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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

BIRMINGHAM, Ala. — Frank Wampol had a dark realization when he came across some alarming data a few years ago: Over 5,000 male construction workers die from suicide annually — five times the number who die from work-related injuries, according to several studies. That’s considerably more than the suicide rate for men in the general population.

“To say this is a crisis would be an understatement,” said Wampol, vice president of safety and health at BL Harbert International, a construction company based in Birmingham with over 10,000 employees.

Since then, the company has added mental health first-aid training for on-site supervisors and distributed information about suicide prevention to laborers in the field. The efforts are part of a larger push led by the industry and supported by unions, research institutions, and federal agencies to address construction workers’ mental health.

But initiatives to combat this mental health crisis are tougher to implement than protocols for hard hats, safety vests, and protective goggles. And some of the potential solutions, such as paid sick leave, have drawn pushback from the industry as it eyes costs.

Safety experts have long been concerned about the physical hazards of construction work. The “Fatal Four” hazards are falls, electrocutions, being struck by an object like a brick or a crane boom, and getting caught between two objects, according to the Occupational Safety and Health Administration.

Only in recent years have the psychosocial hazards of construction work moved onto the public radar. Studies paint a grim picture, said Douglas Trout, an occupational medicine physician and deputy director of the Office of Construction Safety and Health at the National Institute for Occupational Safety and Health.

In addition to high suicide rates, drug use is rampant, especially opioids such as heroin and fentanyl. A recent study from the Centers for Disease Control and Prevention found that construction ranks highest in overdose deaths by occupation.

“Rates of suicides and overdose deaths are some of the worst outcomes related to mental health conditions,” Trout said. “And unfortunately, these are the more measurable ones.”

Less measurable but also prevalent among construction workers are anxiety and depression, which often remain undiagnosed. Almost half of construction workers have experienced symptoms of both, a rate higher than that of the general U.S. population, according to a preliminary 2024 study by the Center for Construction Research and Training, an arm of North America’s Building Trades Unions. But fewer than 5% of construction workers reported seeing a mental health professional, compared with 22% of all U.S. adults, according federal statistics.

The combination of high-hazard environments and organizational factors puts construction workers at particular risk for mental health issues, Trout said. Construction is a high-stress occupation involving long hours, extended separation from family and friends, and low job security due to the industry’s cyclical nature.

Even though health insurance and workers’ compensation are offered by some contractors, paid sick leave for laborers, craft workers, and mechanics is not standard. While 18 states and Washington, D.C., have approved laws requiring paid sick leave and federal contractors have to offer it, the mandates don’t apply to many construction workers. And industry advocates are pushing back against such legal requirements, claiming they don’t fit the transient and seasonal nature of construction work.

If workers get injured, they often “try to tough it out and get back to the job as quickly as possible,” said Nazia Shah, director of safety and health services at the Associated General Contractors of America, the country’s largest construction trade association.

To manage pain from injuries, workers often resort to prescription opioids. Some then develop a dependency and turn to street drugs. “It’s a vicious cycle,” Shah said.

If a worker is fatigued, distracted by pain or personal issues, or impaired by some type of substance, the results can be catastrophic, said Wampol, a 20-year industry veteran who went into construction after retiring from a career as a firefighter and paramedic.

The biggest step, Shah said, is “breaking the stigma and normalizing conversations around mental health.”

The hurdles are particularly high in this male-dominated field, where harassment and bullying are common and speaking up about emotional hardships is often considered a sign of weakness, Shah said.

Several organizations, including the Associated Builders and Contractors, have created short “toolbox talks” to review the signs and symptoms of mental health issues, the risks of self-medicating with drugs and alcohol, and the resources available through health insurance and employee assistance programs.

Some, such as the AGC’s Missouri Chapter, hand out hard-hat stickers, cards, and “Hope coins” — small tokens that symbolize support. They all serve as conversation starters and include information on the 988 Suicide & Crisis Lifeline in English and Spanish.

Many contractors hold regular stand-downs, with supervisors halting work at a construction site to provide on-the-spot training related to a specific mental health issue. Others, such as BL Harbert, offer health education fairs and team with local health clinics for lunch-and-learn events.

But Stanley Wheat, an on-site safety manager at BL Harbert, said that even the best policies, procedures, and training materials won’t stick without making an effort on the ground. “A PowerPoint presentation alone won’t cut it. You’ve got to know your people, and you’ve got to engage them.”

Wheat, a military veteran who has worked in construction for over two decades, said it’s important to make rounds several times a day at a job site — getting to know the workers and observing changes in their behaviors.

“You start noticing the guy who’s isolating himself, sitting alone at lunch, not talking with anybody,” he said.

Wheat can relate. His uncle died by suicide, but his family would never talk about it. During his time in the military, Wheat said, he went to rehab for drug and alcohol addiction. He dropped out of college to work in construction.

“I’ve been there,” he said. “I skinned my knuckles. I pulled my back. I worked injured.”

Wheat tries to strike up conversations with workers who he thinks are having a rough time. He listens, sometimes shares his personal story, and suggests resources for help.

Peer-to-peer support is among the more promising concepts in the effort to curb the mental health crisis in construction. Workers often don’t want to talk with management or outsiders, Trout said, “but they usually trust each other.”

One successful model is Mates, a program for mental health and suicide prevention that originated in Australia in 2008. The idea is to train on-site personnel — workers, foremen, superintendents — to spot and support co-workers in crisis, offer a confidential space to talk, and guide them to help if needed. The volunteers, called “connectors,” are typically identified by green hard hat stickers. Efforts are underway to bring a formalized Mates program to the U.S., Trout said.

Other, often small and local initiatives are being implemented, too. Some contractors have hired full-time wellness coordinators or bring mental health care providers to construction sites so employees can start appointments immediately. A few companies have put dedicated trailers on their job sites that serve as quiet rooms, with lounge chairs, board games, and video consoles, so workers can take a moment to decompress.

Many contractors also have added naloxone — an emergency medication used to reverse opioid overdoses, often known by the brand Narcan — to on-site medical kits.

Going forward, as President-elect Donald Trump takes office next week, the industry faces major uncertainties, including possible ripple effects from tariffs, mass deportations, tax cuts, and deregulation.

No matter what comes, Wampol said, the construction industry needs to understand that the investment in mental wellness and suicide prevention programs creates “a healthier, more productive workforce” — and, ultimately, a better bottom line.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Jessie Mazar squeezed the grab handle in her husband’s pickup and groaned as contractions struck her during the 90-minute drive from her home in rural northeastern California to the closest hospital with a maternity unit.

She could have reached Plumas District Hospital, in Quincy, in just seven minutes. But it no longer delivers babies.

Local officials have a plan for a birth center in Quincy, where midwives could deliver babies with backup from on-call doctors and a standby perinatal unit at the hospital, but state health officials have yet to approve it.

That left Mazar to brave the long, winding road — one sometimes blocked by snow, floods, or forest fires — to have her baby. Women across California are facing similar ordeals as hospitals increasingly close money-losing maternity units, especially in rural areas.

Midwife-operated birth centers offer an alternative for women with low-risk pregnancies and can play a crucial role in filling the gap left by hospitals’ retreat from obstetrics, maternal health advocates say.

Declining birth rates, staffing shortages, and financial pressures have led 56 California hospitals — about 1 in 6 — to shutter maternity units over the past dozen years.

But midwives say California’s regulatory regime around birth centers is unnecessarily preventing new centers from opening and leading some existing facilities to close. Obtaining a license can take as long as four years.

“All they’ve essentially done is made it more dangerous to have a baby,” said Sacramento midwife Bethany Sasaki. “People have to drive two hours now because a birth center can’t open, so it’s more dangerous. People are going to be having babies in cars on the side of the road.”

Last month, state Assembly member Mia Bonta introduced legislation to streamline the regulatory process and fix what she calls “a broken system” for licensing birth centers.

“We know that alternative birth centers lead to often better outcomes, lower-risk births, more opportunity for children to be born healthy, and also to lower maternal mortality and morbidity,” she said.

The proposed bill would remove various bureaucratic requirements, though many details have yet to be finalized. Bonta introduced the bill in its current form as a jumping-off point for discussions about how to expedite licensing.

“It’s a starting place,” said Sandra Poole, health policy advocate for the Western Center on Law & Poverty, a co-sponsor of the legislation.

For now, birth centers struggle with a gantlet of rules, only some clearly connected to patient safety. Over the past decade, the number of licensed birth centers in California dropped from 12 to five, according to Bonta.

Plumas County officials are trying to address one key issue: how far a birth center can be from a hospital with a round-the-clock obstetrics unit. State regulations say it can be no more than a 30-minute drive, a distance set when many more hospitals had maternity units.

The first-of-its-kind “Plumas model” aims to take advantage of flexibility provisions in the law to address the obstacle in a way that could potentially be replicated elsewhere in the state.

But the hospital’s application for a birth center and a perinatal unit has been “languishing” with the California Department of Public Health, which is “looking for cover from the legislature,” said Robert Moore, chief medical officer of Partnership HealthPlan of California, a Medi-Cal managed-care plan serving most of Northern California. Asked about the application, a CDHP spokesperson said only that it was under review.

The goal should be for all women to be within an hour’s drive of a hospital with an obstetrics unit, Moore said. Data shows the complication rate goes up after an hour and even higher after two hours, he said, while the benefit is less compelling between 30 and 60 minutes.

Numerous other regulations have made it difficult for birth centers to keep their doors open.

Since August, birth centers in Sacramento and Monterey have had to stop operating because their heating ducts failed to meet licensing requirements. The facilities fall under the same state Department of Health Care Access and Information regulations as primary care clinics, though birth centers see healthy families, not sick ones, and don’t need hospital-grade ventilation, said midwife Caroline Cusenza.

She had spent $50,000 remodeling the Monterey Birth & Wellness Center to include state-required items, such as nursing and hand-washing stations and a housekeeping closet. In the end, a requirement for galvanized steel heating vents, which would have required opening the ceiling at an unaffordable cost, prompted her heart-wrenching decision to close.

“We’re turning women away in tears,” said Sasaki, who owned Midtown Birth Center in Sacramento. She bought the building for $760,000 and spent $250,000 remodeling it in a way she believed met all licensing requirements. But regulators would not license it unless the heating system was redone. Sasaki estimated it would have cost an additional $50,000 to bring it into compliance — too much to keep operating.

She blamed her closure on “regulatory dysfunction.”

Legislation signed by Gov. Gavin Newsom last year could ease onerous building codes such as those governing Sasaki’s and Cusenza’s heating systems, said Poole, the health policy advocate.

The state has taken two to four years to issue birth center licenses, according to a brief by the Osher Center for Integrative Health at the University of California-San Francisco. The state Department of Public Health “works tirelessly to ensure health facilities are able to be properly licensed and follow all applicable requirements within our authority before and during their operation,” spokesperson Mark Smith said.

Bonta, an Oakland Democrat who chairs the Assembly’s health committee, said she would consider increasing the allowable drive time between a birth center and a hospital maternity unit as part of her new legislation.

The state last updated birth center regulations more than a decade ago, before hospitals’ mass exodus from obstetrics. “The hurdle is the time and distance standards without compromising safety,” Poole said. “But where there’s nothing right now, we would say a birth center is certainly a better alternative to not having any maternal care.”

Moore noted that midwife-led births in homes and birth centers are the mainstay of obstetric care in Europe, where the infant mortality rate is considerably lower than in the U.S. More than 98% of American babies are born in hospitals.

Babies delivered by midwives are more likely to be born vaginally, less likely to require intensive care, and more likely to breastfeed, the California Maternal Quality Care Collaborative has found. Midwife-led births also lead to fewer infant emergency room visits, hospitalizations, and neonatal deaths. And they cost far less: Birth centers generally charge one-quarter or less of the average cost of about $36,000 for a vaginal birth in a California hospital.

If they catered only to private-pay clients, Cusenza and Sasaki could have continued operating without licenses. They must be licensed, however, to receive payments from Medi-Cal and some private insurance companies, which they needed to remain in business. Medi-Cal, the state’s Medicaid health insurance program for low-income residents, paid for 39% of the state’s births in 2022.

Bonta has heard reports from midwives that the key to getting licensed is hunting down the right state health department advocate. “I don’t believe that we should be building resources based on the model of ‘Where’s Waldo?’ in finding a champion inside CDPH,” she said.

Lori Link, director of midwifery at Plumas District Hospital, believes the Plumas model can turn what’s become a maternity desert into an oasis. Jessie Mazar, whose son was born in September without complications at a Truckee hospital, would welcome the opportunity to deliver her planned second child in Quincy.

“That would be convenient,” she said. “We’re not holding our breath.”

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Under President Joe Biden, enrollment in Medicaid hit a record high and the uninsured rate reached a record low.

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.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Throughout her childhood, Julia Lo Cascio dreamed of becoming a pediatrician. So, when applying to medical school, she was thrilled to discover a new, small school founded specifically to train primary care doctors: NYU Grossman Long Island School of Medicine.

Now in her final year at the Mineola, New York, school, Lo Cascio remains committed to primary care pediatrics. But many young doctors choose otherwise as they leave medical school for their residencies. In 2024, 252 of the nation’s 3,139 pediatric residency slots went unfilled and family medicine programs faced 636 vacant residencies out of 5,231 as students chased higher-paying specialties.

Lo Cascio, 24, said her three-year accelerated program nurtured her goal of becoming a pediatrician. Could other medical schools do more to promote primary care? The question could not be more urgent. The Association of American Medical Colleges projects a shortage of 20,200 to 40,400 primary care doctors by 2036. This means many Americans will lose out on the benefits of primary care, which research shows improves health, leading to fewer hospital visits and less chronic illness.

Many medical students start out expressing interest in primary care. Then they end up at schools based in academic medical centers, where students become enthralled by complex cases in hospitals, while witnessing little primary care.

The driving force is often money, said Andrew Bazemore, a physician and a senior vice president at the American Board of Family Medicine. “Subspecialties tend to generate a lot of wealth, not only for the individual specialists, but for the whole system in the hospital,” he said.

A department’s cache of federal and pharmaceutical-company grants often determines its size and prestige, he said. And at least 12 medical schools, including Harvard, Yale, and Johns Hopkins, don’t even have full-fledged family medicine departments. Students at these schools can study internal medicine, but many of those graduates end up choosing subspecialties like gastroenterology or cardiology.

One potential solution: eliminate tuition, in the hope that debt-free students will base their career choice on passion rather than paycheck. In 2024, two elite medical schools — the Albert Einstein College of Medicine and the Johns Hopkins University School of Medicine — announced that charitable donations are enabling them to waive tuition, joining a handful of other tuition-free schools.

But the contrast between the school Lo Cascio attends and the institution that founded it starkly illustrates the limitations of this approach. Neither charges tuition.

In 2024, two-thirds of students graduating from her Long Island school chose residencies in primary care. Lo Cascio said the tuition waiver wasn’t a deciding factor in choosing pediatrics, among the lowest-paid specialties, with an average annual income of $260,000, according to Medscape.

At the sister school, the Manhattan-based NYU Grossman School of Medicine, the majority of its 2024 graduates chose specialties like orthopedics (averaging $558,000 a year) or dermatology ($479,000).

Primary care typically gets little respect. Professors and peers alike admonish students: If you’re so smart, why would you choose primary care? Anand Chukka, 27, said he has heard that refrain regularly throughout his years as a student at Harvard Medical School. Even his parents, both PhD scientists, wondered if he was wasting his education by pursuing primary care.

Seemingly minor issues can influence students’ decisions, Chukka said. He recalls envying the students on hospital rotations who routinely were served lunch, while those in primary care settings had to fetch their own.

Despite such headwinds, Chukka, now in his final year, remains enthusiastic about primary care. He has long wanted to care for poor and other underserved people, and a one-year clerkship at a community practice serving low-income patients reinforced that plan.

When students look to the future, especially if they haven’t had such exposure, primary care can seem grim, burdened with time-consuming administrative tasks, such as seeking prior authorizations from insurers and grappling with electronic medical records.

While specialists may also face bureaucracy, primary care practices have it much worse: They have more patients and less money to hire help amid burgeoning paperwork requirements, said Caroline Richardson, chair of family medicine at Brown University’s Warren Alpert Medical School.

“It’s not the medical schools that are the problem; it’s the job,” Richardson said. “The job is too toxic.”

Kevin Grumbach, a professor of family and community medicine at the University of California-San Francisco, spent decades trying to boost the share of students choosing primary care, only to conclude: “There’s really very little that we can do in medical school to change people’s career trajectories.”

Instead, he said, the U.S. health care system must address the low pay and lack of support.

And yet, some schools find a way to produce significant proportions of primary care doctors — through recruitment and programs that provide positive experiences and mentors.

U.S. News & World Report recently ranked 168 medical schools by the percentage of graduates who were practicing primary care six to eight years after graduation.

The top 10 schools are all osteopathic medical schools, with 41% to 47% of their students still practicing primary care. Unlike allopathic medical schools, which award MD degrees, osteopathic schools, which award DO degrees, have a history of focusing on primary care and are graduating a growing share of the nation’s primary care physicians.

At the bottom of the U.S. News list is Yale, with 10.7% of its graduates finding lasting careers in primary care. Other elite schools have similar rates: Johns Hopkins, 13.1%; Harvard, 13.7%.

In contrast, public universities that have made it a mission to promote primary care have much higher numbers.

The University of Washington — No. 18 in the ranking, with 36.9% of graduates working in primary care — has a decades-old program placing students in remote parts of Washington, Wyoming, Alaska, Montana, and Idaho. UW recruits students from those areas, and many go back to practice there, with more than 20% of graduates settling in rural communities, according to Joshua Jauregui, assistant dean for clinical curriculum.

Likewise, the University of California-Davis (No. 22, with 36.3% of graduates in primary care) increased the percentage of students choosing family medicine from 12% in 2009 to 18% in 2023, even as it ranks high in specialty training. Programs such as an accelerated three-year primary care “pathway,” which enrolls primarily first-generation college students, help sustain interest in non-specialty medical fields.

The effort starts with recruitment, looking beyond test scores to the life experiences that forge the compassionate, humanistic doctors most needed in primary care, said Mark Henderson, associate dean for admissions and outreach. Most of the students have families who struggle to get primary care, he said. “So they care a lot about it, and it’s not just an intellectual, abstract sense.”

Establishing schools dedicated to primary care, like the one on Long Island, is not a solution in the eyes of some advocates, who consider primary care the backbone of medicine and not a separate discipline. Toyese Oyeyemi Jr., executive director of the Social Mission Alliance at the Fitzhugh Mullan Institute of Health Workforce Equity, worries that establishing such schools might let others “off the hook.”

Still, attending a medical school created to produce primary care doctors worked out well for Lo Cascio. Although she underwent the usual specialty rotations, her passion for pediatrics never flagged — owing to her 23 classmates, two mentors, and her first-year clerkship shadowing a community pediatrician. Now, she’s applying for pediatric residencies.

Lo Cascio also has deep personal reasons: Throughout her experience with a congenital heart condition, her pediatrician was a “guiding light.”

“No matter what else has happened in school, in life, in the world, and medically, your pediatrician is the person that you can come back to,” she said. “What a beautiful opportunity it would be to be that for someone else.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Durante la presidencia de Joe Biden, la inscripción en Medicaid alcanzó un nivel récord y la tasa de personas sin seguro médico llegó a su nivel histórico más bajo.

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.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

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KFF Health News chief Washington correspondent Julie Rovner discussed the Department of Health and Human Services, the federal workforce, and Robert F. Kennedy Jr. on WAMU’s “1A” on Jan. 8.

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KFF Health News video producer and visual reporter Hannah Norman discussed PFAS contamination in well water on KVPR’s “Central Valley Daily” on Jan. 7.

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KFF Health News public health local editor and correspondent Amy Maxmen discussed the bird flu outbreak on KMOX on Jan. 8.

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KFF Health News editor-at-large for public health Céline Gounder discussed a new rule banning medical debt from credit reports on CBS Evening News on Jan. 7. Gounder also discussed the increase in covid, flu, respiratory syncytial virus, and norovirus cases across the U.S. as well as what to know about norovirus on CBS News 24/7 on Jan. 6 and Dec. 31, respectively.

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Los incendios forestales que se propagan rápidamente y han transformado gran parte del condado de Los Ángeles en un infierno en llamas no solo están alterando las vidas de decenas de miles de residentes y dueños de negocios. También están poniendo a prueba a los hospitales, clínicas de salud, socorristas y hogares de adultos mayores de la región.

Al menos una clínica médica se ha incendiado por completo. Pacientes mayores han sido evacuados de hogares de vida asistida en ambulancias, mientras las brasas volaban alrededor de ellos y de sus proveedores. Consultorios médicos han cerrado y se han cancelado citas de rutina.

Algunos proveedores han perdido sus hogares o han tenido que ser evacuados, lo que en muchos casos les impide trabajar y dificulta que algunos centros de salud tengan el personal suficiente para atender.

Pero en medio del caos, médicos, enfermeros y otros cuidadores no dejaron de hacer su trabajo.

El martes 7 de enero por la noche, Ravi Salgia, oncólogo del City of Hope Duarte Cancer Center, vio cómo la casa situada más arriba de la suya, en Eaton Canyon, se incendiaba. Mientras caían escombros y chispas, él, su esposa y su hija mayor calcularon que solo tenían unos siete minutos para salir.

En plena noche, Salgia recibió una llamada informándole que el hospital se había convertido en un centro de comando de emergencias y que corría el riesgo de tener que evacuar, lo que significaba que debía ayudar a evaluar a los pacientes y preparar las altas.

Salgia llegó al hospital a las 2:30 am del miércoles. Lo acompañaron sus colegas, muchos de los cuales también habían sido evacuados de sus hogares.

“Todos sentimos con fuerza que necesitábamos cuidar a nuestros pacientes, sin importar lo que nos estuviera pasando física y emocionalmente, o lo que les estuviera pasando a nuestras casas. Necesitábamos asegurarnos de que las personas a las que servimos recibieran atención”, dijo Salgia en una entrevista.

Al cierre de este artículo, todavia no sabia si su casa seguía en pie.

En Pacific Palisades, se quemó por completo la St. John’s Physician Partners, una clínica de atención primaria y pediátrica afiliada a Providence Health & Services, según informó Patricia Aidem, vocera de la gran cadena de hospitales católicos con sede en Renton, Washington.

No lejos del extremo este del incendio de Palisades, Providence St. John’s Health Center en Santa Mónica, uno de los principales hospitales del grupo en el área de Los Ángeles, estuvo tan cerca de evacuar que llamó a otros hospitales de la zona para encontrar espacio para pacientes que iban a ser desplazados, dijo Aidem. El hospital USC Verdugo Hills, en Glendale, también enfrentó una posible evacuación, junto con otros centros de salud de la región.

“Todos los hospitales ubicados cerca de los incendios siguen en alerta máxima y están preparados para evacuar si las condiciones empeoran”, dijo la Hospital Association of Southern California en un comunicado.

“Los incendios están creando obstáculos operativos significativos”, agregó la entidad.

También informó que los servicios de emergencia se han visto afectados por un alto volumen de llamadas, mientras que los cierres de carreteras han dificultado el traslado de pacientes, suministros y trabajadores de salud.

Algunas instalaciones de salud se han quedado sin luz, a la vez que “muchos miembros del personal están directamente afectados por las evacuaciones y las interrupciones relacionadas con los incendios, lo que complica aún más las operaciones”.

El jueves, el Departamento de Atención Médica Administrada de California ordenó a los planes de salud que garantizaran el acceso de sus miembros afectados por los incendios a todos los servicios médicos necesarios, incluido el surtido de medicamentos recetados.

Aidem dijo que algunos médicos y otros trabajadores de salud de Providence St. John’s en Santa Mónica y Providence Holy Cross Medical Center en el Valle de San Fernando han perdido sus casas o han sido evacuados: por todo esto tener suficiente personal se ha vuelto un desafío.

Hospitales en todo el condado informaron que sus salas de emergencia habían atendido pacientes con quemaduras, problemas por inhalación de humo e irritación en los ojos.

Más de 700 personas —y posiblemente muchas más— han sido evacuadas de hogares de adultos mayores y de otras instalaciones de atención, según el Departamento de Salud Pública de California.

El miércoles, el West Valley Health Center, operado por el Departamento de Servicios de Salud del condado de Los Ángeles, cerró a causa de un corte de luz, dijo el departamento. Y UCLA Health informó que el cierre de algunas de sus clínicas en Pasadena y en el lado oeste de Los Ángeles se debió en parte a “cortes de servicios públicos”.

El Hospital Infantil de Los Ángeles informó que dos de sus clínicas de atención especializada, en Encino y Santa Mónica, estuvieron cerradas el jueves “a causa de los impactos de la tormenta de viento, los cortes de luz y los incendios”.

Providence también cerró varias clínicas esta semana.

Los dos incendios más grandes, el de Palisades en las áridas colinas costeras del oeste del condado de Los Ángeles y el de Eaton en el lado este, han quemado juntos más de 50 millas cuadradas, destruido miles de estructuras, reducido a cenizas importantes sitios culturales, matado al menos a 10 personas y herido gravemente a muchas más.

Los vientos descomunales que alimentaron la explosión de los incendios el martes y miércoles han comenzado a menguar, aunque se esperan ráfagas significativas que seguirán complicando la tarea de los bomberos.

Por todo esto, es probable que miles de personas no puedan recibir atención de rutina en los próximos días.

Kaiser Permanente, el gigante proveedor de atención médica, dijo que el jueves tuvo que cerrar múltiples sitios médicos por los incendios, incluidas una farmacia, un laboratorio y una clínica oftalmológica.

El Hospital Huntington en Pasadena, cerca del incendio de Eaton, informó que algunas de sus oficinas ambulatorias se vieron afectadas por avisos de evacuación y por el denso humo.

Dignity Health, otro gran sistema de salud, informó que algunos de sus hospitales estaban operando con generadores debido a los fuertes vientos, y algunos, como el Glendale Memorial Hospital, habían cancelado cirugías electivas.

Otros hospitales, como USC Verdugo Hills y Providence St. John’s, suspendieron temporalmente las cirugías no urgentes a causa del impacto de los incendios forestales.

La enfermera Christine Kirmsse evacuó su hogar en Santa Mónica el miércoles por la noche y está en un hotel a una hora de distancia. Pero dijo que siente la necesidad de ir a trabajar.

“Obviamente se necesita mucha ayuda”, dijo Kirmsse. “Y es importante para mí porque tengo la capacidad para poder ayudar. En momentos como este, es cuando la comunidad es más poderosa”.

Chaseedaw Giles y Tarena Lofton de KFF Health News colaboraron con este artículo.

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