block it, resulting in a legal fight.

KFF Health News has also reported that the program has slowed processing times for other Medicaid applications and for public benefits such as cash assistance and food stamps.

Meanwhile, more than a year after Pathways’ launch, Georgia officials said they still had not removed enrollees for failing to prove they are working, volunteering, or studying for 80 hours a month, KFF Health News has reported.

“State leaders continue to put taxpayer dollars behind their ineffective health care program that has failed by nearly every metric,” Warnock said.

Previous federal research suggests that the high costs per enrollee associated with Georgia’s program could be repeated elsewhere. The Trump administration didn’t properly weigh administrative costs in state applications for work requirements, according to a 2019 GAO report. Pathways is slated to expire on Sept. 30, unless federal officials grant an extension.

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).

Such treatment violates a key part of the Americans With Disabilities Act — as affirmed in the 1999 Olmstead decision from the Supreme Court: that people with disabilities have a legal right to receive care at home or in other community settings.

Some states — Delaware and Oregon — addressed the problems after settling with the DOJ. Others have struggled.

Georgia was among the first DOJ targets for an enforcement lawsuit (and coincidentally the home of the two plaintiffs in the Olmstead case, Lois Curtis and Elaine Wilson). In 2010, the state settled the suit by agreeing to an overhaul of its system to support people with developmental disabilities and mental illness.

The state agreed to finish that work in five years. Nearly 15 years later, it’s not done. And that’s putting some of Georgia’s most marginalized people in jeopardy.

People like Lloyd Mills, a 32-year-old with cerebral palsy and autism. He was confined to a small hospital room for more than eight months because the state agency in charge of his care couldn’t find him a suitable community placement. The stay didn’t help him mentally, physically or emotionally, he said.

“The longer it continues, the more you sort of say, ‘Are we serious about solving this problem?’” said Geron Gadd, a senior attorney with the National Health Law Program.

Disability rights advocates note that it took more than a decade to increase some of the rates the state pays disability and mental health service providers, which led companies that offer direct care services and run group homes to shut their doors. When that happens, providers sometimes dump patients at local hospitals.

But even critics say Georgia has come a long way.

State lawmakers have invested nearly $521 million in community services since the start of the settlement — in quick-response teams to help people with mental illness in crisis and Medicaid programs to help people get care at home.

And a federal judge recently released Georgia from several portions of the 2010 settlement for having attained compliance.

There is still work to do. The state agrees it needs to remove more people with developmental disabilities from psychiatric hospitals, deliver better case management to people with mental illness, and provide more housing with mental health supports.

That final goal is the “bedrock” of Georgia’s mental health and disability system, said Susan Walker Goico, with Atlanta Legal Aid. “You have to have a place to live in order to get your services and to stay out of institutions.”

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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).

In July, his parents, Haresh and Nina Adhvaryu, received a letter saying their applications would be delayed, he said. In August, the Adhvaryus started calling a Georgia helpline, he said, but couldn’t leave a message. It wasn’t until September, when they visited state offices, that they were informed their applications were incomplete.

The couple were mystified. They had Medicaid coverage when they lived in Virginia, before their recent move to metro Atlanta.

While they waited, Adhvaryu’s parents — ages 71 and 76 — delayed care, fearing they couldn’t afford it. They have Medicare, and, in Georgia, Medicaid pays for its premiums, copayments, and deductibles. The lack of extra coverage strained their fixed incomes.

“It was concerning,” Deegant Adhvaryu said, because his family lost a critical financial “lifeline.”

It took Adhvaryu’s parents until late October — more than 120 days after applying — to finally get their Medicaid cards in the mail. Federal rules require states to process most Medicaid applications within 45 days.

For years, Georgia’s public benefits system has been plagued by problems like the Adhvaryus’ — a glitchy website that’s often down for maintenance, a shortage of staff to process applications, and technology that malfunctions, according to consumer advocacy organizations, former state employees, and researchers.

But a KFF Health News analysis shows processing times have worsened since July 2023, when Georgia launched the nation’s only active Medicaid work requirement program, “Georgia Pathways to Coverage.” The program began three months after the state began redetermining the eligibility of all Medicaid enrollees following a covid-19 pandemic pause.

The percentage of Medicaid applicants waiting more than a month and a half to have their applications processed has nearly tripled in the first year of Pathways, the analysis of state and federal records found. Georgia had the slowest processing time in the country as of June, for income-based applications. Preliminary data from July puts the state as the second-slowest. The percentage of applications for financial and food assistance that take more than 30 days to process has also risen by at least 8 percentage points.

Pathways “is really bogging down” a system that was “already functioning relatively poorly,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute, a nonprofit research organization that supports full Medicaid expansion.

Georgia’s effort to run Pathways reveals the challenges that loom for states looking to launch Medicaid work requirements under a second Donald Trump presidency. His first administration approved them in more than a dozen states. On Nov. 5, South Dakota voters gave lawmakers the green light to seek a work requirement for its existing Medicaid expansion population.

Conservative lawmakers around the country would like to add work requirements to Medicaid, the state-federal insurance program for people with disabilities or low incomes, said Joan Alker, who leads Georgetown University’s Center for Children and Families. “If Georgia fails, that’s a big black eye for the Republican Party.”

Pathways is one of Republican Gov. Brian Kemp’s signature health policy initiatives and his alternative to fully expanding Medicaid eligibility under the Affordable Care Act. Applicants must document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage.

Consumer advocacy organizations, former state employees, and researchers say the initiative adds inefficiencies and bureaucracy that slow down other public programs, like the Supplemental Nutrition Assistance Program, or SNAP, and the Temporary Assistance for Needy Families program, or TANF.

As of Nov. 1, just 5,542 residents were participating in the work requirement program. Under a full Medicaid expansion program, nearly 300,000 Georgians would gain health coverage, according to the Robert Wood Johnson Foundation.

Georgia’s work requirement hasn’t been cheap to implement. An analysis by Chan’s think tank found about $13,360 in state and federal spending for each enrollee from January 2021 through June 2024, largely on administrative costs, not health benefits. That doesn’t account for the cost to prepare and submit the application for Pathways to the feds or the fees associated with legal fights over the program.

Officials in Georgia told KFF Health News that, as of June 30, Pathways had cost $40.6 million in state and federal funds.

Pathways also has increased the workload for state staffers who must manually verify complex eligibility requirements and monitor enrollees’ continued eligibility, according to consumer advocacy organizations, former state employees, and researchers.

The Kemp administration blames the processing slowdown of state benefits, in part, on what’s known as the Medicaid “unwinding,” which began in April 2023 as states had to redetermine the eligibility of all enrollees in the wake of the coronavirus pandemic.

“Georgia Pathways is an innovative, Georgia-specific program that has provided coverage to thousands of Georgians who otherwise would be without care,” said Garrison Douglas, a Kemp spokesperson.

Critics say the Pathways rollout stressed a system that’s had snags for years. In contrast, Chan pointed to North Carolina, which fully expanded Medicaid during the unwinding, covering more people for less than the cost per person of Pathways and without creating additional backlogs for other public benefits programs.

Waiting for benefits approval can have concrete consequences for people’s health and well-being, say doctors, researchers, and patient advocates.

Flavia Rossi, a pediatrician in Tifton, about 180 miles south of Atlanta, said some parents skip their kids’ checkups because they fear expensive out-of-pocket costs while waiting for Medicaid coverage for their children.

In October 2023, Ellenwood, Georgia, residents Gloria and William Felder, who have custody of a granddaughter, were told by the state that her Medicaid coverage had lapsed. William Felder said they reapplied three times but waited 11 months for her coverage to be restored, during which they spent over $1,500 on her care. “We wanted to make sure she had coverage,” he said.

After a health insurance navigator queried the state, Felder said, the state finally informed them in September that she had Medicaid again.

Georgia officials haven’t invested enough in the state agency that processes public benefits applications, said Laura Colbert, executive director of Georgians for a Healthy Future, a nonprofit policy advocacy organization. The problem is exacerbated by staffing shortages, high staff turnover, and outdated technology, she said.

In November 2023, the U.S. Department of Agriculture notified state officials that Georgia was “severely out of compliance” with timeliness standards for processing SNAP applications. A recent progress report details the scope of the issues: a system that incorrectly prioritizes applications, not enough staff to handle a backlog of nearly 52,000 new applications, and no system to promptly reassign applications when staff are off.

“These delays create real hardship, forcing families to make choices between paying for medicine, food, or rent while they wait for the support they’re entitled to,” Colbert said.

The state checked the eligibility of about 2.7 million residents when the pandemic-era Medicaid continuous coverage requirement ended. Nearly half a million Georgians lost coverage — including nearly 300,000 children, according to an analysis by Alker’s nonprofit.

Instead of investing more to ensure that people who were wrongly removed could reenroll, the state continues to pour money into the Pathways program, Alker said. She cited a recently launched $10.7 million ad campaign aimed at boosting Pathways enrollment with money from federal pandemic recovery funds.

The contract for that work was awarded to the consulting firm Deloitte, which has already received millions from Georgia to build and implement Pathways. It’s also responsible for the state’s Gateway technology system, which people use to access public benefits and Georgia officials have described as having ongoing problems, according to KFF Health News’ reporting.

Deloitte did not respond to a request for comment for this article. It previously told KFF Health News that it does not comment on state-specific issues.

In a November letter to KFF Health News, Deloitte spokesperson Karen Walsh said the firm’s clients — state governments — “understand that large system implementations are challenging due to the complexity of the programs they support, and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.”

Deegant Adhvaryu had to help keep his parents afloat as they waited months to get approved for Medicaid and SNAP. He bought them groceries and helped cover their rent. Not every applicant is that lucky.

“There are people in the state of Georgia with far less financial resources, far less family connections to be able to help them that need these services,” he said.

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

USE OUR CONTENT

This story can be republished for free (details).

In February, the 32-year-old with autism, cerebral palsy, and kidney disease was brought to Grady Memorial Hospital from the group home where he had been living because he was having auditory hallucinations and suicidal thoughts, he said.

“Being here is not helping me, mentally, physically, emotionally,” Mills said.

He wanted to return to a group home or some other community setting where he could receive the care he needs without being confined. It’s his legal right. But it took the state agency overseeing his care more than eight months to get that done — and that placement would be short-lived.

Nearly 15 years ago, the U.S. Department of Justice sued Georgia for unnecessarily segregating people with developmental disabilities and mental illness. The state settled the case and agreed to a massive overhaul of the services it offers to that population. Despite hundreds of millions of dollars in investments and some notable improvements, the state’s system of caring for people with developmental disabilities and mental illness still has holes. The gaps often leave people like Mills sequestered in institutional settings and without the proper community supports.

Advocates said those failures continue to violate the rights of Georgians who have been historically marginalized and put their health at risk. “It’s an emergency,” said Susan Walker Goico, director of Atlanta Legal Aid Society’s Disability Integration Project. “Anytime somebody has to live in a segregated setting when they don’t want to, it’s terrible.”

The Americans with Disabilities Act, as clarified in a 1999 U.S. Supreme Court decision, says Mills and other people with disabilities have been legally entitled to receive care at home and in other community settings instead of being unnecessarily confined to places like hospitals and nursing homes.

That decision in Olmstead v. L.C. became the foundation for the lawsuit the Department of Justice levied against Georgia in 2010 that sought to force the state to fix its system.

Later that year, state officials agreed to stop putting people in state hospitals solely because they have developmental disabilities. They also agreed to use Medicaid to pay for people to receive care in the community, and to establish crisis response and housing services for those with mental illness.

The state agreed to make the fixes within five years. Nearly a decade and a half later, it’s still not finished.

Even critics acknowledge Georgia has made considerable improvements in the services it provides for people with developmental disabilities and mental illness. Since the start of the settlement, the state has invested nearly $521 million in community services. And, in late September, a federal judge released the state from many parts of its Olmstead settlement.

However, the DOJ, patient advocates, and even state officials acknowledge more work remains. They say there are many reasons it’s taking so long: the scale of the undertaking, loss of momentum over time, a workforce shortage that has limited appropriate community placements, and a lack of political will.

“The longer it continues, the more you sort of say, ‘Are we serious about solving this problem?’” said Geron Gadd, a senior attorney with the National Health Law Program.

The main challenges won’t be easy to solve without appropriate attention, investments, and commitment from lawmakers, advocates said. In a recent court filing, the state admitted it needs to remove more people with developmental disabilities from psychiatric hospitals, improve case management for people with mental illness, and provide more housing with mental health supports.

That final goal is the “bedrock” of Georgia’s mental health and developmental disability system, Goico said. “You have to have a place to live in order to get your services and to stay out of institutions.”

But people with developmental disabilities and mental illness regularly can’t find appropriate community placements, so they cycle in and out of hospitals and nursing homes, Goico and other observers noted.

In 2010, Georgia launched a housing voucher program for people with mental illness who are chronically homeless, incarcerated, or continually in and out of emergency rooms.

The state agreed to create the capacity to offer vouchers to 9,000 people by July 2015. Currently, only about 2,300 are in the program. Even so, state lawmakers declined to fund additional waivers in next year’s budget, saying they were waiting for an update on Georgia’s compliance with the DOJ settlement.

A legal settlement may dictate that states do certain things, but “the state legislature has to still vote to allocate funds,” said David Goldfarb, former director of long-term supports and services policy at the Arc of the United States, a disability rights organization.

The settlement has resulted in a huge transformation of Georgia’s service system, even though “it’s taking them quite a time to get there,” said Jennifer Mathis, a deputy assistant attorney general with the DOJ’s civil rights division.

For people with developmental disabilities, like Mills, that prolonged arrival means more time confined to hospitals and nursing homes.

Mills said he has had dozens of hospital stays, though none as long as his eight-month stint. “Sometimes it would go from two weeks to a month,” he said in September. “It’s stressful.”

Kevin Tanner, head of Georgia’s Department of Behavioral Health and Developmental Disabilities, noted that the number of people stuck in hospitals had been as high as 30 a day. It’s “down to the teens now,” he said, due in part to the recent opening of two homes for people with developmental disabilities in crisis, with eight beds to serve people statewide.

“No system’s perfect,” Tanner said.

Other states have struggled to achieve compliance. Virginia and North Carolina have been under similar federal oversight since 2012.

But some states have shown it’s possible to make fixes. Delaware entered an Olmstead settlement with the DOJ in 2011 and exited federal oversight five years later. Oregon settled a case in 2015 and achieved compliance in 2022.

In Georgia, a shortage of housing for people with developmental disabilities and mental illness has been exacerbated by the shuttering of home and community service providers in recent years, said Lisa Reisman, owner of Complete Care at Home, which offers home medical care to older adults and people with disabilities.

Many service providers blamed the shortage of home and community services on Georgia’s low Medicaid reimbursement rates, which have made it hard for providers to keep workers. Years of low rates “decimated the infrastructure,” said Ryan Whitmire, president of Developmental Disabilities Ministries of Georgia.

Reisman said she has had to turn down placement requests from the state because she couldn’t accommodate them. In those situations, she said, a state official said service providers would sometimes drop off clients at ERs because they “were out of money and they didn’t know where to put them.”

Service providers, including Whitmire, said nurses and other caregivers often leave for higher-paying jobs in fast food or retail.

This year, state lawmakers appropriated more than $106 million to increase Medicaid rates for mental health and developmental disability service providers. Some of those rates hadn’t been raised since 2008.

State lawmakers also recently passed a bill that would require a study every four years of rates it pays providers — though it would still be up to lawmakers to increase payments.

Not only was Lloyd Mills’ extended time in the hospital hard mentally and physically, it also made him lose his Medicaid coverage, said his representatives from the Georgia Advocacy Office, a nonprofit that represents people with disabilities.

Because he was in a hospital, he was unable to spend his monthly Supplemental Security Income payments, which accumulated until he had too much money to keep his health coverage.

In late October, eight months after his hospital stay began, the state moved him to a group home in Macon, about 85 miles southeast of Atlanta. In the days before his move, Mills said he was ready to start his next chapter.

“I’m just ready to live my life, and I don’t plan on ever coming back here again,” he said.

But his stay was short. In mid-November, after just a few weeks of living at the group home, Mills ended up back in a hospital. His advocates worry he won’t be heading to a community placement anytime soon.

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).

Trump, long an ACA opponent, expressed interest during the campaign in retooling the health law. In addition, some high-ranking Republican lawmakers — who will now have control over both the House and the Senate — have said revamping the landmark 2010 legislation known as Obamacare would be a priority. They say the law is too expensive and represents government overreach.

The governing trifecta sets the stage for potentially seismic changes that could curtail the law’s Medicaid expansion, raise the uninsured rate, weaken patient protections, and increase premium costs for millions of people.

“The Republican plans — they don’t say they are going to repeal the ACA, but their collection of policies could amount to the same thing or worse,” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a research and policy institute. “It could happen through legislation and regulation. We’re on alert for anything and everything. It could take many forms.”

Congressional Republicans have held dozens of votes over the years to try to repeal the law. They were unable to get it done in 2017 after Trump became president, even though they held both chambers and the White House, in large part because some GOP lawmakers wouldn’t support legislation they said would cause such a marked increase in the uninsured rate.

Similar opposition to revamping the law could emerge again, especially because polls show the ACA’s protections are popular.

While neither Trump nor his GOP allies have elaborated on what they would change, House Speaker Mike Johnson said last month that the ACA needs “massive reform” and would be on the party’s agenda should Trump win.

Congress could theoretically change the ACA without a single Democratic vote, using a process known as “reconciliation.” The narrow margins by which Republicans control the House and Senate mean just a handful of “no” votes could sink that effort, though.

Many of the more ambitious goals would require Congress. Some conservatives have called for changing the funding formula for Medicaid, a federal-state government health insurance program for low-income and disabled people. The idea would be to use budget reconciliation to gain lawmakers’ approval to reduce the share paid by the federal government for the expansion population. The group that would be most affected is made up largely of higher-income adults and adults who don’t have children rather than “traditional” Medicaid beneficiaries such as pregnant women, children, and people with disabilities.

A conservative idea that would let individuals use ACA subsidies for plans on the exchange that don’t comply with the health law would likely require Congress. That could cause healthier people to use the subsidies to buy cheaper and skimpier plans, raising premiums for older and sicker consumers who need more comprehensive coverage.

“It’s similar to an ACA repeal plan,” said Cynthia Cox, a vice president and the director of the Affordable Care Act program at KFF, a health information nonprofit that includes KFF Health News. “It’s repeal with a different name.”

Congress would likely be needed to enact a proposal to shift a portion of consumers’ ACA subsidies to health savings accounts to pay for eligible medical expenses.

Trump could also opt to bypass Congress. He did so during his previous tenure, when the Department of Health and Human Services invited states to apply for waivers to change the way their Medicaid programs were paid for — capping federal funds in exchange for more state flexibility in running the program. Waivers have been popular among both blue and red states for making other changes to Medicaid.

“Trump will do whatever he thinks he can get away with,” said Chris Edelson, an assistant professor of government at American University. “If he wants to do something, he’ll just do it.”

Republicans have another option to weaken the ACA: They can simply do nothing. Temporary, enhanced subsidies that reduce premium costs — and contributed to the nation’s lowest uninsured rate on record — are set to expire at the end of next year without congressional action. Premiums would then double or more, on average, for subsidized consumers in 12 states who enrolled using the federal ACA exchange, according to data from KFF.

That would mean fewer people could afford coverage on the ACA exchanges. And while the number of people covered by employer plans would likely increase, an additional 1.7 million uninsured individuals are projected each year from 2024 to 2033, according to federal estimates.

Many of the states that would be most affected, including Texas and Florida, are represented by Republicans in Congress, which could give some lawmakers pause about letting the subsidies lapse.

The Trump administration could opt to stop defending the law against suits seeking to topple parts of it. One of the most notable cases challenges the ACA requirement that insurers cover some preventive services, such as cancer screenings and alcohol use counseling, at no cost. About 150 million people now benefit from the coverage requirement.

If the Department of Justice were to withdraw its petition after Trump takes office, the plaintiffs would not have to observe the coverage requirement — which could inspire similar challenges, with broader implications. A recent ruling left the door open to legal challenges by other employers and insurers seeking the same relief, said Zachary Baron, a director of Georgetown University’s Center for Health Policy and the Law.

In the meantime, Trump could initiate changes from his first day in the Oval Office through executive orders, which are directives that have the force of law.

“The early executive orders will give us a sense of policies that the administration plans to pursue,” said Allison Orris, a senior fellow at the Center on Budget and Policy Priorities. “Early signaling through executive orders will send a message about what guidance, regulations, and policy could follow.”

In fact, Trump relied heavily on these orders during his previous term: An October 2017 order directed federal agencies to begin modifying the ACA and ultimately increased consumer access to health plans that didn’t comply with the law. He could issue similar orders early on in his new term, using them to start the process of compelling changes to the law, such as stepped-up oversight of potential fraud.

The administration could early on take other steps that work against the ACA, such as curtailing federal funding for outreach and help signing up for ACA plans. Both actions depressed enrollment during the previous Trump administration.

Trump could also use regulations to implement other conservative proposals, such as increasing access to health insurance plans that don’t comply with ACA consumer protections.

The Biden administration walked back Trump’s efforts to expand what are often known as short-term health plans, disparaging the plans as “junk” insurance because they may not cover certain benefits and can deny coverage to those with a preexisting health condition.

The Trump administration is expected to use regulation to reverse Biden’s reversal, allowing consumers to keep and renew the plans for much longer.

But drafting regulations has become far more complicated following a Supreme Court ruling saying federal courts no longer have to defer to federal agencies facing a legal challenge to their authority. In its wake, any rules from a Trump-era HHS could draw more efforts to block them in the courts.

Some people with ACA plans say they’re concerned. Dylan Reed, a 43-year-old small-business owner from Loveland, Colorado, remembers the days before the ACA — and doesn’t want to go back to a time when insurance was hard to get and afford.

In addition to attention-deficit/hyperactivity disorder and anxiety, he has scleroderma, an autoimmune disease associated with joint pain and numbness in the extremities. Even with his ACA plan, he estimates, he pays about $1,000 a month for medications alone.

He worries that without the protections of the ACA it will be hard to find coverage with his preexisting conditions.

“It’s definitely a terrifying thought,” Reed said. “I would probably survive. I would just be in a lot of pain.”

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).

Trump, que durante mucho tiempo se opuso a ACA, expresó durante la campaña su interés en modificar la ley de salud. Además, algunos legisladores republicanos de alto rango —que ahora tendrán el control tanto de la Cámara de Representantes como del Senado— han dicho que para ellos sería una prioridad renovar la histórica legislación de 2010, conocida como Obamacare. Afirman que es una ley demasiado cara y que representa una intromisión excesiva del Gobierno.

El futuro gobernante prepara el terreno para hacer cambios potencialmente sísmicos que podrían limitar la expansión de Medicaid, aumentar la tasa de personas sin seguro, debilitar las protecciones para los pacientes y elevar los costos de las primas para millones de personas.

“Los planes republicanos no dicen que vayan a derogar ACA, pero el conjunto de sus políticas podría equivaler a lo mismo o a algo peor”, dijo Sarah Lueck, vicepresidenta de política sanitaria del Center on Budget and Policy Priorities, un instituto de investigación y política. “Los cambios podrían sobrevenir a través de la legislación y de las regulaciones. Estamos alerta ante cualquier cosa porque sabemos que podrían adoptar muchas formas”.

En estos años, los republicanos del Congreso han votado docenas de veces intentando derogar la ley. No pudieron lograrlo en 2017, después que Trump se convirtiera en presidente, a pesar de que tenían la Casa Blanca y mayoría en ambas cámaras.

Esto ocurrió, en gran parte, porque algunos legisladores del GOP no quería apoyar una legislación que, explicaban, podía causar un aumento tan marcado en la tasa de personas sin seguro.

En esta oportunidad podría surgir una oposición similar a reformar la ley, especialmente porque las encuestas muestran que las protecciones que establece ACA son populares.

Aunque ni Trump ni sus aliados del Partido Republicano han dado detalles sobre lo que cambiarían, el presidente de la Cámara de Representantes, Mike Johnson, dijo en octubre que ACA necesita una “reforma profunda” y que esa política estaría en la agenda del partido.

Teóricamente, el Congreso podría cambiar ACA sin un solo voto demócrata, utilizando un proceso conocido como “reconciliación”. Sin embargo, como los republicanos controlan la Cámara de Representantes y el Senado por márgenes estrechos, sólo un puñado de votos en contra podría hundir ese esfuerzo.

Muchos de los objetivos más ambiciosos requerirían la intervención del Congreso. Algunos conservadores han pedido que se modifique la fórmula de financiamiento de Medicaid, el programa de seguro médico del gobierno federal y estatal para personas de bajos ingresos y con discapacidades.

La idea sería utilizar la reconciliación presupuestaria para convencer a los legisladores de que  aprueben una reducción de la parte de los recursos que paga el gobierno federal para la población cubierta por la expansión.  El grupo que se vería más afectado está compuesto en gran parte por adultos de ingresos más altos y adultos sin hijos, en lugar de los beneficiarios “tradicionales” de Medicaid, como las mujeres embarazadas, los niños y las personas con discapacidades.

Una iniciativa conservadora que permitiría que las personas utilicen los subsidios de ACA para comprar en el mercado planes de salud que no cumplen con la ley, probablemente necesitaría de la aprobación del Congreso.

Esto podría provocar que las personas más saludables utilicen los subsidios para comprar planes más baratos y limitados, lo que aumentaría las primas para los consumidores de mayor edad y más enfermos, que necesitan una cobertura más completa.

“Es algo parecido a un plan de derogación de ACA”, dijo Cynthia Cox, vicepresidenta y directora del programa de la Ley de Cuidado de Salud a Bajo Precio en KFF. “Es una derogación con otro nombre”.

“Trump hará lo que crea que puede hacer sin consecuencias”, dijo Chris Edelson, profesor adjunto de Gobierno en American University. “Si quiere hacer algo, simplemente lo hará”.

Los republicanos tienen otra opción para debilitar ACA. Pueden simplemente no hacer nada.

Los subsidios temporales y mejorados que reducen los costos de las primas —y que contribuyeron a alcanzar la tasa de personas sin seguro más baja de la historia del país— expirarán a finales del próximo año si el Congreso no actúa. Según datos de KFF, en promedio, las primas se duplicarían o más para los consumidores subvencionados en 12 estados que se inscribieron a través del mercado federal de ACA.

Esto significaría que menos personas podrían permitirse esta cobertura. Y aunque es probable que aumente el número de personas cubiertas por planes ofrecidos por empresas, según estimaciones federales se proyecta que habrá 1.7 millones más de personas sin seguro cada año entre 2024 y 2033.

Muchos de los estados que se verían más afectados, incluidos Texas y Florida, están representados en el Congreso por republicanos, lo que podría hacer que algunos legisladores no estén convencidos de permitir que los subsidios caduquen.

La administración Trump también podría optar por dejar de defender la ley contra las demandas que buscan modificar algunas de sus partes esenciales.

Uno de los casos más notables cuestiona el requisito de ACA de que las aseguradoras cubran algunos servicios preventivos, como las pruebas gratuitas de detección del cáncer y el asesoramiento sobre el consumo de alcohol. En la actualidad, unas 150 millones de personas se benefician de este requisito de cobertura.

Si el Departamento de Justicia retirara su petición después que Trump asuma el cargo, los demandantes no estarían obligados a cumplir con el requisito de cobertura, lo que podría inspirar desafíos similares con implicaciones más amplias. Según Zachary Baron, director del Centro de Política Sanitaria y Derecho de la Universidad de Georgetown, una sentencia reciente deja la puerta abierta a que otras empresas y aseguradoras presenten recursos judiciales en busca de la misma reparación.

Mientras tanto, Trump podría iniciar cambios desde su primer día en el Despacho Oval a través de órdenes ejecutivas, que son directivas que no pasan por las aprobaciones del Congreso, y que tienen fuerza de ley.

“Las primeras órdenes ejecutivas nos darán una idea de las políticas que la administración planea seguir”, dijo Allison Orris, investigadora principal del Centro de Prioridades Presupuestarias y Políticas. “Las señales tempranas a través de órdenes ejecutivas enviarán un mensaje sobre qué tipo de orientación, regulaciones y políticas podrían venir después”.

De hecho, Trump se basó en gran medida en estas órdenes ejecutivas durante su mandato anterior. Una orden de octubre de 2017 ordenó a las agencias federales que comenzaran a modificar ACA y, como resultado, aumentó el acceso de los usuarios a planes de salud que no cumplían con la ley.

Al principio de su nuevo mandato, Trump podría emitir órdenes similares, utilizándolas para iniciar el proceso de cambios obligatorios a la ley, como por ejemplo con una supervisión más estricta para prevenir fraudes.

La administración podría tomar desde el principio otras medidas que vayan en contra de ACA, como recortar los fondos federales destinados a la divulgación y asistencia para inscribirse en estos planes. Estas acciones ya disminuyeron la inscripción durante la administración anterior de Trump.

El nuevo presidente también podría utilizar regulaciones para implementar otras propuestas conservadoras, como aumentar el acceso a planes de salud que no cumplan con las protecciones al consumidor que tiene ACA.

La administración Biden revirtió los esfuerzos de Trump para ampliar los llamados “planes de salud de corto plazo”, y los calificó como “seguros basura” porque pueden no cubrir ciertos beneficios y, también, negar la cobertura a personas con problemas de salud preexistentes.

Se espera que la administración de Trump utilice regulaciones para deshacer la decisión de Biden, permitiendo que los consumidores mantengan y renueven estos planes de corto plazo por períodos mucho más largos.

Sin embargo, redactar regulaciones se ha vuelto mucho más difícil debido a un fallo de la Corte Suprema que establece que los tribunales federales ya no están obligados a respaldar automáticamente las decisiones de las agencias federales cuando se cuestiona su autoridad legal. Como resultado, cualquier nueva regla emitida por el HHS durante una administración de Trump podría enfrentar más intentos de bloqueo en los tribunales.

Algunas personas con planes de ACA cuentan que están preocupadas. Dylan Reed, un pequeño empresario de 43 años, de Loveland, Colorado, recuerda los días anteriores a la existencia de ACA y no quiere volver a una época en la que era difícil conseguir seguro de salud, y también pagarlo.

Además del trastorno por déficit de atención con hiperactividad (TDAH) y ansiedad, Reed padece de esclerodermia, una enfermedad autoinmune asociada con dolores de las articulaciones y entumecimiento en las extremidades. Incluso con su plan de ACA, calcula que paga alrededor de $1,000 al mes solo en medicamentos.

Le preocupa que, sin las protecciones de ACA, le resulte difícil encontrar cobertura debido a sus enfermedades preexistentes.

“Definitivamente es un pensamiento aterrador”, confiesa Reed. “Probablemente sobreviviría, pero con mucho dolor”.

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).

Sen. JD Vance (R-Ohio) during a Sept. 17 rally

During a recent presidential campaign rally in Wisconsin, Sen. JD Vance (R-Ohio) was asked how a Trump administration would protect rural health care access in the face of hospital closures, such as two this year in Eau Claire and Chippewa Falls.

In response, he turned to immigration.

“Now, you might not think that rural health care access is an immigration issue,” said Vance, former President Donald Trump’s running mate. “I guarantee it is an immigration issue, because we’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.”

More than 150 rural hospitals have closed or eliminated inpatient services since 2010, researchers at the University of North Carolina-Chapel Hill reported. Losing a hospital can resonate throughout a community — reducing access to timely care and disrupting the local economy.

The federal government has made efforts to keep the far-flung facilities afloat, but it’s not been an easy problem to solve.

What Is Plaguing Rural Hospitals?

Experts said Vance’s statement implies that immigrants who are in the country illegally strain the resources of these hospitals, which often operate on thin margins, by taking time and energy away from other patients without paying their bills.

We contacted both Vance and Trump campaign staff members for additional information. They did not respond.

Experts on hospital financing and industry representatives generally disagreed with Vance’s assertion, noting that many other factors figure in closures.

“When we speak with our rural hospital members, that is not what we hear,” said Shannon Wu, director of payment policy at the American Hospital Association, a trade group of more than 5,000 hospitals around the country.

Brock Slabach, chief operating officer of the National Rural Health Association, said border state hospitals face challenges treating immigrants who are in the country illegally. “But I’ve never, in my discussions, had anyone link it directly to a hospital closure,” he said.

The specific situations that lead a rural hospital to close its doors are unique to each facility, researchers said, but many face some of the same stressors.

Rural hospitals tend to have low patient volumes, which presents its own set of problems. They’re frequently located in small communities, and some residents may choose to travel to hospitals in bigger cities where they can get more complex care, what researchers call “hospital bypass.”

That small number of patients can cause financial losses at small rural hospitals, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a national health care payment and delivery systems policy center.

Hospitals have fixed costs, such as for running emergency departments, and need to have a high enough patient volume to cover them, he said.

“If a patient comes into the ED and doesn’t have insurance or can’t pay, it doesn’t really increase the cost to the hospital very much at all because the physician is already there,” he said, using an abbreviation for emergency department.

Rural hospitals treat a higher share of patients covered by Medicare and Medicaid compared with urban hospitals, according to the American Medical Association. The public insurance programs for older and low-income Americans generally pay providers less than private insurers do.

Nevertheless, Medicare is “one of the better payers” for small rural hospitals, Miller said. That’s partly because facilities with a special “critical access hospital” designation get paid more by Medicare — and, in some states, Medicaid.

Hospital industry officials and some experts say Medicare Advantage plans’ rising popularity has also hurt rural hospitals’ bottom lines because the private insurance companies that offer the plans tend to be less reliable payers than traditional Medicare.

For starters, the negotiated rates paid by Advantage plans can be lower, which is especially noticeable for those critical access facilities. Advantage plans also introduce extra levels of expensive, staff-intensive administrative burdens to ensure payment.

“They’ll deny the claim or say the patient really didn’t need that service through prior authorization, and so the hospitals don’t get paid for the service from someone who has insurance,” Miller said.

The insurance industry trade group AHIP pushed back on the assertion that Medicare Advantage plans harm rural hospitals, citing a federally supported study saying the plans actually increase rural hospital financial stability.

But the study did not compare actual payments between Medicare Advantage and traditional Medicare plans and looked at only 14 states.

People lacking legal immigration status generally cannot obtain Medicaid or Medicare coverage. But a provision within Medicaid law does allow some immigrants in the country illegally to temporarily obtain coverage, said Hayden Dublois, data and analytics director for the think tank Foundation for Government Accountability.

Medicaid, which pays less than Medicare and private insurance, “is not exactly a financial boon for hospitals,” and this could be some of what Vance is referring to, Dublois said.

In data from a few states, Dublois found a rise in people enrolling in Medicaid without being able to verify their immigration status. But his research hasn’t looked specifically at how this population might affect rural hospitals’ financial viability.

Some states have acted in recent years to expand health coverage to people in the country illegally — offering insurance to more than 1 million low-income immigrants.

One of those states, California, has had nine hospitals close or end in-patient services since 2005.

People may be able to pay out-of-pocket for care, researchers said, or may have access to private insurance through an employer.

Covering the costs for the uninsured is only one financial stressor rural hospitals face, said George Pink, deputy director of the North Carolina Rural Health Research Program.

“Is that going to be enough to drive a hospital into bankruptcy? Probably not,” he said.

A financial decline can take years, Pink said. As losses mount, hospitals can be forced to sell property or other assets, draw down any financial reserves, and max out their credit.

“This is not an overnight phenomenon,” he said.

Our Ruling

Vance said providing care for immigrants without legal status was “bankrupting” rural hospitals and forcing them to close.

Although that population is more likely to be uninsured, living in the country illegally does not mean people lack the ability to pay for health care — especially if they live in states that offer them insurance coverage.

Research shows many factors contribute to rural hospital closures — not solely financial losses from providing care for those without insurance, whether those people are migrants in the country illegally or U.S. citizens.

We rate Vance’s statement False. 

Our sources:

PBS NewsHour, “WATCH LIVE: Vance Addresses Campaign Rally in Eau Claire, WI,” Sept. 17, 2024.

HSHS Hospital Sisters Health System, “HSHS Sacred Heart Hospital and HSHS St. Joseph’s Hospital Closure Information,” accessed Sept. 26, 2024.

Cecil G. Sheps Center for Health Services Research, the University of North Carolina-Chapel Hill, “Rural Hospital Closures,” accessed Sept. 27, 2024.

GAO, “Rural Hospital Closures: Affected Residents Had Reduced Access to Health Care Services,” Dec. 22, 2020.

The Journal of Rural Health, “The Impact of Rural General Hospital Closures on Communities — A Systematic Review of the Literature,” Nov. 20, 2023.

Rural Health Information Hub, “Rural Emergency Hospitals (REHs),” accessed Sept. 30, 2024.

KFF Health News, “Federal Program To Save Rural Hospitals Feels ‘Growing Pains,’” Jan. 16, 2024.

Microsoft Teams interview, Shannon Wu, director of payment policy at the American Hospital Association, Oct. 1, 2024.

Zoom interview, Brock Slabach, chief operating officer, National Rural Health Association, Oct. 1, 2024.

Cecil G. Sheps Center for Health Services Research, the University of North Carolina-Chapel Hill, “Patterns of Hospital Bypass and Inpatient Care-Seeking by Rural Residents,” accessed Oct. 1, 2024.

Zoom interview, Harold Miller, president and CEO, Center for Healthcare Quality and Payment Reform, Sept. 26, 2024.

American Medical Association, “Issue Brief: Payment & Delivery in Rural Hospitals,” accessed Oct. 15, 2024.

Rural Health Information Hub, “Critical Access Hospitals (CAHs),” accessed Sept. 30, 2024.

KFF, “Medicare Advantage Enrollment, Plan Availability and Premiums in Rural Areas,” Sept. 7, 2023.

KFF Health News, “Tiny, Rural Hospitals Feel the Pinch as Medicare Advantage Plans Grow,” Oct. 23, 2023.

Email interview, James Swann, director of communications and public affairs, AHIP, Oct. 21, 2024.

Medicaid.gov, “Implementation Guide: Citizenship and Non-Citizen Eligibility,” accessed Oct. 10, 2024.

Zoom and email interview, Hayden Dublois, data and analytics director, the Foundation for Government Accountability, Oct. 1, 2024.

The Commonwealth Fund, “How Differences in Medicaid, Medicare, and Commercial Health Insurance Payment Rates Impact Access, Health Equity, and Cost,” Aug. 17, 2022.

KFF Health News, “States Expand Health Coverage for Immigrants as GOP Hits Biden Over Border Crossings,” Dec. 28, 2023.

Phone interview, George Pink, deputy director, North Carolina Rural Health Research Program, Sept. 30, 2024.

KFF, “State Health Coverage for Immigrants and Implications for Health Coverage and Care,” May 1, 2024.

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).